Differences in Medicine: Unraveling Practices, Techniques, and Bodies

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Overview

Western medicine—especially in contrast with non-Western traditions of medical practice—is widely thought of as a coherent and unified field in which beliefs, definitions, and judgments are shared. Marc Berg and Annemarie Mol debunk this myth with an interdisciplinary and intercultural collection of essays that reveals the significantly varied ways practitioners of “conventional” Western medicine handle bodies, study test results, configure statistics, and converse with patients .
Combining theoretical work with interviews and direct observation of the activities and interactions of doctors, nurses, technicians, and patients, the contributors to this volume provide comparative studies of specific cases. Individual chapters explore topics such as the contested domain of fetal surgery in a California hospital, the construction of gender identity before transsexual surgery in Germany, and differences in the treatment and definition of pain by two clinics in France. Differences in Medicine advances earlier studies on medicine’s social diversity and regional variations to expose significant differences in the presumptions and decisions that affect patients’ lives, and marks a dramatic development in both the study of medicine and in science studies generally.
Revealing the ways in which the bodies and lives of people are constructed as medical objects by practitioners, technologies, and textbooks, this collection calls for and initiates new, more textured investigations and theories of the body in medicine and the practice of science. It will open new discussions among medical and healthcare professionals as well as scholars in medical anthropology, science studies, sociology, philosophy, and the history of medicine.

Contributors.
Isabelle Baszanger, Marc Berg, Geoffrey C. Bowker, Monica J. Casper, Charis M. Cussins, Nicolas Dodier, Stefan Hirschauer, Annemarie Mol, Vicky Singleton, Susan Leigh Star, Stefan Timmermans, Dick Willems


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Editorial Reviews

From the Publisher
“An outstanding example of some of the best work done at the research front of the field and of recent work that strives to go beyond both technological and social/cultural determinism.”—Alberto Cambrosio, McGill University

"This book, as part of a ‘second wave’ of science studies, advances our understanding of patients, bodies, and subjectivities in much the same way the first wave altered our understanding of objectivity and experimental practice."—Bruno Latour, Ecole Nationale Supérieure des Mines

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Product Details

  • ISBN-13: 9780822321743
  • Publisher: Duke University Press Books
  • Publication date: 6/28/1998
  • Series: Body, Commodity, Text Series
  • Pages: 272
  • Product dimensions: 5.90 (w) x 9.28 (h) x 0.85 (d)

Meet the Author

Marc Berg is a researcher at the School of Health Sciences at Maastricht University.

Annemarie Mol is Professor of Political Philosophy at the University of Twente.

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Read an Excerpt

Differences in Medicine

Unraveling Practices, Techniques, and Bodies


By Marc Berg, Annemarie Mol

Duke University Press

Copyright © 1998 Duke University Press
All rights reserved.
ISBN: 978-0-8223-9917-9



CHAPTER 1

PERFORMING SEXES AND GENDERS IN MEDICAL PRACTICES


Stefan Hirschauer

* * *

To talk of differences in medicine is to evoke the vast array of heterogeneous discourses and practices among different medical disciplines, settings, and groups, and the various diseases and bodies incorporated in these discourses and practices. This chapter contributes to this discussion by showing how three medical disciplines involved in a sex change determine the sex of an individual and how they define the meaning of "sex" by various differentiating practices: practices that set apart, divide, distinguish, categorize, classify, segregate, dissect, discriminate, and separate.

The specific case of sex change also raises the question of how a difference already made in everyday life (the sex difference) is drawn into, reproduced, and changed in medicine. This question of "differences in medicine" concerns the way in which medical disciplines reconstruct, protect, and mould the life-world distinction between men and women. And by looking at how medical practice is embedded in a wider cultural context, we are also able to see how the disunity of medicine can be induced and reduced by this context.

Some of the practices that construct "sexes" in everyday life are well known through ethnomethodological and interactionist research. Participants in public and private interactions maintain ongoing processes of gender presentation and gender attribution in order to display and categorize each other as members of a specific sex category (Garfinkel 1967; Goffman 1976; Kessler and McKenna 1978; West and Zimmerman 1987). In current feminist contributions on the performance of gender (Butler 1990), these phenomena have given rise to theories of the contingency and esthetic multitude of gender. Unfortunately, poststructural discourse analysis has not taken into account empirical explorations of the performative dimension of sex membership. In fact, it has highlighted the contingency of gender by implicitly contrasting it with a biomedical notion of sex as a monolithic, ontological entity. Since outside of identity politics there is no need to oppose ontologies, I will try, instead, in this essay to reconstruct the ontologies inherent in different medical practices.

From the biographical perspective, the process of sexing an individual starts in a medical setting: in the deciphering of the gray shadows of ultrasound pictures or—more important for the legal fixing of gender—at birth. Knowing that the strange creature emerging there must be either a "boy" or a "girl," a doctor or a midwife takes certain anatomical features as a good reason to apply one or other gender category to the baby.

To understand transsexuality as a social phenomenon, it is useful to think of it as a delayed revocation of that first attribution: "No, I'm not a girl. I'm a boy." Such a revocation leads to uncertain social situations with opposing categorizations, that is, to a micropolitical conflict between, on the one hand, a person making a verbal claim to being one gender and, on the other hand, people in his/her environment who believe him/her to be the other gender because of his/her public appearance or their past knowledge of this person. Two parties emerge here: the first is the majority of people, embarrassed by this severe interruption of the routine workings of their classificatory practices; the second is that tiny minority who develop a modest rhetoric of self-determination as a consequence of their political weakness. They don't aggressively claim to be the other gender or simply live as such, but they subjectively feel it "inside."

In the history of the medicalization of this social conflict, such clashes have been reconstructed as divides between "body" and "soul," "sex" and "gender" (Stoller 1968)—divisions that reflect territories of different medical disciplines. These divides have given rise to the well-known formula of a person with a "female (or male) soul being captured in a wrong body." The formula has a life-world predecessor. In nineteenth-century Germany it was framed in moral language that implied that gender deviants (called Urninge) had the wrong body, given their sexual preferences: "What we do is not false, what is false is our body." At the end of the nineteenth century this sense of wrongness acquired theoretical meaning, with the development of a biological etiology and symptomatology for homosexuals. Finally, since the 1920s, the wrongness has acquired pragmatic meaning with the development of genital surgery. A body now can be experienced as "wrong" because it can be corrected.

The delegation of the problem to medicine has also shifted its controversial character into medicine. The disunity of people in families and at places of work over the gender of an individual became a profound disunity within medicine, which was expressed in heated ethical debates about the legitimacy of genital surgery. The micropolitical conflict about whose gender definition must adapt itself was transformed into a question of medical treatment: whether one should adapt the soul to the body psychiatrically or the body to the soul surgically. And social conflicts about the validity of gender migrants' claims were transformed into theoretical controversies about nosological classification: labeling transsexuality a psychotic condition, a neuroendocrinopathy, a borderline syndrome, or a creative defense mechanism—each implied a political position with regard to the social conflict.

The debates were largely settled in the 1960s with the formation of interdisciplinary treatment programs for transsexuals, where careful selection of candidates was designed to guarantee a successful sex change under medical management (Green and Money 1969). Professionals participating in such programs included psychiatrists, urologists, gynecologists, plastic surgeons, endocrinologists, medical practitioners, voice therapists, cosmeticians, social workers, and legal experts.

In what follows, I will describe some aspects of this treatment program, which I studied in a two-year ethnographic project in Germany. I will concentrate on the three most important medical disciplines, ignoring other professions and some of the local differences. I make use of an ideal-typical description of practices that enables the contrasts and comparisons required for my argument—which can also be spelled out in a myriad of situated events and conversational details (see Hirschauer 1993). My analysis will not focus on the differences between medical actors in, for example, their education, ethos, theoretical views, and prejudices. Instead, my guiding questions are: What are the different praxeontologies of sex and gender that are incorporated in different medical practices of psychiatry, endocrinology, and surgery? And how are these disparate practices linked?


PSYCHIATRY: RECIPROCAL GENDER ATTRIBUTION

Psychiatry's task in the medical management of a sex change is to diagnose transsexuality—not so much for its own therapeutic approach but as a service for endocrinologists, surgeons, and judges. In the case of transsexuality, compared to other syndromes, psychiatrists do not have much to rely on in their diagnosis: the electroencephalograms of gender changers are not noticeably different, psychological testing mostly reveals nothing interesting, and their behavior isn't sufficiently "mad" to be called psychotic.

The diagnostic procedure that was designed to cope with this embarrassing situation consists of a one-year period in which the patients have to live as the other gender—the so-called everyday test—to prove their claim. This is combined with a series of interviews intended to rule out other syndromes and to understand the biographical development of the patients' "personal conflict."

The psychiatrists I studied were fairly nominalist in their attitude to the label "transsexual." They either viewed the decision to label someone as a transsexual as "crucial but simple"—a matter of adding symptoms together—or they were not concerned at all in whether "transsexual" was the right label for a patient. Those who took the latter view were interested in understanding the person's life and focused on the problem of the right treatment for a patient.

Psychiatrists' decisions about whether someone is a transsexual or not are informed by heterogeneous factors, including their experience with different types of gender changers, their detailed knowledge of a patient's personality, or even by their wish to get rid of a difficult patient. But the most important factor influencing their decision is what psychiatrists call their personal conviction that someone is a certain gender. Evidence for this is sought in three ways: through biographical data, through whether the patients pass the "everyday test," and by interactive experience in the therapeutic situation.

First, patients are asked to tell biographical stories that show their longstanding conviction that they are the other gender and have behaved like someone of that gender. Second, patients are called on to solve the problems that come up in their everyday life as they actually live in their new gender; they are urged to show that they "are" the other gender.

The problem with these two approaches is that psychiatrists know very well that gender changers extensively reconstruct their biographies: they create matching stories, conceal much and gloss over problems in their life as the new gender when talking about their experience in the everyday test. In a therapeutic context, doctors can only hope to observe the gradual adaptation of the patients' public appearance to their verbal claims, that is, an increasingly routine gender presentation. But even so there is an additional complexity for—in contrast to everyday relevances in gender diagnosis—a perfect presentation may not convince the psychiatrist. Instead, it may lead to new questions about whether the patient is suffering too little pain for the gender presentation to be a proper proof that he (for example) is really a man. So sometimes psychiatrists are more interested in efforts than in successes as signs of the patient's conviction.

Interaction thus becomes the most important factor for psychiatric diagnosis. To understand what happens it is not enough to look at the presentation and attribution of gender separately. Distinguishing the production of gender signals from their cognitive processing (Kessler and McKenna 1978) will not do. Rather, one has to ask how the participants are able to recognize how they are perceived by their coparticipants: the social reality of gender attribution lies in the gender presentation of the other. This is a bodily account of what the other sees when looking at an individual: his/her own gender, or the other one. This applies both to patients and to psychiatrists: transsexual patients read from the psychiatrist's reactions how they are perceived. And the more convincing the transsexual's gender presentation becomes, the more psychiatrists are drawn into a different perception of their own gender.

If a male psychiatrist, for instance, sits casually and talks with a patient about women (as an absent gender), everyone understands that the patient is a man. If the same psychiatrist starts to flirt and use more polite forms of greeting and choice of words (especially in connection with sexual matters), everyone understands that the patient is a woman. Psychiatrists interactively realize the patients' gender together with their own, and vice versa. This coproduction of two interactive genders remains problematic for a long time. Transsexuals manage to convey their conviction by a permanent and refined imputation that they are convincing. And psychiatrists are constantly trying out the transsexuals' gender in their own behavior. They test whether patients can still be addressed in their old gender or if the imputation of their new gender is strong enough to support the psychiatrists' gender as well. The interaction of transsexual and psychiatrist often leads to situations of great uncertainty and suspicion. These may culminate in situations like the encounter of people unsure of whether they know each other, who communicate with their eyes about what can be seen.

If one puts this subtle interaction into the mechanics of a classification process, the subject and object of classification become blurred. The distinction of sexes in psychiatry, and in any interaction, is a case of classification as self-classification. There are two sides to this: first, the object to be diagnosed suggests how it should be classified. It is not passive, simply receiving judgments, but acts as an active and powerful agent in its own classification: it provides a public appearance and arguments, it begs and urges in endless talk, it works and fights for its acknowledgment.

Second, when classifying a patient as a certain gender, the diagnosing psychiatrists also classify themselves: as belonging to the patient's gender or as being different from it. Treating a patient as a woman, for example, is at the same time a move to distinguish oneself from the patient or to join the patient in a fellowship of gender. Gender diagnosis draws or withdraws a distinction between those who interact.

When they finally diagnose transsexuality in a patient, psychiatrists reconstruct the interactive accomplishment of two genders and the efforts of the object at self-classification as a psychological identity that this individual is supposed to possess—as it is revealed by psychiatric expertise. With this "glossing" diagnosis, patients are referred to endocrinology.


ENDOCRINOLOGY: SEXING FIGURES

Endocrinologists cannot diagnose transsexuality. No test exists to determine the syndrome in patients' bodies. There is nothing measurable. Rather, the only diagnostic task left to endocrinology is to rule out the possibility that transsexuals have any organic pathologies that could make them believe themselves to be the other gender. For example, a patient should neither have a tumor of the adrenal cortex, which leads to abnormal levels of sex hormones, nor an underdeveloped hypophysis with reduced hormone production. In other words, gender change patients should be endocrinologically sound.

This results in a paradoxical position for endocrinologists: in order to turn someone into a woman, the doctors need to know from her hormone level that she is a real man; and they need to know from the psychiatric diagnosis that the same person is really a woman in order to treat her as a woman, that is, with female hormones.

Like the midwife who knows that in order to determine the sex of a baby one must look between its legs, an endocrinologist knows that to determine the sex of a person one must first take some blood. The blood sample has then to be sent to a laboratory, accompanied by a form requesting measurements of the estrogen and testosterone levels.

At the observed laboratory, the incoming sample is placed alongside hundreds of other samples that are to be measured in the same way. They are all centrifuged for approximately fifteen minutes and then a radio immune assay is done. The basic reagents of this biochemical method are supplied by industrial manufacturers of so-called kits. A kit consists of three elements: monoclonal antibodies with a specific binding point; a tracer (a radioactivity-marked hormone); and so-called standards with a known concentration of hormone.

Two further "reagents" of a radio immune assay are supplied by the laboratory itself: they are the prepared blood sample and the laboratory assistants. The latter are each assigned one hormone to test each day. Members of the laboratory believe that this human "reagency" has to be as neutral as possible. In order not to disturb the natural reaction of the chemical substances, the assistants have to follow strict instructions: not to confuse blood samples, to be precise when they pipette, not to overlook hemolytic samples, to make sure that their timing is right, and so on.

The next steps in determining the sex of a patient are as follows: assistants dissolve standards and tracer in distilled water and they pipette fifty microliters of the standard and five hundred microliters of the blood sample into different test tubes. To reduce errors in pipetting, two tubes are filled per sample and the pipetting tip is changed for every sample. The whole set, with its chemical reagents, is then placed on a shaking grate to perform its incubation by itself.

Next, the laboratory staff locate the most important activity within the test tubes. They say that during incubation a competition takes place between the hormone molecules of the blood sample and the radioactively traced hormone molecules. These compete to bind to the antibodies as fast as possible. The more hormone in the blood sample, the more successful it will be in seizing binding points.

After a certain time, the assistants stop this action in the test tubes by placing them in a bath of ice water. Then the test tubes are centrifuged again, the superfluous tracer is decanted, and the test tube is put into a beta counter. The counter sends four-digit figures onto a screen, and a computer converts these into further figures and prints them out in long columns.

Having made figures out of blood, the next problem in endocrinological sex determination is how to make meaningful data out of these figures. There are three steps in their interpretation. First, all reagents in an assay are checked internally by looking at each measurement. The standard curve should be smooth, and the two figures for each sample should show only slight variation. If this is the case, then the figures are taken to be values of sample hormone concentration. However, measurements often have to be repeated the next day to get sufficiently similar figures for a sample.


(Continues...)

Excerpted from Differences in Medicine by Marc Berg, Annemarie Mol. Copyright © 1998 Duke University Press. Excerpted by permission of Duke University Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Acknowledgments
Differences in Medicine: An Introduction 1
Performing Sexes and Genders in Medical Practices 13
Working on and around Human Fetuses: The Contested Domain of Fetal Surgery 28
Clinical Practice and Procedures in Occupational Medicine: A Study of the Framing of Individuals 53
Stabilizing Instabilities: The Role of the Laboratory in the United Kingdom Cervical Screening Programme 86
Inhaling Drugs and Making Worlds: The Proliferation of Lungs and Asthmas 105
Pain Physicians: All Alike, All Different 119
Missing Links, Making Links: The Performance of Some Atheroscleroses 144
Ontological Choreography: Agency for Women Patients in an Infertility Clinic 166
The Architecture of Difference: Visibility, Control, and Comparability in Building a Nursing Interventions Classification 202
Order(s) and Disorder(s): Of Protocols and Medical Practices 226
References 247
Index 267
Contributors 271
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