- Email: [email protected]
Menopause. A midlife passage
476
Book Reviews
policy tradition. Only preventive measures delivered by injections or tablets were in accordance with this tradition. The health and welfare policies changed slowly. The conservative social policy agenda relied on the m a r k e t - health care was a ' c o m m o d i t y ' - - a n d in addition on a limited 'safety net' for people who experienced personal catastrophies. The disarray was strengthened as the 'Golden Age' of medical dominance of health policy came to an end. Another related development was the end of the special relationship between business and medicine. As a result, by the 1990s, physicians are more isolated as an interest group than they have been since the licensing laws 150 years earlier. The book ends with a discussion of prospects for policy. Fox not only states his own priorities but additionally gives interesting comments on what kind of ideas attract policy makers. These comments are made also to contradict the conventional cynical wisdom that policy makers overlook all good ideas. Fox finally puts forward two interrelated goals for a new health policy. First, some of the money now spent for redundant acute care have to be redistributed in order to manage better the consequences of chronic disabling illness. Second, as redistribution proceeds, reclaimed money should be spent on efforts to postpone or prevent disease and injuries, and disabling consequences of illness. One way to this direction is to change the ratio of subspecialties to primary care physicians. This could be supported by a reallocation of subsidies to the medical schools and teaching hospitals. Another change concerns a reduction in the number of acute hospital beds. This could be
supported by home care and other forms of care outside hospitals. The new health policy goals are no easy task and cannot be achieved at once. But changes are not impossible. This is pointed out by examples from some U.S. states which already have followed a new approach to health policy as suggested by Fox. While we must admit that societies vary in their health care systems, funding and paying for services and policy priorities, m a n y issues in health are, however, more similar in the industrial countries than one might judge from Fox's book. One reason for this is the role of the medical profession. In the Western medical education Oslerian/ Flexnerian principles have been broadly applied since the beginning of this century. Therefore, pressures for hospitals and acute care also exist where public health, prevention and postponing of chronic illness and disability are more deeply rooted in the health care system than in the United States. This book is very well written, almost exciting, and therefore easily accessible to the reader. One can recognize that it is based on a large material, much larger than is apparent at first sight. The relevance of the book makes it good reading in the United States as well as elsewhere. Further advantages include that it can be recommended to both medical and social scientists, researchers as well as other people interested in health and health care.
Menopause. A Midlife Passage, edited by Joan C. Callahan. Indiana University Press, Bloomington, 1993. 220 pp. xii, U.S. $29.95 (cloth), U.S. $12.95 (paper).
focus narrows as five authors zero in on "The H o r m o n e Replacement Therapy Debate". In addition to the references at the end of each chapter, there is an excellent selected bibliography with eight subtopical headings and an Afterword on "Creating a Visual Image of Menopause: the Hot Flash Fan", because "'menopause simply does not have a recognized visual tradition" (p. 205). I'd have opted for a color version of this lovely handmade work for the cover instead of the photo which adorned my paperback, a group of women in front of a power station with a huge bumper sticker proclaiming: "They are N O T H O T FLASHES. They are P O W E R SURGES". Beginning with a chapter on film was an inspiration, and Jean Kozlowski's spritely style lightens but doesn't detract from the intensity of her feminism. "In m e n . . , the aging process is associated with a buildup of power, while aging women are dismissed as 'over the hill'... We've been taught to laugh at them as targets of mother-hatred and exemplars of all that is no longer sexually desirable" (p. 6). Film enthusiasts will be vastly edified by the research on the careers of Shirley Maclaine and Mary Astor, and I'd have loved to read more than one page of the author's thoughts about more recent Hollywood treatments of women in films like Fried Green Tomatoes (p. 20). To me it was astonishing that she chose to be so gentle in her account of how older women are depicted in literature, screen-plays included. Not only are they degraded as undesirable, but often as dangerously and hilariously lascivious. One need only look as far as The Mikado (or Ruth in Patience) where the battleaxe Katisha is wooed by an unwilling Ko-Ko. Hoping she'll decline, he asks if she's old enough to marry and she replies ruefully, "I think I am sufficiently decayed". Joy Barbre serves up some chilling examples of Victorian medical thinking about menopause, but I thought her brief chapter rather longer on horror stories than it needed to be and short on contemporary thinking about menopause.
This collection of articles, a feminist view of the issues around menopause, is a proper challenge for a reviewer's fairmindedness. Critiquing the book is a bit like estimating the cuisine of a country on the basis of a buffet: there's ample nourishment and lots of variety, but the risks are a shortage of coherence and unevenness of quality. An outgrowth of a "multidisciplinary, multidimensional conference on menopause which drew a standing-room-only crowd of more than 300 participants" (p. x) in Fall 1989, the book contains updated conference papers supplemented by several invited essays. All proceeds go to the W o m e n ' s Studies Program at the University of Kentucky. In her Foreword, Carolyn Bratt describes how the project got started: three women in their early forties "had been experiencing minor sleep disturbances coupled with vague feelings of uneasiness...(and) were puzzled" (p. ix). Somewhat surprisingly, "none of the women had discussed her experiences with anyone else" (lb.), but while attending a conference sponsored by the Kentucky Commission on W o m e n in 1987, they compared notes. Dismayed at how little they knew about menopause and concluding that this was because it was "another one of those events in our lives like menstruation, pregnancy and childbirth that we go through without enough information and that is treated as an illness" (Ib.), they arrived at the idea of a conference. The book is bifurcated. Two-thirds of the material is in Part One, "Cultural Constructions, Policy, and Practice" made up of six assorted articles with witty, evocative titles: "Women, Film, and the Midlife Sophie's Choice: Sink or Sousatzka", "Meno-Boomers and Moral Guardians", "Metaphors of Menopause", "Heresy in the Female Body" and "Selfish Genes and Maternal Myths". In Part Two the
Department of Public Health P.O.B. 21 00014 University of Helsinki Finland
Eero Lahelma
Book Reviews
477
Geri Dickson's intriguing notions for a metalanguage of science are so well-organized that even methodologists who don't concur will be impressed with the clarity of her arguments for 4 paradigms--biomedical, sociocultural, feminist and postmodern. And for teachers there are first rate conceptual summaries (pp. 62q53), a succinctly elegant table (p. 53) and a luxuriant bibliography (pp. 55 58). With admirable flair Dickson quotes part of Kozachenko's whitehot poem "Midpoint", and the citation set me to wondering why none of the contributors invoked the work of Taslima Nasrin, surely one of the world's most powerful feminist voices, as for example, "Happy Marriage" (1994). Deft restraint in the use of literature gives buoyancy to Jacquelyn Zita's -The Rhetorics of Menopause". The quotation from Rosetta Reitz " . . . t h e best is yet to come sexually" struck me as a point too little emphasized and sexuality in post-menopausal women is a subject neglected in this book as it is in many. It reminded me of many patients, including a 74 year old woman analysand whose treatment, somewhat to our joint surprise, resulted in lively and ardent explorations of sexual intricacies. Not expecting to be held in thrall by a chapter on "Who Needs a Menopause Policy'?", I was held to the text by Jill Rips' lucidity and evenhandedness. It's not often one encounters a scholar of policy humble enough to put herself out of business: "...creation of alliances based on shared concerns of race, class and sexual freedom will do more than a menopause policy to empower women and to free both men and women from the shackles of sexism and ageism" (p. 89). Patricia Smith's chapter, subtitled, "A Look At Postmenopausal Pregnancy" raised my hopes that she might explore the fate of maternal dynamics in mature women, instead she turned to an equally worthy topic, the implications of medical progress in fertility problems. Now that "a gestational mother (with further help from technology) can be postmenopausal'" (p. 94) "women...have reason to be... circumspect before rushing down yet another primrose path (if the) "authority of medical science' (has the) effect of perpetuating women's traditional roles and again in a way that is lucrative to medical doctors" (p. 95). "The older man assumes he can have a child at sixty because someone else will be the primary caretaker.., having children not because you plan to spend your life with them, but as ego extensions, as sources of immortality" tp. 104). As a psychoanalyst I was embarrassed for Smith. The almost reflex criticisms of analytic ideas about women (e.g. pp. 115 16) are at best lamentably dated (Deutsch and Erikson), at worst bad scholarship. A survey of standard data bases would have turned up more than 30
years of serious, thoughtful literature, much of it by women analysts. Reports of two research studies introduce the material on Hormone Replacement Therapy and Kathleen MacPherson delivers an excellent inventory of "The False Promises of Hormone Replacement Therapy and Current Dilemmas": eternal beauty and femininity, 1966-1975, a safe, symptomfree menopause, 1975-1981 and escape from chronic diseases, 1980-present (pp. 146-47). My favorite article in the last part of the book was Ann Voda's meaty account of the endocrinology of menopause which deserves any scientist's study and is garnished with wry humor, e.g. the first heading: "Another Fine Myth You've Gotten Us Into" (p. 160). Like her colleagues Voda urges persuasively that women's best hope is to be rational, skeptical and above all intelligently informed, a sentiment with which few could disagree. I was puzzled and curious about the beginnings of the project. How could three bright, educated women find themselves so unaware of menopause that they had failed to think of it as related to their anxiety and insomnia? Even in 1987 there was a respectable feminist literature on the subject. And what about friends, women colleagues and family? In the rush to become scholarly experts about the lives of women, are we in danger of foregoing more traditional wellsprings of succor and information? This book bristles with a gritty, 'put-up-yer-dukes' style of feminism which blames historically destructive male medical thinking for much of the suffering and neglect of menopausal women. The authors document these atrocities amply, but one must wonder how much these need to be reiterated. Nothing's shabbier and more apt to detract from the durability of valid argument than a conceptual landscape littered with used straw men. Caveats notwithstanding, I liked the book and hope the authors will expand into a series of conferences including other topics in the health and happiness of mature women, e.g. sexuality after menopause, retirement into multiple career paths and (my own special favorite) how women die. The field's wide open for an enterprising group. May they have Godspeed.
Unassisted Childbirth, by Laura Kaplan Shanley. Bergin and Garvey, Westport, CT 06881, 1994. 151 pp., U.S. $14.95 (paperback).
ness exhibited by many young people throughout Western countries at that time. The book has a lot to offer, in enabling midwives, obstetricians, social workers and law enforcers the opportunity to understand the perspective of individuals practising such beliefs. The Bibliography provides a useful reference list for further reading to those interested in the topic. However, it is a book which requires reading with an open mind. Certainly the beliefs expressed are not those of mainstream society. It develops logically, looking first at the difference between traditional, non-Western approaches to childbirth and technocratic Western medicalization of childbirth. It continues on to consider briefly the physical and psycho
An easily readable book, by a freelance author, who normally writes for magazines and journals on the topics of childbirth and spirituality. The book reflects an ongoing discussion in the Western World, concerning the medicalization of pregnancy and childbirth, and the rebellion against this in some parts of Western society. She demonstrates considerable knowledge of American attitudes, both within formal medicine, and the informal kind practised in the 60's and early 70's. It reminded me of the extraordinary freedom and liveli-
1111 Gilehrest Dr. Pittsburgh.. PA 15235-5224 U.S.A.
Lucy Zabarenko
REFERENCE
Nasrin T. Happy marriage. The New Yorker. Sept. 19. p. 55, 1994.
Book Reviews
policy tradition. Only preventive measures delivered by injections or tablets were in accordance with this tradition. The health and welfare policies changed slowly. The conservative social policy agenda relied on the m a r k e t - health care was a ' c o m m o d i t y ' - - a n d in addition on a limited 'safety net' for people who experienced personal catastrophies. The disarray was strengthened as the 'Golden Age' of medical dominance of health policy came to an end. Another related development was the end of the special relationship between business and medicine. As a result, by the 1990s, physicians are more isolated as an interest group than they have been since the licensing laws 150 years earlier. The book ends with a discussion of prospects for policy. Fox not only states his own priorities but additionally gives interesting comments on what kind of ideas attract policy makers. These comments are made also to contradict the conventional cynical wisdom that policy makers overlook all good ideas. Fox finally puts forward two interrelated goals for a new health policy. First, some of the money now spent for redundant acute care have to be redistributed in order to manage better the consequences of chronic disabling illness. Second, as redistribution proceeds, reclaimed money should be spent on efforts to postpone or prevent disease and injuries, and disabling consequences of illness. One way to this direction is to change the ratio of subspecialties to primary care physicians. This could be supported by a reallocation of subsidies to the medical schools and teaching hospitals. Another change concerns a reduction in the number of acute hospital beds. This could be
supported by home care and other forms of care outside hospitals. The new health policy goals are no easy task and cannot be achieved at once. But changes are not impossible. This is pointed out by examples from some U.S. states which already have followed a new approach to health policy as suggested by Fox. While we must admit that societies vary in their health care systems, funding and paying for services and policy priorities, m a n y issues in health are, however, more similar in the industrial countries than one might judge from Fox's book. One reason for this is the role of the medical profession. In the Western medical education Oslerian/ Flexnerian principles have been broadly applied since the beginning of this century. Therefore, pressures for hospitals and acute care also exist where public health, prevention and postponing of chronic illness and disability are more deeply rooted in the health care system than in the United States. This book is very well written, almost exciting, and therefore easily accessible to the reader. One can recognize that it is based on a large material, much larger than is apparent at first sight. The relevance of the book makes it good reading in the United States as well as elsewhere. Further advantages include that it can be recommended to both medical and social scientists, researchers as well as other people interested in health and health care.
Menopause. A Midlife Passage, edited by Joan C. Callahan. Indiana University Press, Bloomington, 1993. 220 pp. xii, U.S. $29.95 (cloth), U.S. $12.95 (paper).
focus narrows as five authors zero in on "The H o r m o n e Replacement Therapy Debate". In addition to the references at the end of each chapter, there is an excellent selected bibliography with eight subtopical headings and an Afterword on "Creating a Visual Image of Menopause: the Hot Flash Fan", because "'menopause simply does not have a recognized visual tradition" (p. 205). I'd have opted for a color version of this lovely handmade work for the cover instead of the photo which adorned my paperback, a group of women in front of a power station with a huge bumper sticker proclaiming: "They are N O T H O T FLASHES. They are P O W E R SURGES". Beginning with a chapter on film was an inspiration, and Jean Kozlowski's spritely style lightens but doesn't detract from the intensity of her feminism. "In m e n . . , the aging process is associated with a buildup of power, while aging women are dismissed as 'over the hill'... We've been taught to laugh at them as targets of mother-hatred and exemplars of all that is no longer sexually desirable" (p. 6). Film enthusiasts will be vastly edified by the research on the careers of Shirley Maclaine and Mary Astor, and I'd have loved to read more than one page of the author's thoughts about more recent Hollywood treatments of women in films like Fried Green Tomatoes (p. 20). To me it was astonishing that she chose to be so gentle in her account of how older women are depicted in literature, screen-plays included. Not only are they degraded as undesirable, but often as dangerously and hilariously lascivious. One need only look as far as The Mikado (or Ruth in Patience) where the battleaxe Katisha is wooed by an unwilling Ko-Ko. Hoping she'll decline, he asks if she's old enough to marry and she replies ruefully, "I think I am sufficiently decayed". Joy Barbre serves up some chilling examples of Victorian medical thinking about menopause, but I thought her brief chapter rather longer on horror stories than it needed to be and short on contemporary thinking about menopause.
This collection of articles, a feminist view of the issues around menopause, is a proper challenge for a reviewer's fairmindedness. Critiquing the book is a bit like estimating the cuisine of a country on the basis of a buffet: there's ample nourishment and lots of variety, but the risks are a shortage of coherence and unevenness of quality. An outgrowth of a "multidisciplinary, multidimensional conference on menopause which drew a standing-room-only crowd of more than 300 participants" (p. x) in Fall 1989, the book contains updated conference papers supplemented by several invited essays. All proceeds go to the W o m e n ' s Studies Program at the University of Kentucky. In her Foreword, Carolyn Bratt describes how the project got started: three women in their early forties "had been experiencing minor sleep disturbances coupled with vague feelings of uneasiness...(and) were puzzled" (p. ix). Somewhat surprisingly, "none of the women had discussed her experiences with anyone else" (lb.), but while attending a conference sponsored by the Kentucky Commission on W o m e n in 1987, they compared notes. Dismayed at how little they knew about menopause and concluding that this was because it was "another one of those events in our lives like menstruation, pregnancy and childbirth that we go through without enough information and that is treated as an illness" (Ib.), they arrived at the idea of a conference. The book is bifurcated. Two-thirds of the material is in Part One, "Cultural Constructions, Policy, and Practice" made up of six assorted articles with witty, evocative titles: "Women, Film, and the Midlife Sophie's Choice: Sink or Sousatzka", "Meno-Boomers and Moral Guardians", "Metaphors of Menopause", "Heresy in the Female Body" and "Selfish Genes and Maternal Myths". In Part Two the
Department of Public Health P.O.B. 21 00014 University of Helsinki Finland
Eero Lahelma
Book Reviews
477
Geri Dickson's intriguing notions for a metalanguage of science are so well-organized that even methodologists who don't concur will be impressed with the clarity of her arguments for 4 paradigms--biomedical, sociocultural, feminist and postmodern. And for teachers there are first rate conceptual summaries (pp. 62q53), a succinctly elegant table (p. 53) and a luxuriant bibliography (pp. 55 58). With admirable flair Dickson quotes part of Kozachenko's whitehot poem "Midpoint", and the citation set me to wondering why none of the contributors invoked the work of Taslima Nasrin, surely one of the world's most powerful feminist voices, as for example, "Happy Marriage" (1994). Deft restraint in the use of literature gives buoyancy to Jacquelyn Zita's -The Rhetorics of Menopause". The quotation from Rosetta Reitz " . . . t h e best is yet to come sexually" struck me as a point too little emphasized and sexuality in post-menopausal women is a subject neglected in this book as it is in many. It reminded me of many patients, including a 74 year old woman analysand whose treatment, somewhat to our joint surprise, resulted in lively and ardent explorations of sexual intricacies. Not expecting to be held in thrall by a chapter on "Who Needs a Menopause Policy'?", I was held to the text by Jill Rips' lucidity and evenhandedness. It's not often one encounters a scholar of policy humble enough to put herself out of business: "...creation of alliances based on shared concerns of race, class and sexual freedom will do more than a menopause policy to empower women and to free both men and women from the shackles of sexism and ageism" (p. 89). Patricia Smith's chapter, subtitled, "A Look At Postmenopausal Pregnancy" raised my hopes that she might explore the fate of maternal dynamics in mature women, instead she turned to an equally worthy topic, the implications of medical progress in fertility problems. Now that "a gestational mother (with further help from technology) can be postmenopausal'" (p. 94) "women...have reason to be... circumspect before rushing down yet another primrose path (if the) "authority of medical science' (has the) effect of perpetuating women's traditional roles and again in a way that is lucrative to medical doctors" (p. 95). "The older man assumes he can have a child at sixty because someone else will be the primary caretaker.., having children not because you plan to spend your life with them, but as ego extensions, as sources of immortality" tp. 104). As a psychoanalyst I was embarrassed for Smith. The almost reflex criticisms of analytic ideas about women (e.g. pp. 115 16) are at best lamentably dated (Deutsch and Erikson), at worst bad scholarship. A survey of standard data bases would have turned up more than 30
years of serious, thoughtful literature, much of it by women analysts. Reports of two research studies introduce the material on Hormone Replacement Therapy and Kathleen MacPherson delivers an excellent inventory of "The False Promises of Hormone Replacement Therapy and Current Dilemmas": eternal beauty and femininity, 1966-1975, a safe, symptomfree menopause, 1975-1981 and escape from chronic diseases, 1980-present (pp. 146-47). My favorite article in the last part of the book was Ann Voda's meaty account of the endocrinology of menopause which deserves any scientist's study and is garnished with wry humor, e.g. the first heading: "Another Fine Myth You've Gotten Us Into" (p. 160). Like her colleagues Voda urges persuasively that women's best hope is to be rational, skeptical and above all intelligently informed, a sentiment with which few could disagree. I was puzzled and curious about the beginnings of the project. How could three bright, educated women find themselves so unaware of menopause that they had failed to think of it as related to their anxiety and insomnia? Even in 1987 there was a respectable feminist literature on the subject. And what about friends, women colleagues and family? In the rush to become scholarly experts about the lives of women, are we in danger of foregoing more traditional wellsprings of succor and information? This book bristles with a gritty, 'put-up-yer-dukes' style of feminism which blames historically destructive male medical thinking for much of the suffering and neglect of menopausal women. The authors document these atrocities amply, but one must wonder how much these need to be reiterated. Nothing's shabbier and more apt to detract from the durability of valid argument than a conceptual landscape littered with used straw men. Caveats notwithstanding, I liked the book and hope the authors will expand into a series of conferences including other topics in the health and happiness of mature women, e.g. sexuality after menopause, retirement into multiple career paths and (my own special favorite) how women die. The field's wide open for an enterprising group. May they have Godspeed.
Unassisted Childbirth, by Laura Kaplan Shanley. Bergin and Garvey, Westport, CT 06881, 1994. 151 pp., U.S. $14.95 (paperback).
ness exhibited by many young people throughout Western countries at that time. The book has a lot to offer, in enabling midwives, obstetricians, social workers and law enforcers the opportunity to understand the perspective of individuals practising such beliefs. The Bibliography provides a useful reference list for further reading to those interested in the topic. However, it is a book which requires reading with an open mind. Certainly the beliefs expressed are not those of mainstream society. It develops logically, looking first at the difference between traditional, non-Western approaches to childbirth and technocratic Western medicalization of childbirth. It continues on to consider briefly the physical and psycho
An easily readable book, by a freelance author, who normally writes for magazines and journals on the topics of childbirth and spirituality. The book reflects an ongoing discussion in the Western World, concerning the medicalization of pregnancy and childbirth, and the rebellion against this in some parts of Western society. She demonstrates considerable knowledge of American attitudes, both within formal medicine, and the informal kind practised in the 60's and early 70's. It reminded me of the extraordinary freedom and liveli-
1111 Gilehrest Dr. Pittsburgh.. PA 15235-5224 U.S.A.
Lucy Zabarenko
REFERENCE
Nasrin T. Happy marriage. The New Yorker. Sept. 19. p. 55, 1994.