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. .-.-:-:-:-:-:-:-:-:-:-:-.-.-. . .. -:-::::-:-:-:-:-:-:-:-:-::::::::-:-.- ::--- :::-. ~ .-:-:-:-:-:-:-:-:-:-----------:-:-:-:-:-:-:-:-:-:-: . -:-:-. .-::-:-::::: ::-:: :'::-:-::-. -:-:::::::::::::::-:- :::-. I-:- : - - - :-: - ~:-:: :.: :.! - - :.: : :- -:. - : - .:.-:-- -: - - .. ::- -.-.- .- ' 2----:-.- -:-:--:-- ::: Health Through the Life Span: The Reproduci;ive Years No single event marks the threshold to American adulthood. In many traditional societies, on the other hand, the transition to the status of the fully grown (and fully responsible) adult hap- pens abruptly and in public. Rituals recognizing the onset of menstrua tion, or the attainment of a certain age, or the successful completion of prescribed tasks or trials, or initiation into a secret society, or any of a number of other milestones, have for millennia ushered junior members into manhood or womanhood. Even within living American memory, the formal debut transformed upper-class schoolgirls into marriageable women in a whirl of balls and tea dances. Mere generations ago, an American boy graduated into long pants and an American girl put up her hair and dropped her hemline to mark the passage to man's and woman's estate. But today Americans generally osmose into adulthood, taking on the prerogatives of their majority only by gradual, and often confusing, degrees. We can generally drive, drop out of school, and get a regular job at 16. Most people, though, continue their studies at least through high school graduation at about 18, the age that allows voting, military service, and signing valid contracts. But no one can legally drink until 21, and various states permit marriage at various ages, often different for the two 75

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I N H E R O WN R ~ G HT sexes. Nor does any one of these conflicting milestones in universally recognized maturity. itself confer The cost of post-secondary education often further delays en- tree to adulthood, keeping many people dependent on their families well into their twenties. A tight employment market can do the same, forcing large numbers back into their parents' homes even after earning degrees or credentials that theoretically equip them to make their own way. Mean- while, as they pass all these formal landmarks, American youth, as we have seen, also traverse, each at his or her own pace, an informal curriculum of adult behaviors that includes initiation into sexual activity, and, for far too many, into smoking, drinking, and drug use as well. At various points, young people also pass from the medical care arrangements that saw them through their growing-up years, either out- growing their pediatricians or moving away to campus, military posting, or out-of-town work. Depending on their own and their families' finan- cial, employment, and educational situations, they also eventually lose coverage under their parents' health insurance. What, if anything, replaces it depends on each individual's eligibility in his or her own right to ben- efits from the military, student health services, employers' insurance plans, or public assistance programs. For most Americans, fortunately, this period of awkward tran- sition is also an era of excellent health. The childhood ailments are over, and the commonest chronic diseases and debilities lie decades in the fu- ture. Only violence and accidents, usually involving firearms or motor vehicles, claim substantial numbers of young lives, more often male than female. A MAJOR CHALLENGE This does not mean, however, that women entering or even well into their third decade have no serious health needs. For the over- whelming majority, sexual activity, whether within or without marriage, has become a routine and open fact of life. For at least the next two decades, fertility and its consequences dominate most women's health as well as economic, social, and career concerns. For women, of course, the issue of when and whether to have 76

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C HA P T E R 5 Cal Health Through the Lfe Span: The Repwductive Years children, and then whether and how to raise them, shapes not only physi- cal well-being, but also personal identity, career prospects, and, to a large extent, economic status. The fact, indeed, that childbearing is now an issue, rather than, as it was for millennia, an unavoidable and generally uncontrollable fact of life, indicates the immense importance of the tech- nologies that now allow women lately to shane. rather than merely to endure, their reproductive destinies. ~, ~, The three decades since the introduction of modern contra- ception (which also subsume the two decades since Roe v. Wade over- turned almost all bans on elective abortion) have seen perhaps the most drastic change in gender roles and attitudes in human history. Women on aircraft carriers, construction sites, and the Supreme Court; women as army generals, attorneys general, and surgeons general; women outnum- bering men in newsrooms, elite medical schools, manufacturing plants; women entering every occupation from astronaut to zookeeper this so cial revolution closely followed two other revolutions, the technological one that culminated in the Pill and the judicial one that legalized abortion. It might seem, then, that the miracle of modern medicine has essentially resolved American women's reproductive dilemma, reducing it to a mere personal decision about when most conveniently to have one's desired number of planned children. For millions, though, this compla- cent assumption is far from the truth. Despite their huge strides in the workplace, American women trying to control their fertility face an in- creasingly difficult situation. "Since 1980 the reproductive health status of Americans has deteriorated''' Wymelenberg writes for IOM. "The rates of unintended pregnancy and abortion in the United States are among the highest in the Western world, and our rates for adolescent pregnancy, abortion and child- bearing are the highest. In infant mortality, a key indicator of national health, the United States ranks twentieth among industrialized nations, behind Hong Kong and Singapore. Despite our considerable research resources, American women have fewer contraceptive choices than their European counterparts. More than half the 6 million pregnancies that occur annually in this country are unintended, and half those unintended pregnancies about 1.6 million end in abortion. Meanwhile, concern about infertility appears to be increasing among many men and women.") 77

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I N H E R O WN R ~ G HT A sharp dichotomy between millions who find themselves un- willingly pregnant and countless others who long vainly to conceive hardly indicates a nation in control of its fertility. The spectacle, furthermore, of thousands of newborns needlessly suffering and dying from preventable problems seems alien to a nation blessed with the best in medical resources the world has ever known. And yet the same United States that suffers these ills also gave the world both the Pill and the IUD and has long been at the forefront of both science and practice in obstetrics and pediatrics. As we will explore in later chapters, features of our health care delivery and research systems in large measure account for these medical anomalies. The vast majority of American women and couples seeking the right contraceptive strategy to limit their fertility in fact face a daunting problem even apart from macroscale issues of social structure. Over 95% of the nation's more than 54 million sexually experienced women of childbearing age also have at least some experience with contraception. Over 70% of the married couples in the fertile years use some form of birth control. The Pill is the nation's popular choice, followed by female sterilization, condoms, and male sterilization. "Never before in history," notes IOM's Committee on Contraception about the choice made by one-third of the women at risk for unintended pregnancy, "has a systemic drug such as the oral contraceptive been used so widely on a continuing basis by predominantly healthy women for a protective purpose."2 But the list of choices open to Americans also goes a long way to explaining some puzzling disparities. Only one of the leading methods would seem to meet most people's criteria for a highly desirable contra- ceptive; only one, in other words, is very effective, takes advantage of advanced research, does not impinge on the sexual act, and allows people to change their minds and later become pregnant. And that one, the Pill, requires daily attention and raises safety issues for some individuals. Of the other leading choices, the condom used by 16% of the partners of women who face unintended pregnancy is a crude and ancient device that requires discipline, interferes with pleasure, and depends for its effec- tiveness on users paying meticulous attention every single time. The re- maining two options demand a surgical operation as well as a usually irreversible decision never again to have children. Despite this often dismaying finality, sterilization is still the 78

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C HA P T E R 5 Cry Health Through the Lice Span: The Repwductive Years preference of one-fifth of all the women between 18 and 49 at risk for unintentional pregnancy and 15% of their male partners.3 Indeed, "fifteen or more years after their first marriage," the committee notes, "44% of all women practicing contraception are sterilized, and another 24% are mar- ried to men who are sterilized."4 Why so many more women than men take this step, despite the greater difficulty and danger of the female pro- cedure, probably involves both differences in the strength of one's desire not to conceive and differing notions of manhood and womanhood. Still. between 2 and 13% of women especially those sterilized in their twen ties or early thirties regret their decision within 6 months to 6 years. As many as 8% seek to reverse the operation surgically, but only a minority of these attempts succeed.5 A DEARTH OF OPTIONS These figures, along with the problems that we have already seen facing teenagers who seek suitable contraception, certainly suggest that many Americans have contraceptive needs unmet by any available option. There are only four other readily available possibilities: with- drawal and abstinence, the choice of 5% each; the diaphragm, used by 4 to 6%; the IUD, the choice of 3%; and foams, jellies, creams, and supposito- ries, at about 1% each.6 A new category of long-lasting contraceptives, the subdermal (under-skin) implants, involve placing a unit under the skin to provide a continuing supply of hormonal medication not unlike that found in the Pill. They are highly reliable and protect for months or years at a time, but have thus far been used in this country only on a very limited scale. Like the Pill, the condom, and sterilization, moreover, each of these reversible methods has serious faults for at least some users. The diaphragm and IUD are generally quite safe and effective (and, in the case of the diaphragm, provide some protection from infection), but both require doctor visits and medical supervision that place them beyond the means of some people. The diaphragm must be correctly inserted each time and later removed for cleaning, requirements that many find intru- sive and unaesthetic. The IUD is not suitable for young women before a first birth. The remaining popular methods, though cheap and easily used 79

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I N H E R O WN R ~ G HT without a prescription, are markedly less reliable. The implants require minor surgery for both installation and removal. In short, "every method in use today has drawbacks," the com- mittee concludes, "and collectively, current methods leave major gaps in the ability of people to control fertility safely, effectively, and in culturally acceptable ways throughout their reproductive life cycle."7 Americans face widely varying, and often changing, circumstances. Successful birth control requires contraceptives tailored to the individual's particular needs. As we have seen, teenagers face one set of problems in finding a method that works, and women in other circumstances face different, but equally troubling, obstacles. For example, low-income Hispanic women, con- cluded Scrimshaw and colleagues in a Los Angeles study, have no accept- able method that allows them both to breastLeed and reliably to space their families. They fear the Pill may interfere with lactation, and they reject barrier methods as unsuitable either for their partners or themselves. The IUD has no effect on breastLeeding but does have a high propensity to fail. be expelled, or perforate the uterus when inserted shortly after birth.8 Possible hormonal effects of implants on nursing babies are not known. Advancing age and special health needs also form obstacles to using some of the most reliable methods. The Pill, for example, is less safe for women over 35 or who smoke. Neither hormonal nor intrauterine methods suit those with insulin-dependent diabetes or those with certain cardiovascular conditions; both categories need contraception that neither aggravates their diseases nor raises their risk of infection. And even if a woman is physically suited to a method, her circumstances and skills may not permit her to use it to best advantage. Studies of various developed and developing countries have shown that not all groups, even within the same nation, can use all methods with equal effectiveness. Educated women and those who have all the children they want generally enjoy the greatest success.9 A couple's chances of avoiding pregnancy depend, moreover, not only on their motivation and knowledge but also on the method they choose. Better than 99.5% of sterilized men and women, for example, can rest assured that they will not conceive in the first year after the operation. The same goes for 97% of Pill users and 94% of IUD users. Only 88% of condom users, will succeed, however, and 82% of those depending on the 80

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C HA P T E R 5 Cal Health Through the Lfe Span: The Repwductive Years diaphragm, cervical cap, or withdrawal. Fewer than four-fifths of those counting on periodic abstinence, the contraceptive sponge, or spermicidal creams and jellies used alone will find their faith justified.~ Even though success rates of the various methods tend to rise in subsequent years as users become more expert at using them, the failure rates represent large numbers of lives disrupted by unplanned pregnancies. The average 8% failure rate of the condom, for example (a number that includes both new and experienced users), represents more than half a million American women facing pregnancies they did not intend. In all, contraceptive failure accounts for between 1.6 and 2 million such "acci- dents" each year, and about three quarters of a million abortions. These failures, plus the fact that many women spend substantial periods of time without the protection of an appropriate method, add up to unintended pregnancy for more than half of American women at some time in their lives. "We could reduce abortions in this country by 50% overnight if we had totally successful contraception," says Sheldon Segal, Ph.D., dis- tinguished scientist at the Population Council in New York.~3 "One polio vaccine solved the problem of poliomyelitis," the contraceptive committee observes, "but one contraceptive will never meet all societies' and all individuals' changing needs.... There are important and obvious gaps in the range of available methods. These gaps could be filled, in part, by developing new, safe, effective and acceptable methods tor men, for breastLeeding women, for teenagers, for older women, and for those with particular health conditions."~4 Far from welcoming exciting innovations to the market, though, the American public has actually seen contraceptive options con tract in recent years, as manufacturers have withdrawn products, particu larly IUDs, from sale in this country in the wake of the Dalkon Shield disaster, in which a combination of faulty design and corporate duplicity injured scores of thousands of women and resulted in a financial settle- ment in excess of $2 billion. In addition, "since the introduction of the pill and the IUD in the early 1960s, no fundamentally new contraceptive methods have been approved for use in the United States," the committee notes, although several have become available abroad. Nor does it foresee "dramatic changes" in the years ahead. Although various lines of inquiry may even 81

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I N H E R O WN R ~ G HT tually yield useful results, "one person's promising new development is, for another, a preposterous idea or only a trivial modification."~5 Our nation's relatively dismal contraceptive record cannot be attributed only to lack of methods. Countries that do better than we do in preventing unwanted pregnancies also do better at getting existing prod- ucts into the hands of those who need them. In this country, most women consult obstetricians and gynecologists for contraceptive care; in the more successful countries, family doctors generally provide this service. Here family planning clinics serve those who cannot afford a private physician; in the more successful countries, they specialize in counseling first-time users of many social classes. Here "the choice of a caregiver is determined by the patient's financial state; in other countries, the determinant is the patient's need," Wymelenberg notes. Contraceptives are costly in the United States, but elsewhere they are cheap or free. In other countries advertising, education, publicity, even brochures distributed in drugstores, spread information about sexuality and birth control. In this country, the mass media give low priority to informing the public about contraception. Many schools, too, are constrained in the instruction they offer. This information gap leaves the young and poorly educated largely ignorant of the true risks of unprotected intercourse and the real advantages of effective contraception. It also leaves unchallenged many women's unfounded fears about safety. More than three-quarters of American women, for example, believe that oral contraceptives carry sub- stantial health risks. In fact, however, three times as many Americans 14 per 100,000 die each year in childbirth as die from the Pill. Besides being much safer than carrying to term for the woman under 35 who smokes fewer than 15 cigarettes daily, it also protects against cancer of the endometrium and ovaries, benign breast tumors, ectopic pregnancy and pelvic inflammatory disease advantages that outweigh any cardiovascular risk it may carry. i7 {ERMINATING PREGNANCIES "When a contraceptive fails, whether the man or woman was using it, the health of the woman is put at risk," Segal says. Our nation's high abortion rate clearly mirrors our outsized rate of unwanted preg 82

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C HA P T E R 5 Cal Health Through the Lfe Span: The Repwductive Years nancy, and in both of these dubious distinctions we lead the Western industrial democracies. What distinguishes us is not our level of sexual activity, which varies little among the Westernized countries, but two other equally dubious world records: the low availability of the most effective means of controlling the outcome of that activity, especially the Pill; and the highest percentage of women using no contraception of any developed nation.~9 With 28.5 abortions per 1,000 women per year, we outpace the Netherlands by 500% and rank about midway among the nations that keep accurate abortion statistics, close to Singapore and the former East Germany. On average, American couples want 1.25 children but end up instead with 1.6 kids and an abortion.20 For that procedure, most American women choose first trimes ter vacuum aspiration, a minor surgical procedure. Later terminations re- quire more complicated interventions. All the methods available here can require a woman to wait, sometimes for several weeks, between the dis covery of the pregnancy and the point when it can be safely and effec- tively terminated. As with contraception, many authorities argue, Ameri- cans need a wider range of choices. Any new techniques, however, must consider "both moral and physiological ideals, as well as psychological concerns," states Etienne- Emile Baulieu, M.D., Ph.D., of the Faculte de Medecine Paris-sud in France. "For centuries, abortion has been not only a morally difficult event for women, but also a physically painful and often dangerous proce- dure." Thus, any "medical means for pregnancy termination should di- minish this threat to women's health" as well as "allow them to maintain their dignity."2i What's more, "the beginning of pregnancy is now understood to be a progression of steps" rather than a single event as formerly thought. Physicians and lay people had once believed that the moment when a woman first felt her fetus move, an event traditionally known as the "quickening" (literally "coming to life"), marked the actual change of a previously inert mass into a living creature. Today we know that two gametes merge into a single-celled being that multiplies, travels, embeds itself in the womb, changes form, and grows into a person able to live outside the mother's body through a number of stages separated by no sharp breaks. This process can therefore be halted at a number of points 83

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I N H E R O WN R ~ G HT both before and after fertilization. Thus, "the distinction between abor- tion and contraception has lessened," Baulieu notes.22 In light of all these issues, "to develop a medical tas opposed to a surgical] method was a must in terms of women's health and potentially a step toward more privacy for those having taken the difficult decision of pregnancy termination."23 Baulieu and others thus sought a method "that . . can Provo. ce pregnancy ~nterruphon . . . as soon 1 1 1 r .1 1 1 as possible after preg nancy nas occurred, Before tne worn abortion Is appropriate."24 In addi tion, they wanted something "safer than surgical technique" and "rela tively convenient and cheap (no anesthesia, no operating room)."25 The drug mifepristone, more commonly know as RU 486, fulfilled these requirements so strikingly that it "immediately got the nick- name 'abortion pill,' despite the many other potential medical uses already predicted when the compound was announced" and which ultimately came to realization.26 Given along with the compound prostaglandin, it counteracts the body's own progesterone, a hormone essential to main- taining early pregnancy. "Almost a decade of research is now available" on this action by RU 486, notes the IOM's Committee on Antiprogestins (the technical name for this class of drugs). "Drug regulatory officials in France, Sweden and the United Kingdom" have found it a "safe and efficacious medical treatment for early pregnancy termination."27 But not, as yet, in the United States, where the controversy over abortion created a climate that discouraged the French manufacturer, Roussel-Uclaf, from entering the U.S. market. In an April 1993 Execu- tive Order, President Clinton called for research into uses of the antiprogestins. With RU 486 now licensed by Roussel to the Population Council, an American nonprofit organization, FDA approval is antici- pated in 1997. "As a pharmacological class, the antiprogestins appear to have great potential as regulators of reproductive potential," the committee continues.28 In addition to facilitating first trimester abortions, possibilities include use as a "morning-after pill," to provide retroactive contraceptive protection; and to promote cervical ripening, whether for late-trimester abortions, termination of dead fetuses, or induced deliveries at full term. Much broader uses also wait to be explored, including promising leads in treating endometriosis; fibroid tumors of the uterus; breast cancer; tumors 84

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C HA P T E R 5 Cry Health Through the Lfe Span: The Repwductive Years of the membranes around the brain; and Cushing's syndrome, a disease of the adrenal gland. INFERTILITY While the fear of unwanted pregnancy bedevils tens of millions of Americans, other millions struggle with the opposite problem: inability to conceive or bear children when they wish or, in many cases, ardently crave to. Doctors consider a couple infertile if they do not conceive in a year of unprotected intercourse or if they do conceive but cannot carry a baby to term. At least 2.3 million married couples 1 in every 12 in the nation experience this frustration. The overall infertility rate has fallen somewhat in the last 30 years, most markedly among families that already have at least one child and desire more (a condition known as secondary infertility) .29 The same period, however, has seen almost a doubling of young women unable to have a first child. At least 7% of 20- to 24-year- olds, the group that bears a third of all babies born in this country, now suffer from this so-called primary infertility, mainly because diseases like gonorrhea and chlamydia are so widespread among today's sexually very active young people. Infections often picked up and possibly even dis- covered, treated, and cured in adolescence or the very early years of adulthood thus can leave lifelong physical and psychological scars. Second only to the common cold and influenza in frequency, these two diseases account for almost 40% of infertility in this country.30 The total number of involuntarily childless couples has also doubled since 1965 to 1 mil- lion.31 Ninety percent of infertility arises from some cause that doctors can pinpoint, and half of couples receiving fertility treatment do succeed in conceiving at least once. Most of those go on to have a child.32 The hunt for an answer generally starts with the woman's doctor, either a family practitioner or a gynecologist, the specialty that does about 80% of basic infertility treatment.33 A urologist usually checks the man for prob- lems. If these efforts do not produce results, the quest often leads next to physicians, practices, or clinics specializing in infertility, frequently highly expert teams at medical schools or major hospital centers. 85

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I N H E R O WN R ~ G HT in a later chapter, reasons that have as much to do with the welfare of insurance companies as of women and infants. Whether women delivering by cesarean make a more difficult transition to motherhood than those who deliver vaginally is not clear. It is obvious, however, that many women, no matter how they delivered, do find this major life passage quite stressful. Some 10% suffer a depression following childbirth that is severe enough to interfere with their daily lives.55 This so-called postpartum depression can involve either unipolar or bipolar disorder. Though most of these depressive episodes pass quickly, some last as long as two years. And even after their depression lifts, some new mothers continue to have difficulty with mood. Women who have not suffered other depressions unrelated to childbirth seem to have the best chance of full recovery.56 MENTAL DISORDERS w ~-- r Depression, whether technically "postpartum" or not, is a much Or problem for women than for men during the reproductive years, notes the IOM's Committee on Health and Behavior, and most "particu- larly for mothers and young wives."57 Is it biochemistry or bawling babies that afflicts them? Like puberty, the era of early marriage and young children combines rapid hormonal changes with drastic and often abrupt transformations of a woman's self-image and expectations. Once again we are left to ponder the relative contributions of hormones and the stress of trying to fulfill demanding and often conflicting roles. With many moth- ers holding down tiring jobs both inside and outside the home, with high- quality child care still an expensive and hard-to-find necessity, with grow- ing numbers of women raising children on their own, the sources of depression, anxiety, substance abuse, and other mental disorders present little mystery. Among adults, alcohol is the most common drug of abuse, although the binge drinking of youth drops off for both genders as people take on the responsibilities of adulthood. Marriage in particular seems to have a sobering effect. "In the aggregate," remarks Kaye Fillmore, Ph.D., of the Institute for Health and Aging at the University of California San Francisco, "men and women seem to waltz or foxtrot or jitterbug across 92

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C HA P T E R 5 Cal Health Through the Lfe Span: The Repwductive Years the life course in tandem by age with respect to their main drinking patterns." When one gender's average intake increases or decreases, so does the other's. At no point, however, does "women's drinking level exceed that of the men's."58 In particular, women between 25 and 34 generally drink quite moderately, a finding that holds across "culture and history," Fillmore adds, "suggesting the influence of childbearing and childrearing."59 Some women do, however, either begin or continue drinking to excess. An important precipitant appears to be divorce. For reasons still not entirely understood, furthermore, the number of young women in alcohol treatment programs has risen noticeably in the past 15 years. About a third of Alcoholics Anonymous members are now female, a rise over former years, when the fellowship was over~vLelmingly male. Even so, experts believe women are still underrepresented in treatment; twice as many males as females appear to abuse alcohol, but four times as many come forward to seek treatment. A stigma much stronger than that for men, including an ancient association of female drunkenness with loose sexuality, seems to keep many women from coming forward for help.60 Still, chemically dependent women need treatment as much as men, and possibly more. As we have already noted, many more females than males suffer severe depression along with alcoholism. Indeed, among women seeking alcohol treatment in this country, "the two phenomena go hand in hand," according to Fillmore.6i Liver disease also constitutes a more serious threat for women drinkers, and many more have unstable marriages, partners who themselves drink, or families unsympathetic to their treatment. Their self-esteem is lower than drinking men's, their child care responsibilities heavier, their families of origin more chaotic. Many more of them have suffered sexual abuse and tend to turn to the bottle in the face of life crises.62 Despite these very particular and pressing feminine needs, how- ever, most of our methods for treating drug and alcohol abuse "were developed by working with men," says Beth Glover Reed, Ph.D., of the University of Michigan School of Social Work.63 Indeed, it was recover- ing men in self-help groups, rather than professionals in clinics, who evolved the model that dominates chemical abuse treatment today, the highly successful 12-step programs. Informal, anonymous fellowships of 93

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I N H E R O WN R ~ G HT male alcoholics shared and analyzed their mutual problems and gradually built up a body of literature and lore that they found helpful. From this history, Reed believes, arose ideas that reflect masculine rather than femi- nine realities. Indeed, the very conceptualization of the problem with "its violence, its crime, its drunk driving and work disruption and product disruption by people who are high or drunk on the assembly line," in- volves "things that happen more often in men."64 The key concept of denial, for example, viewed as a major impediment to recovery, "psychodynamically . . . really means the sup- pression of any kind of negative affect in a very simplified way." Though perhaps prevalent among men, and perhaps reflecting male coping styles, the rejection of one's own feelings of distress does not square with the "very high depression and anxiety scores" seen among chemically depen- dent women.65 Enabling, another key concept from alcohol recovery groups, is "getting picked up by a lot of drug programs and more generic pro- grams" as well, Reed notes. "A mixture of behavioral theory and social 1 '' 1 1 1 1 1 1 1 systems theory, it denotes practices by the people close to the substance abuser that "enable" the abuse to continue: making excuses for the alco- holic, supplying money, ignoring clues of alcoholism, setting right the intoxication's disastrous consequences, accepting promises that similar ca- tastrophes "won't happen again." Such behavior, Reed suggests, is not inherently alcoholic but rather "gendered. I'm using a women's studies term here on purpose," she explains, "in that much of the way we think about these problems is confounded with male gender role." Progress in recovery can only begin when "enabling" ceases and the addict is forced to face the consequences of the addiction. A woman, it seems, and a wife or mother in particular, is much likelier than a man to "stand by" an addictive family member, doing what she can to hold her home together a model both of feminine nurturance and loyalty and of classic "en- abling."66 And, indeed, research among HIV-positive users of injection drugs finds that mothers and other female relatives continue to provide material and emotional support. The uninfected female partners of HIV- positive men often even permit their sexual relationships to continue.67 94

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C HA P T E R 5 Cal Health Through the Lfe Span: The Repwductive Years WOMEN AND AIDS To all the damage that drugs and alcohol have done to women's bodies, minds, and spirits over the centuries, the past decade has added a new and yet more terrible danger. Drug addiction, whether a woman's own or her sexual partner's, now serves as a major route of HIV infection. Intravenous drug users can, of course, catch the virus directly from con- taminated needles, an ever-present risk among the many addicts who rent "works" in "shooting galleries" or who consider sharing them among friends a sign of trust and solidarity. Because crack cocaine is smoked, it does not expose its users directly to the virus. But the "crack house," where many addicts go both to buy and to use the drug, is generally a scene of uninhibited and anonymous sexuality. In these squalid surround- ings, female addicts often trade sex either for money or for the "rocks" themselves. Worldwide, more than 3 million over~vLelmingly young women now have the HIV virus. In large cities in this country and throughout the Americas, Western Europe, and sub-Saharan Africa, more women between 20 and 40 now die of AIDS than of any other cause.68 Though women still constitute a small proportion of American AIDS cases, their share is rising rapidly, and fastest among African American and Hispanic heterosexual women and injection drug users.69 Sex has now overtaken the needle as the main vehicle of direct female contagion. Women find themselves in special jeopardy because very few have any means of defense against the virus that is wholly under their own control. Contraceptives that do not impede male pleasure, such as spermicides, sponges, and diaphragms, do not significantly impede HIV either. The one device definitely shown to make sex safer though not, of course, wholly safe is the condom, little help to many women. Not only does proper use cut down on many men's enjoyment, it also requires their active cooperation right in the midst of intercourse. Public health campaigns have concentrated on exhorting people to insist on condoms, but the scanty research that exists on sexual practices among groups at high risk for HIV indicates that use is not generally a strictly individual decision, nor one that women can very often effectively influence. Rather, found IOM's Committee on Substance Abuse and 95

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I N H E R O WN R ~ G HT Mental Health Issues in AIDS Research, consistent condom use is "a characteristic of social relationships rather than an individual attribute." People sometimes used them and sometimes did not, one Brooklyn study showed, depending on whom they were with, how they felt, or any one of a number of unknown factors.70 In general, only about two-thirds of drug injectors infected with HIV consistently used condoms during sex with non-drug users.7i Condom use in the general population is probably a good deal lower even than that sorry figure. Fewer than one-fifth of those with multiple part ners, and about 10% of those whose partners are known to be risky, use condoms every time.72 Adding to the danger of unprotected sex are the other venereal diseases and infections that help speed the virus's passage from person to person. Widespread where condom use is scarce, syphillis, gonorrhea, herpes, and genital warts all increase a person's likelihood of picking up the infection during vaginal or oral sex, as do the burns and sores that often afflict the mouths and lips of crack smokers.73 Americans simply do not seem to have generally adopted the condom habit. Indeed, the AIDS committee observes, "Many of those at risk for HIV infections whether through sex or drug use do not recog- nize the danger they face." What's more, "even when they do, knowl- edge alone is not enough to effect behavior change to reduce their risks."74 In the poor minority communities where HIV is spreading most rapidly, knowledge may be essentially irrelevant to a woman's fate. The theoretical models that have shaped our national approach to AIDS education assume, in the committee's words, "that individuals are acting in an intentional and volitional manner" when having sex; that, in other words, they voluntarily and knowingly choose to take part and have some control over their actions.75 Clearly, for large numbers of women, this assumption drastically distorts reality. We saw in the last chapter how even well-educated girls come to sexuality poorly equipped to influence male decisions; how much worse is the bargaining power of poor, badly edu- cated ones! And in the life-and-death negotiations surrounding exposure to HIV, various subgroup customs severely increase women's already dan- gerous disadvantage. In certain cultures, Scrimshaw reports, including some promi- nent in the United States, a woman does not "have a choice on sex when 96

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C HA P T E R 5 Cal Health Through the Lfe Span: The Repwductive Years tshe's] tired" or at any other time she does not wish to satisfy her man's desire. Some Latin American women, she continues, use the expression " 'Abuso del hombre,' which means 'abuse by the man,' tas a] euphemism for sex. Or, 'me uso anoche' Which means] 'he used me last night,' is a euphemism for saying 'we had sex last night.' ''76 Women's " 'permanent inequality' in status and power" separates many of them from their men and undermines their freedom of action, the AIDS committee observes.77 When sex is a masculine prerogative, tradition generally also dictates that "women should not initiate discussion of sexual practices or try to change their male partner's sexual behavior," the AIDS committee goes on. A man may well see a request that he use a condom "as an act of distrust and suspicion, rather than an act of caring, respect and mutuality" as portrayed in the public health campaigns.78 What's more, "violence and abuse are a daily reality in the lives of many addicted women and among women with male partners who are addicted." Recent research even "suggests that fear of the partner's anger" should the subject of protection arise strongly influences "condom use among Hispanic/Latina women." In a stunning understatement, the committee concludes that to stem the spread of AIDS, "programs that highlight the importance of open com munication between women and their partners . . . may be of limited value."79 If culture does not allow women to defend their health, then technology in the form of some protective barrier that women can con- trol and men will accept may be the only hope. A "female condom" marketed under the name "Reality" came on the U.S. market in January 1994. Composed of a plastic sheath held in the vaginal canal by a pair of plastic rings, it combines features of the diaphragm and the condom and overcomes several of the important objections to the familiar male device. The woman can insert it before intercourse, rather than having to inter- rupt lovemaking. Lying loosely inside the vagina, it interferes less with male sensation, breaks less often, and covers a greater portion of the fe- male tissue exposed to STD infection. Nor need it be removed immedi- ately after ejaculation. Indeed, limited testing shows that both women and men, including commercial sex workers and their clients, find it more acceptable and feasible than the alternative device. Despite these "promis- ing results," however, the AIDS committee notes tnat research nas not yet 97 .. . . .

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I N H E R O WN R ~ G HT definitively proven Reality's effectiveness as either a contraceptive or a barrier against infection, nor is it yet widely available in the United States.80 Nor, of course, does such a device offer any relief to the many women, mostly Hispanic and African American, already infected, nor to the children they continue to bear. For many poor women, the AIDS committee believes, "the role of mother is the primary pathway to greater social status and respect in their communities. Particularly for those women devalued" by their status as drug users, motherhood "takes on added importance." A woman "torn between the value placed on children and motherhood and the possibility that the child may be born HIV positive" has little chance of succeeding at contraception.8i Then, when her own infection erupts into full-blown AIDS, she finds herself both "consumed with worry" over the care of her chil- dren after her impending death and "less likely to have the support of a mate" than women without HIV. Should the children also have the virus, their often desperately ill mother has the additional concern that they "may suffer even greater discrimination" in the already overburdened foster care system. With a support network "more constricted than that of other AIDS patients," this hapless soul must also contend with poverty that keeps her from both "obtaining the expensive drugs needed to treat AIDS" and "traveling long distances for the limited amount of care that may be available."82 For women, then, HIV and AIDS present dangers, issues, chal- lenges, and needs quite unlike those facing men. Scientific assumptions based on masculine circumstances that an individual can control the terms of sexual contact, that the possibility exists of protecting oneself, that a support system will step in to provide care during illness are jeop- ardizing the health of countless women and their children. Only through a drastic rethinking of our approach to the disease and its spread can we hope to alleviate vast future female suffering. MOVING ON As American women move into their forties, the great majority have completed their families. They have also, often unwittingly, made decisions that will affect their health for many years ahead, just as decisions 98

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C HA P T E R 5 cry Health Through the Lice Span: The Repwductive Years made in childhood and adolescence have already helped shape their adult lives. The timing of a woman's children, for example, influences her risk of breast cancer, which starts to rise slowly in the fifth decade and then more rapidly in the decades beyond. For all its sociological drawbacks, childbearing before 20 does bring at least one advantage, albeit a benefit that hardly outweighs the costs in lost opportunities. It markedly reduces breast cancer risk. Waiting until 30 to give birth, an increasingly common choice among the edu- cated, on the other hand, raises this risk, as does having no children at all. One's choice of contraception can also affect future chances of disease. The Pill and other hormonal types protect against ovarian cancer. Barrier types like the diaphragm and the condom cut down on sexually transmit- ted diseases. Having had many lovers has the opposite effect and also raises the risk of cervical cancer. A woman who has been physically active, kept her weight under control, and eaten sensibly has also cut her risks of osteoporosis, heart disease, and reproductive cancers. Whatever health choices a woman made in the early stages of her life, as she moves into middle age, she will soon begin to see the rewards or errors of her ways. NOTES 6. 12. 13. 14. 15. 16. 17. 1. Science and Babies: Private Decisions, Public Dilemmas, 1-2. 2. Developing New Contraceptives: Obstacles and Opportunities, 14. 3. Ibid. 4. Ibid., 20. 5. Ibid., 20-1. Ibid., 19-20. 7. Ibid., 13. 8. Ibid., 26-7. 9. Ibid., 22. 10. Ibid. 11. Ibid., 22-3. Science and Babies, 44. IOM 1992 Annual Meeting, 139. Developing New Contraceptives, 28. Ibid., 30. Science and Babies, 60. Ibid., 57. 18. IOM 1992 Annual Meeting, 137. 19. Science and Babies, 7. 20. Ibid., 53. 99

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I N H E R O WN R ~ G HT 21. Clinical Applications of Mfespristone (RU 486) and Other Antiprogestins: Assessing the Science and Recommending a Research Agenda, 72. 184. 22. Ibid. 23. Ibid., 92. 24. Ibid., 72. 25. Ibid., 92. 26. Ibid., 93. 27. Ibid., 6. 28. Ibid., 3. 29. Science and Babies, 15. 30. Ibid., 19. 31. Ibid., 15. 32. Ibid., 5. 33. Ibid., 18. 34. Ibid., 21. 35. Ibid., 21-3, passim. 36. Ibid., 36. 37. Ibid., 98. 38. Ibid., 97. 39. Ibid., 96. 40. Ibid., 98. 41. Ibid., 107. 42. Ibid., 97. 43. Ibid., 105. 44. Medical Professional Liability and the Delivery of Obstetrical Care, Vol. II, 34. 45. Healthy People 2000: Citizens Chart the Course, 171. 46. Access to Health Care in America, 52. 47. Medical Professional Liability, Vol. I, 26. 48. Science and Babies, 107. 49. 50. 51. 52. 53. 54. 55. 56. Nutrition During Pregnancy, 51. Medical Professional Liability, Vol. II, 28-30, passim. Ibid., 30. Ibid., 28. Ibid., 32. Ibid., 34-5. Reducing Risks for Mental Disorders: Frontiersfor Preventive Intervention Research, 65. Assessing Future Research Needs: Mental and Addictive Disorders in Women (Transcript), 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. Ibid., 95. Health and Behavior, Frontiers of Research in the Biobehavioral Sciences, 165. Assessing Future Research Needs (Transcript), 129. Ibid., 130. Broadening the Base of Treatmentfor Alcohol Problems, 356-7. Assessing Future Research Needs (Transcript), 131. Broadening the Base of Treatmentfor Alcohol Problems, 357. Assessing Future Research Needs (Transcript), 243. Ibid., 243-5. Ibid., 244. Ibid., 242-3. AIDS and Behavior: An Integrated Approach, 91. Ibid. 100

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C HA P T E R 5 Cal Health Through the Lfe Span: The Repwductive Years 70. Ibid., 71. Ibid. 72. Ibid., 83. 73. Ibid., 50. 74. Ibid., 83. 75. Ibid., 7. 76. Scrimshaw (1991), 24. 77. AIDS and Behavior, 96. 78. Ibid., 92-3. 79. Ibid., 96-7. 80. Ibid., 112-3. 81. Ibid., 97. 82. Ibid. 101

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