Am I Still a Woman? Hysterectomy and Gender Identity

Sex Roles: A Journal of Research,  Jan, 2005  by Ann Rosen Spector

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Am I Still a Woman? Hysterectomy and Gender Identity. Jean Elson, Philadelphia, PA, Temple University Press; 2004. 254 pp. 59.50 cloth, 19.95 paper.

Women's reproductive capacity has a relatively clear beginning, middle, and end, demarcated by menarche at one end and menopause (natural or surgical) at the other. That is the biology of being female. How women feel about those transitions is both cultural and individual; they are influenced by a host of demographic and social factors including social class, religion, fertility history, marital history, educational and occupational roles, as well as time and place.

The title of the book, I thought, should reflect the complex differences between the biology of reproduction and the personal and social components of gender as understood by women who undergo hysterectomies--perhaps it should be "Am I Still Feminine?" Author Jean Elson said that the

     women I interviewed continuously cross back and forth between the
     boundaries of woman as sex (biology) and as gender (social and
     cultural prescriptions) (p. 11)

Her analysis must therefore reflect and clarify the multiple ways women reflect on their experience of surgery, and her discourse should have added the clarity.

Elson asks, "Do all women feel the same way about their hysterectomies?" The answer, predictably, is "No." In her own words, her "research indicates that [the] objective criteria do not always predict which women will be most emotionally affected by the loss of their wombs" (p. 122). It might have been groundbreaking even to ask that question 25 years ago, but it seems far less so today. There have been numerous other studies of women asked the same questions about aspects of their reproductive lives. Thus, rather than breaking new ground, this book echoes the work done by many scholars since the 1960s.

Through her interviews, Elson elicits a range of responses including "perceived loss, stability, or enhancement" (p. 2); that is, she finds an expected continuum of answers. The group is a small "convenience sample" (p. 23). There are no cross-cultural comparisons; the book is about a few contemporary women who seem to live in or near Boston, Elson's home base. She is careful to say that her analysis does not "represent the only authentic experience of hysterectomy and oophorectomy (removal of ovaries) for all women in all cultures at all times" (p. 204). Although her aim is to present diversity, not only of age, marital status, childbearing history, and sexual orientation, it's interesting that the women's educational level and occupational status are omitted. How can we examine the meaning of gender identity without some of the strongest self-identifiers that women and men use? Many other researchers have demonstrated that women's sense of agency and competency regarding their own achievement is a strong and significant predictor for how they define their personal identities.

The core of the book consists of Elson's interviews with 44 women, aged 24-97, whose recollections of the actual surgeries and their feelings at the time (emphasis mine) vary not only with their age at the time of the surgery, but also with the time elapsed from the procedure. It's not clear why she emphasizes the novelty of ethnographic, qualitative research as its scholarly relevance has been well established. Her literature review is fairly thorough. Using detailed quotes from her interviews, she traces the relevance of surgical removal of reproductive organs to women's sense of gender identity. She reviews 19th century views of women as mere extensions of their biology and refutes the 19th and early 20th century "medical" claims that women's psychosocial problems "actually cause them to seek hysterectomies" (p. 18), rather than result from them.

Elson's seeming inability to distinguish between infertility and sterility is troubling. As defined by the American Society of Reproductive Medicine, infertility is a condition of reproductive impairment, which may be treated and resolved (emphasis mine). Sterility is the complete absence of reproductive capacity, which is the outcome of a hysterectomy. Elson uses the word infertility to refer to these postsurgical cases, and I found it jarring, in great part because it is inaccurate. Sterility is not even listed in her index. In addition, she describes one mother, post-surgery, as "thrilled to become infertile" (p. 97), and wrote that "nearly all of the childless women ... were distraught ... that they were now infertile" (p. 97). One should not use the term infertile when reproductive capacity is completely absent.

In addressing the characteristics of surgeon-patient relationships, Elson emphasizes the difficult ones, where power, control, and information are not equitably distributed. She also describes a few cases where the women were pleased with the discussion of treatment options and outcomes. Unfortunately, she does not give the reader sufficient information to decide whether it was a matter of chance, or whether some women, by virtue of higher educational or occupational status, or a more assertive demeanor, demanded more from their physicians than others did. Also unclear is whether she believes the relationships she describes are characteristic of surgeon-patient relationships in general or somehow related to the gender of the patient and doctor or, perhaps, the scope of the surgery (p. 182).