**4. Sexuality and health**

linked to androgens, which are produced in testicles, in men, and androgens and oestrogen in women, produced in ovaries, as well as testosterone and oxytocin. According to some studies, how we experience sexuality may also be gender-specific, but although the belief that men are more sexual than women, and the principal initiators of sex, while women are more passive, and recipients, is still prevalent in some places, it has become increasingly clear that the differences are differences in the expression of sexuality, which is informed by the culture and social (gendered) roles as well as the expected sexual behaviour for men and women. The belief that women's erogenous zones are more widely dispersed on the body than in men is also prevalent. The way women perceive themselves and their own sexuality is also influenced by prevailing culture – women learn to be passive. They respond to visual and other impulses and become aroused as quickly as men, but being sexually liberated is much more socially acceptable for men. Myths persist about female sexuality in relation to the idea that women

Where do we currently stand with regard to female sexuality, socially speaking? There are, of course, multiple types of discourse, and we can highlight the abuse of female sexuality on multiple levels, including devaluation, objectification, the focus on the physical female body in the media, and the propagating of a certain ideal female appearance, which currently means a slim body with no cellulite and the right curves in the right places, with shifting ideas of how much curviness is still acceptable. In addition, female sexuality is constantly being redefined, still seen as goods to be traded in order to survive, to provide protection or sometimes to climb the social ladder; in traditionalist environments, female sexuality is the expression of a woman's worth or worthlessness, as evidenced by the revival of the cult of virginity, which must be maintained until entering a monogamous relationship [11]. Even today, the myth of supposedly passive female sexuality as opposed to active male sexuality persists in popular culture; at the same time, female sexuality is perceived as mysterious, or demonized and regarded as a threat to men. Messages in the media reinforce the chosen model of female sexuality through culturally selected behavioural patterns for each gender and selected sexually informed images that only emphasise certain kinds of sexual expression. This model is perpetuated through various types of discourse about the necessity of maintaining health, beauty and youthfulness through self-discipline and through the simultaneous popularization

It is vital to continuously recollect relevant thoughts of feminist authors about the female body, sexuality, health, and motherhood, which take issue with the culturally prevalent "selfevident" and "common-sense" concepts of sex, which are frequently based on the idea of duality and opposition and on the inequality and imbalance of both sides: nature vs. culture, woman vs. man, sex vs. gender. To mention some: Simone de Beauvoir, Adrienne Rich, Shulamith Firestone, Gena Corea, Evelyn Fox Keller, Emily Martin, Ann Oakley, and Barbara Katz Rothman. We must work towards fighting this amnesia, for to forget the findings about the cultural basis of the dominant understanding of sex, bodies and sexuality, which are the result of numerous excursions into these topics in history, sociology, anthropology, cultural studies and the social history of medicine (Edward Shorter), the history of the body (Thomas Laqueur), the history of the family and birth (Phillip Ariès, Jacques Gélis) and the sociology

have a greater need to form an emotional bond.

146 Sexology in Midwifery

of the post-modern commandment of "Enjoy yourself!"

Sexuality is also linked to health issues. People have general health needs regardless of gender, but also face limitations on various levels in meeting those needs and providing the optimal conditions to lead a healthy, or, more generally, a comfortable life, including sexuality.

Both genders have specific health needs; however, women's health has an additional dimen‐ sion to it due to their reproductive capacity. Throughout history, women have often been reduced to their bodies and their specific biological capacity for procreation (S. de Beauvoir). According to Edward Shorter, a professor of social history of medicine, in his famous work *Women's Bodies* [12], women were victims of their own bodies for centuries, adding that pregnancy, labour and gynaecological diseases constituted high risks. Women could not live out their sexuality due to dismal living conditions and the risks posed to their well-being or life, which also provided grounds for the oppression of women by men. Women were more vulnerable and therefore more closely controlled due to their potential or actual motherhood. Both the biological capacity of the female body to procreate and the social implications of this are more pronounced and more closely linked to subjugation than the biological and social role played by men in procreation. An influential French historian focusing on the history of women, motherhood and sexuality, Yvonne Knibiehler, points out that mothers, motherhood and the "production" of children are stakes of those of power [13]. Control over female fertility is an excellent example of the domination of one gender by the other from a privileged position of power.

### **5. Knowledge and science about women**

Hatred or dislike of women has formed the basis for sexist prejudice and ideology serving as justification for the oppression of females in male-dominated societies throughout the long history of our culture; as in the first era of feminism and feminist theory, the reconstruction of knowledge is now at the forefront. The female has been the gender more closely associated with physicality throughout history; that is, the idea of the female is less easily separated from the body than that of the male. This is why it is all the more important to evaluate the invest‐ ments of science into the reproductive capacity of women, pregnancy, labour and motherhood, as well as female sexuality. In large part this means reconstructing knowledge about the female body in certain scientific fields and expanding our understanding of multiple links between types of discourse and institutional practices which view the female body through the lens of its sexual and procreative functions.

In particular, light needs to be shed on the way our physical "nature" – an indivisible union of biology and nature shaped by human evolution – is shaped, reinforced or repressed by social conditioning. Most of the time, nature and nurture have simultaneous effects, and the filtering and profiling of what can and cannot be expressed also contributes to every culturally specific definition of male and female sexuality. Carefully thinking about the nature of the physical does away with the expectation that removing historical layers from the cultural conceptual‐ ization of masculinity and femininity should lead us to the (pre-)historical, pure, natural male and female body [14, 15]. The simplified sex-neutral history of the human body needs to be disregarded [16]. Let us introduce our reflections on female sexuality and medicine by paraphrasing the famed phrase "the body has a history" (of sociology of the body) [17] – "the body has a herstory, too". We have to speak about *historicized* bodies. The body is a location of control and the exercise of both social and medical power; the social and the medical aspects frequently cannot be told apart, because the medical point of view, as regards the modern idea of health and the individualization of responsibility for health and illness, is inherently linked to social control over the health of the population(s) [17, 18].

The history of women is characterized by the desire to exercise control over them and their reproductive functions, in different aspects such as pregnancy, childbirth, and mother‐ hood [19-23]. This means, for example, that the patriarchal social order abuses the procre‐ ative capacity of women to create and maintain unjust relationships between men and women. The reproductive capacity of a woman may be turned against her, and she may fall victim to oppression precisely because of this special ability of bearing and birthing offspring. In such systems, the (postulated or actual) specific characteristics labelled as female or feminine, including female sexuality, are underappreciated, degraded, re‐ pressed or entirely overlooked and abused, as well as being given mythical properties [24]. Control over female sexuality is connected to the patriarchal need to establish male control over women's fertility and reproduction on the one hand, and to the attempted control over women's gratification and enjoyment on the other, especially if such enjoyment is specific to women. In its extreme, the control of female sexuality is manifested in physi‐ cal violence: the mutilation of female genitalia, rape (including marital rape and rape in war), brutal punishment of infidelity or sexual activity before marriage, etc. This not limited to violence practised by individual men over individual women; instead, these acts of violence are socially tolerated or even officially permitted as acts aimed at gaining power and consolidating power relations in a community [25].

### **6. Why women, and women in particular, need health care**

Along with benefits for women (and women's health), sexual activity, pregnancy, labour, breastfeeding, menstrual and menopausal cycles also carry risks of a lower quality of life [10]. Half of humankind face specific health issues connected to the biological and sociocultural role of women as key for the proliferation of the species. These issues affect actual mothers as well as women who have no children due to social or personal circumstances. Some of these issues are an added burden on women's health; they may pose a health risk, restrict the maintenance and improvement of health or act as a hindrance to recovery; in extreme cases, they can cause illness, injury or death. Compared to men, women are particularly vulnerable due to their biological capacity in particular. Until recently, they risked their well-being and lives in ways that men did not due to unwanted pregnancies, complications during pregnancy or childbirth, consequences of miscarriages, abortions and other reproductive cycle events – in some places these risks are still significant. These are some of the key social conditions in which women live and which determine their worth, their standing in the family and the community, and their access to basic necessities, including education and health care. But women's sexual and procreative health is also threatened by sexual violence, sexually transmitted diseases, insufficient or inaccessible prenatal care and birth control, inaccessibility of safe abortions, and so on: despite modern social changes, women continue to face more hardship and limitations as regards their personal freedom than men.

In particular, light needs to be shed on the way our physical "nature" – an indivisible union of biology and nature shaped by human evolution – is shaped, reinforced or repressed by social conditioning. Most of the time, nature and nurture have simultaneous effects, and the filtering and profiling of what can and cannot be expressed also contributes to every culturally specific definition of male and female sexuality. Carefully thinking about the nature of the physical does away with the expectation that removing historical layers from the cultural conceptual‐ ization of masculinity and femininity should lead us to the (pre-)historical, pure, natural male and female body [14, 15]. The simplified sex-neutral history of the human body needs to be disregarded [16]. Let us introduce our reflections on female sexuality and medicine by paraphrasing the famed phrase "the body has a history" (of sociology of the body) [17] – "the body has a herstory, too". We have to speak about *historicized* bodies. The body is a location of control and the exercise of both social and medical power; the social and the medical aspects frequently cannot be told apart, because the medical point of view, as regards the modern idea of health and the individualization of responsibility for health and illness, is inherently linked

The history of women is characterized by the desire to exercise control over them and their reproductive functions, in different aspects such as pregnancy, childbirth, and mother‐ hood [19-23]. This means, for example, that the patriarchal social order abuses the procre‐ ative capacity of women to create and maintain unjust relationships between men and women. The reproductive capacity of a woman may be turned against her, and she may fall victim to oppression precisely because of this special ability of bearing and birthing offspring. In such systems, the (postulated or actual) specific characteristics labelled as female or feminine, including female sexuality, are underappreciated, degraded, re‐ pressed or entirely overlooked and abused, as well as being given mythical properties [24]. Control over female sexuality is connected to the patriarchal need to establish male control over women's fertility and reproduction on the one hand, and to the attempted control over women's gratification and enjoyment on the other, especially if such enjoyment is specific to women. In its extreme, the control of female sexuality is manifested in physi‐ cal violence: the mutilation of female genitalia, rape (including marital rape and rape in war), brutal punishment of infidelity or sexual activity before marriage, etc. This not limited to violence practised by individual men over individual women; instead, these acts of violence are socially tolerated or even officially permitted as acts aimed at gaining power

to social control over the health of the population(s) [17, 18].

148 Sexology in Midwifery

and consolidating power relations in a community [25].

**6. Why women, and women in particular, need health care**

Along with benefits for women (and women's health), sexual activity, pregnancy, labour, breastfeeding, menstrual and menopausal cycles also carry risks of a lower quality of life [10]. Half of humankind face specific health issues connected to the biological and sociocultural role of women as key for the proliferation of the species. These issues affect actual mothers as well as women who have no children due to social or personal circumstances. Some of these issues are an added burden on women's health; they may pose a health risk, restrict the maintenance

In traditionalist historiography, medicine was given the role of saviour; medicine was portrayed as key in freeing women from the role of females who need to sacrifice themselves for the human kind to survive [26]. Due to the rise of contraceptives, safe abortion, and hospital childbirth, and the raising of popular awareness about sexual health, medicine has been regarded as a force that freed women from the risks of the unreliable and dangerous repro‐ ductive female body. It is a widely accepted belief that doctors are the only "true" experts on women's health, including sexual health, and that biomedicine is the key to improvement [10].

Globally, we strive to provide all women with optimal health care when they need it, and medicine plays an important part in this. Although medicine has undoubtedly accomplished much to maintain, improve and restore women's health and well-being, we cannot overlook its role in propping up women's unjust, subservient position in society, which is linked to reproductive capacity and sexuality in particular, as demonstrated above.

Do these types of discourse and practice contribute to liberation and the provision of free personal choice? Or do they instead restrict and regulate these, participating in decisionmaking on what is considered good and healthy as regards reproductive life, or risky, pathological or deviant as regards sexuality. As demonstrated by Turner, medical advice on how people should live may function as moral discourse to regulate bodies, control people's everyday life [27], and regulate the "quality" of populations – this is known as "biopolitics", the style of government that regulates populations by applying political power to various biological aspects of human life [28]. This type of medicine is particularly striking in fields like "public health", in measures to "promote health" or "a healthy lifestyle" for pregnant women, in organizing birth care, in the promotion or limitation of breastfeed‐ ing, in regulating how a mother should care for her child, in providing advice on how mothers should raise children, and so on [20, 29].

It must be stressed that when speaking of medicine, what is meant is not a monolithic structure, but rather a patchwork of complex dispersed processes, struggles, contradictions and incon‐ sistencies; this has varying effects on the lives of people, depending on their gender, social status, age, and so on. We differentiate medicine as an institution with certain types of discourse and practice and health professionals. Among these professionals are individuals who may not always hold power, especially when they are women – midwives and nurses are often lower in the hierarchy than doctors, for example. On the other hand, being a woman does not always mean more equal cooperation with other members of health teams and empathy towards patients.
