Intimate Wars (9 page)

I knew that many doctors had a deep commitment to women and their reproductive health
.
They had seen firsthand the results of illegal abortion. Most knew that whether abortion was legal or not, women would move heaven and earth to have one if needed, and often lose their lives in the process. Some had a political commitment to the issue and
felt that abortion should be an integral part of women's health care. Others saw it as a good way to earn extra money. The stigma that has come to haunt abortion providers had not yet fully materialized, so there was little deadly social drawback to offering abortions as part of their practice. Whatever their reason for getting involved, most doctors who did this work saw abortion services as an integral part of women's reproductive lives.

But sometimes it was the most committed of the physicians who were the most misogynistic—though they never saw it that way themselves. They were just doing what they had been taught, and at that time being a male doctor meant being in charge, in control of the interaction and the procedure. Doctors were members of a brotherhood; their authority, power, and good intentions were never questioned by anyone, including themselves. I began to grasp that many of the good-hearted male doctors supporting the clinic didn't see abortion in the context of a woman's right to control her reproduction, and thus her life. It was more of a way for them to control women's messy, complicated bodies.

Often, the problem started early. Most women were examined by a man before they had intercourse with a man. Even in that time of liberation, women held too much of the shame and fear that the previous generation had felt with regard to their bodies, especially their reproductive systems. Being a woman meant you were immediately pathologized, that control over your body was not in your hands. Menstruation, sex, pregnancy, abortion—everything had to be explained by doctors.

With her doctor, a woman had her first vaginal examination, chose a contraceptive device, was guided in her decision about whether to bear children, how to bear them, how to raise and feed them. Women were completely dependent
upon the doctor's knowledge and in a sense forced into a position of trust. All this resulted in women remaining powerless and having things done
to
them rather than
with
them.

And yet, abortion clinics were poised to be platforms for change. This new field of medicine provided the opportunity for a restructuring of power dynamics and a woman-centered approach to medical care. In the early 1970s, many minority and special interest groups were exploring their own histories and asserting their rights. Acknowledging patients as a class with rights and responsibilities seemed to me an appropriate analytical and political vehicle for combating the victimization of female patients by a generally male medical establishment. The most radical aspect of abortion—then legal in just a few states, but soon to be legal nationwide—was the potential for women to turn this situation on its head.

Clinics like Eastern Women's Center and CRASH, the two largest for-profit New York facilities, caught onto this trend and put “chicks up front” to give the impression that their clinics were women-run even though they were actually owned and controlled by male doctors. But at Flushing Women's I implemented policies that would truly put the patients' interests first.

To start, I made sure patients were never left alone with the doctor. A counselor or I stayed with the women throughout the entire procedure, fielding their questions and making them comfortable. I was especially good with hostile patients who would answer a question with, “It's none of your business,” or “Who the hell are you to tell me”—the ones who had an innate distrust of authority.

Thinking that casual humor helped relax patients, some doctors would make blatantly sexist remarks. “Come on, you knew how to spread your legs before you got here, you can spread them for the exam,” a doctor once chided. Another
commanded a patient to keep still, saying, “Keep your backside on the table—you should know pretty well how to do that by now.”

These types of remarks, betrayals of the trust that I had established with the patients, infuriated me. My clinic was supposed be safe from misogyny, not another place where women were attacked at their most vulnerable. When problems occurred, I would speak privately with the doctor involved. If I witnessed an instance of disrespect, I worked to neutralize it.

I realized that restricting the roles of doctors was the realistic way to facilitate productive ties between the established male medical hierarchies and my patient-centered philosophy. Rather than expecting them to consistently provide emotional support for the patients in these intense, anxious situations, I put counselors in charge of educating and psychologically supporting the patients. The doctors had only to perform the procedure, and the support staff took care of the other equally important needs of the patients.

The necessity of these counseling sessions, these safe spaces for patients, was instantly obvious. Women didn't know how to process what was happening to them, how to organize the confusing thoughts they faced. Because this was the first time many of them had been in a room with someone who was totally focused on them, they spilled out so much of themselves: their relationships with their parents, distress over their boyfriends, fears about the future. We helped them articulate to a stranger, something that they had never verbalized—why they did not want to be pregnant. To us, they admitted that they did not want to be mothers; that they wanted, needed, to have an abortion.

Some of my counselors felt it was necessary for an abortion counselor to have had an abortion to be able to relate to
patients. In the early seventies, many feminist centers were practicing a form of peer counseling called consciousness-raising; women would meet in small groups to “rap” about their experiences under the assumption that the leader or facilitator of the group should be someone who had experience with the particular demon at hand. Women had previously been isolated from each other, and much importance was placed on being able to relate to one another as individuals who had experienced the same problems. This rationale was also operative in gender differentiation among physicians: some people requested women doctors, thinking that only females could relate to their problems.

There is of course some truth to gender generalizations; after all, a man will never know what it is to put his legs in gynecological stirrups. But to my mind this thinking is too limiting. Doing an abortion is a technical procedure. There is no difference between male and female physicians' ability to dilate a cervix or perform an extraction. In the seventies women had become physicians in a very male-dominated field, and their behavior and attitude could be just as negative as that of men. The power lay in making sure that patients were treated by compassionate people, no matter who performed the actual procedure.

Counselors had the ability to shape each patient's trust, which could be made or broken by the right words or the wrong information—a huge responsibility. In those early days there were no codified narratives, no context to help women process their feelings about having an abortion. It was up to the counselors and me to define new models. I developed a counseling manual to train and teach others as I learned more about what worked. We explained the abortion procedure, answered the patients' questions about sex, pregnancy, and side effects, discussed other options besides abortion,
and taught patients about birth control, centering on the three main options available to women at that time: the Pill, diaphragms, and IUDs. I eventually wrote a pamphlet to distribute at each counseling session. It introduced patients to the importance of what I called ESP—effectiveness, safety, and personality—in determining which method to use.

I knew that patients in any doctor's office were usually too intimidated to ask the questions we answered in the counseling rooms. Women were rightly afraid of upsetting or angering their physicians, these men who had life-and-death power over them—a power they would not voluntarily surrender. As Frederick Douglass said, “Power concedes nothing without a demand”; it had to be taken back by the patients. Because I knew how very difficult this could be, I suggested they bring a friend who could be there as a witness, or a tape recorder so that nothing the doctor said would be lost on the patient in her flood of anxiety. I wanted to reduce the amount of iatrogenic pregnancies, to rescue these women from the ignorance and prejudice of their doctors, but I could not be with them for every appointment. Each one of them had to be a warrior on her own.

Immersed in the world of Flushing Women's, balancing my drive for power with my empathic connection and compassion for my patients, I came face to face with the questions abortion forces us to ask about women's reproductive freedom. My anger at what was happening grew. The metaphoric role of physicians as surrogate fathers and deities resulted in them communicating in a kind of code, a language that only the members of the brotherhood spoke and understood. And they were communicating about women. Making decisions for us. I viewed this as a violation of their oath “to do no harm,” a betrayal of trust, and ultimately a dangerous situation for women.

Women's health needed a reformation, a
95 Theses
to translate the language of medicine so that women would be able to make choices about their own health. By teaching women about their bodies, by sharing this sacred knowledge, it would be possible to transfer some power to the patient.

Yes, that was it: patients needed their own bill of rights. Doctors needed to know what these rights were, too—and at Flushing Women's, they'd better learn to respect them.

Flushed with frustration after hearing yet another horror story from one of my patients in the counseling room, I arranged for one of the counselors to stay with her while I rushed to my desk and started to write, my anger spilling out into my pen.

 

Patients have rights:

In order to help people visualize this philosophy I created a poster with the image of god (à la Michelangelo's Sistine Chapel) shooting RX thunderbolts from the sky at patients on the ground holding placards with quotations from my Patients' Bill of Rights. I had it replicated and sent to all the HIP medical groups throughout the city. My referral sources, the social workers in the HIP groups, were generally sympathetic to me, and they tacked my posters up in their clinics and offices.

Needless to say, it created quite a scandal. Doctors tore them off the walls.

Marty was challenged at a board meeting as to why these kinds of political propagandistic posters were being posted. Many doctors found it extremely threatening, and the idea that it was mounted by staff without asking permission from the medical administration of the groups was unheard of. It must have appeared to them to be some kind of insurrection.

Marty was bemused by the entire thing. On the one hand he was extremely proud of me, and liked being the enfant terrible by proxy, but on the other, he could not afford to
alienate board members. I was allowed to hang posters at Flushing Women's, but I could no longer distribute them to other HIP offices.

Witnessing their outrage, I was ever more certain I'd hit upon something true. The concept of women as consumers of medical care rather than passive recipients of treatment—the awareness that women's holding to traditional relationships with physicians was ultimately destructive to them individually and as a class—led to my formulating and expanding on a philosophy that would soon become a movement. I called it Patient Power.
⁴

 

IN 1973, the historic Supreme Court decision
Roe v. Wade
legalized abortion for the entire country. For the first time, female patients were given equal power in decision making with their physicians for a particular medical procedure.

What I had experienced with Flushing Women's in New York became true on a national level. The legalization of abortion brought women out of the bloodstained back alleys that had been their medical habitats for hundreds of years. It thrust abortion into the traditional American medical system of health care, yet, because of its highly politicized nature, it created an entire health care system of its own—one that was to be the forerunner of new ambulatory care models.

The Supreme Court decision, in essence, initiated the women's health movement as a defined phenomenon. It created a visible, observable, demanding reality: the reality of the female medical consumer. Millions came out to access gynecological and abortion services. The reformation had begun, and women began connecting with each other, sharing the fears, anxieties, and challenges of being a female patient. People were aware of the need for change, and others, particularly certain religious groups, became active in resisting it.