Sexism in Healthcare

 

 

 

Jen Crutchfield & Katy Drazba


            The repression of women’s access to the health care system is intrinsically interconnected with women’s subordinate role in society. Women’s secondary status in economic, political, social and educational institutions directly correlates with increasing patriarchal control over the female body; as men gradually expanded their influence in society, moral and legal restrictions steadily inhibited women’s knowledge about issues concerning female health and often created unnecessary, avoidable health complications. In essence, the patriarchal nature of the health care system exemplifies “a microcosm of society and reflects, in an enhanced manner, the dominant prejudices and biases of society” (Prakash, et al). It was not until the women’s rights movement of the 1960’s that women acknowledged and exposed the overwhelming ignorance and misinformation about the anatomy and physiology of women’s bodies and female-specific medical procedures. Consequently, women pressured political, social, and educational institutions to develop an unbiased health care system that is both receptive and sensitive to women’s health and allows women to claim power and responsibility over their own bodies. Today, even in the most progressive societies, subtle occurrences of sexism persist within the health care system due to the preservation of traditional attitudes and protocol. Access to unbiased knowledge has been the key element in empowering the women’s movement to amplify its pressure on the patriarchal institutions that uphold health care biases and provoke necessary changes to establish equality.

     Although women and men contribute essential elements to reproduction, women must endure the most physically demanding aspects of reproduction: menstruation, pregnancy and childbirth. Not all women experience these unique biological processes, and many modern women do not choose to identify their existence with respect to their biological makeup. However, historical documents describe many centuries where biology (sex) ultimately forged one’s destiny. The ability to give birth created a unique, but secondary social role in response to the dominance of androcentric political, philosophical, and scientific observations. In pre-industrial societies, female-controlled reproductive practices remained a private, domestic issue, but these became mainstream public issues as women sought to improve their social status with education and public activism, and regain control over their own bodies. Unfortunately, the inferior status of women restricted funding, research and knowledge about female issues before the 20th century, especially in regard to topics relating to reproduction including birth control, abortion, menstruation, and psychological health.

     Although early forms of birth control did not successfully prevent pregnancy as frequently as modern day forms of contraception, efforts to control pregnancy date back to ancient times and, to a degree, allowed families to control the size of their family. Both women and men exhibited the desire to control the number of children they wanted based on economic, social, physical, emotional, and religious reasons. Since men assumed the primary role in family life, female influence did not always take precedence in decision-making, despite women’s critical role in reproduction.  Only when primary accountability for the embryo shifted from men to women did the responsibility for preventing pregnancy also transfer from men to women. However, before modern contraception was developed, this often meant uncomfortable and unsafe approaches for women without the same physical risks and consequences for men. 

     Philosophers such as Aristotle believed that men contributed more components to a fetus – women were solely receptacles for the developing embryo (Gilbert 547). Therefore, it is not surprising that some of the earliest forms of birth control were male-controlled; coitus interruptus, coitus obstructus and coitus reservatus are methods that prevent semen from entering the vagina. Many religions, including Judaism and Catholicism, condemned these practices as a “vice against nature” because they obstructed fertilization, or “God’s will” (London). Furthermore, doctors also voiced against these methods, claiming it was “dangerous, caused nervousness, ultimately impotence” and even might “lead to the hardening of the uterus in women” because men could not climax (ejaculate) in a woman’s vagina (London).  Clearly, male participation in intercourse was deemed more important and even essential for women’s fertility.
With the development of the condom in 1562, men could climax intra-vaginally and prevent pregnancy at the same time. Early condoms were expensive and rare, so men often washed and reused them – and consequently created a greater risk for infection for both partners. Interestingly, the condom was not initially promoted as a way to retain sexual pleasure during intercourse during WWI, but as a method to prevent the spread of venereal disease (London). The extent of developing male birth control methods temporally ends with the condom - to this day the condom is not more than 99% effective (Levay & Valente 301). 
     With increasing knowledge about the female role in reproduction, women assumed a more active role in preventing pregnancy.  Many pre-modern forms of birth control allowed women adequate control over their fertility, but some came with serious health risks. Women and midwives concocted abortifacients with a variety of ingredients to prevent fertilization or induce spontaneous abortions. One such recipe included: mashed ants, foam from a camel’s mouth and the tail hairs of a black tail deer dissolved in bear fat. Women in colonial America drank liquids with gunpowder. Also, women routinely used vaginal suppositories that killed and/or blocked sperm from entering the cervix. Intrauterine devices blocked sperm from passing though the vagina, but increased chances of infection: women in Africa used plugs of chopped grass or cloth, Greek and Islamic women used wool, and Jewish women developed a sponge (a sea sponge wrapped in silk with a tie at the end) that was sufficiently effective. Douching with vinegar was also practiced, but was not a valuable method of preventing pregnancy (London).
     Abstaining from sex during ovulation, the rhythm method, was practiced, but very ineffective until doctors in the 20th century reexamined the notion that women were most fertile just before or during menstruation; they identified that most women ovulate later in the fertility cycle. Furthermore, women prolonged breastfeeding infants because women are less likely to conceive while they are allocating biological resources to another offspring. Even though women could not comprehend physiological benefit of this method, they used it to their advantage by delaying subsequent pregnancies. These methods, while somewhat helpful, did not always prevent pregnancy and often caused women physical harm.
     Abortion was another widespread practice to control both the size of families and populations. Early Chinese, Greek, Egyptian and Roman medical texts describe abortion techniques as an essential element to maintaining a stable population and evidence from forensic archaeologists describe primitive abortion techniques that include: herbs, poisons, sharp sticks, and abdominal pressure (London). Early abortions did not provide entirely safe and risk-free method of avoiding pregnancy, but ancient evidence of abortion illustrates women’s efforts to privately maintain control over their reproductive responsibilities. Expert female midwives generally performed abortions before men gradually seized control over the medical field.
     The Catholic Church maintained a relatively tolerant attitude about abortion in the early stages of pregnancy before the 19th century. Canon law passed in 1180C.E. stated that abortion did not equate to homicide and abortion did not occur before “ensoulment,” which occurred 40 days after conception for a male, but 80 days after conception for a female since females were not as complex (Grundmann). In the 13th century, Pope Innocent III claimed that abortion before “quickening,” or the time when the fetus is felt in the womb, was not a mortal sin or grounds for excommunication.  However, the Church reversed its permissive attitude of abortion in 1869, when Pope Pious IX confirmed that abortion – at any stage of pregnancy – was considered homicide (murder) and provided grounds for immediate excommunication. Some scholars argue that in the face of its declining political power, the Church’s stricter view on abortion was necessary to reinforce its spiritual and political control. However, women suffered the brunt of the Church’s backlash against women’s efforts to promote freedom of reproductive rights. 
     For centuries, abortion was not punished under English or American common law. British society in general regarded abortion as a moral issue. Punishment for abortion was rare, and until after the mid-19th century, the State did nothing to regulate abortion. In 1670, the question of whether or not abortion was murder came before an English Judge, Sir Matthew Hale. His decision clearly indicated that if the woman died as a result of an abortion, the crime was murder. The fetus however was not mentioned. In 1803, the tolerant approach to abortion ended when Lord Ellenborough codified a law that made abortion of a "quick" fetus a capital offense. In 1832, an article in the London Legal Examiner maintained that much stricter abortion laws were essential because abortion was very hazardous and often fatal for the woman, but that the destruction of an embryo was not a crime. Physicians were the driving force behind the move to criminalize abortion in England, the United States and Canada. Their concern was principally for the health of women, and secondly for the destruction of fetal life. However, many references suggest that the main reason for doctors' opposition to abortion was to further establish their professional status and to remove midwives (the traditional abortion providers), herbalists and "quacks" from the practice of medicine (Grundmann). Another way that men dominated the field of women’s health, simply for there own benefit, ignoring the price that it would cause women.
     Menstruation also creates biological boundary between men and women because most women experience this process at some point in their lives, while men never do. Many ancient cultures believed that menstrual blood could “make crops fail, wine go sour, infants die, or men become impotent.”(Sapiro 179). In many religions, menstruation deemed women dirty and impure, largely due to lack of sanitary methods to control menstruation. Women were not allowed to touch men (let alone sleep in the same bed with them) while they were menstruating. In Orthodox Judaism, women traditionally performed a ritualistic “cleansing process” each month before they were permitted to touch their husband (Levay & Valente 128). Much of the stigma of menstruation stems from misunderstandings about the differences in physical and emotional symptoms between women and the sexism surrounding the impure notion of women’s bodies.
     Psychological problems related to femininity also reinforced traditional views that women are irrational and emotion, and therefore needed to be dominated by men. A balanced family formed the foundation of a harmonious society, so when women acted out in socially unacceptable ways, husbands often took drastic measures to control their wives. In the Victorian era, women often underwent ovariotomies because ovaries were “regarded as dangers to mental health” and caused “emotional instability;” surgeries removed the ovaries to “cure women of many problems, such as overeating, masturbation, ‘erotic tendencies,’ suicidal tendencies and persecution manias.” Husbands sometimes forced their wives to undergo clitoridectomies (removal of the clitoris; often mistakenly referred to as “female circumcision”) to control “unruly” and “unmanageable wives” (Sapiro 175). Male doctors and psychologists recommended these procedures without regard to the correct functions of female reproductive anatomy. They disregarded female sexuality as a serious flaw and ignored women’s right to assume control over their own bodies in order to preserve traditional views of women.
     Also, diagnoses for common feminine psychological problems, such as melancholia, included masculine-contrived solutions such as the “rest cure.” This entailed women laying in beds and limiting their entire physical or intellectual energy to only two hours a day! Women spent the remaining part of the day lying in bed, literally wasting away. In the late 19th century, Charlotte Perkins Gilman wrote a book entitled The Yellow Wallpaper describing the emotional trauma that women faced while enduring the rest cure. To elucidate the mental ruin that many women encountered during this treatment to prevent madness, one physician stated it was “the best description of incipient insanity he had ever seen.” Another review highlights the general reaction when the story first came out in 1891: a Boston physician protested that “‘such a story ought not to be written,’” he said; “‘it was enough to drive anyone mad to read it’” (Gilman). Gilman regained power over her own intellectual ability when she wrote the book and demonstrated the need to develop unbiased treatments that are not based entirely on prejudices about a person’s sex or gender.
     Modern day society faces new challenges with respect to birth control, abortion, menstruation and psychological diagnosis in correlation with the development of new technology and more colorful political scenery. American history from the 19th century to the present illustrates the modern efforts of women to identify and challenge traditional beliefs and practices that expose sexism within the current health care system. Furthermore, the birthing process, sterilization, research biases and cancer treatments contribute more aspects of conspicuous male-bias within the health care system that women recognize the need to equalize.
     Birth control methods remain relatively unchanged, although the development of synthetic materials drastically improved effectiveness of traditional customs. Many men and women practice similar techniques to those in pre-industrial societies, however there is blatant emphasis female contraception that does not detract from male pleasure or masculine identity. Coitus interruptus, obstructus and reservatus, while still practiced among conservative couples, are not publicly promoted because they contrast the mainstream emphasis on overt male sexuality and dominance. Condom manufacturers did not acknowledge “her pleasure” until the 21st century. Because the burden of pregnancy and childbirth shifted onto women in conjunction with a better understanding of the reproductive process, male birth control research and development remains at a standstill. Will men ever have a birth control pill or a shot to inhibit the vitality of their sperm? 
     When the women’s role in reproduction became more apparent, many women took a more active role in their fertility and sexuality, but also faced with sexism when impeded through legislation or forced birth control. In the early 19th century, a progressive woman named Margaret Sanger recognized the need for a safe and more effective way for women to control their fertility after experiencing firsthand the consequences of illegal abortions and working with families that had more children than they could financially support. Sanger traveled throughout Europe to research birth control methods, since European counties did not ban the distribution about contraceptive devices (Sapiro 246). Sanger’s ultimate goal was to make birth control (a term she coined) available to all women for any private personal, social, economic or medical reason. Many opponents rejected these reasons claiming moral degradation was a worse predicament than unwanted children.
     Sanger’s principal hurdle in promoting birth control, the Comstock Laws of 1873, proved extremely difficult to overcome legislatively.  The Comstock laws were enacted in order to prevent circulation of pornography in the mail, but also prevented the circulation of information about contraceptive methods, birth control, and abortion (Sapiro 420). Sanger and many pro-birth control activists faced arrest for violating the Comstock Laws. Not until 1965 did the Supreme Court declare a law banning married couples from using birth control unconstitutional in Griswold v. Connecticut. In 1972, the right to birth control extended to single individuals and to minors in 1977 (Sapiro 421). The acceptance of the birth control pill and other contraceptive method marks a revolutionary change in women’s rights to control her reproduction and continues to sexually liberate women as methods are improved in efficiency and convenience.
     The birth control movement is not without major flaws, however, since race played a major role in the development of a marketable birth control pill. The first pills were tested on Puerto Rican women in the 1950s (The Pill, 1999) because many women sought to improve their economic situation by having fewer children. While some women raved about its efficiency, some women suffered serious health problems (or died) due to the extremely high levels of estrogen contained in the pill. Not testing the pill on white women indicates a combination of racist and classist attitudes/intentions of researchers.
     Currently, a major battle providing evidence for a sexist health care system is the conflict between Viagra and birth control. In 1998, many insurance companies “moved to cover prescriptions for Viagra, the first oral pill to treat impotence, as soon as it was approved by the FDA” (Sapiro 423). As of 1998, even though birth control had been developed almost four decades before Viagra, most insurance companies did not cover the cost of the best forms of birth control. Employers often argued that men did not receive reimbursement for condoms; therefore, women could not justify the right for contraception coverage, despite vast differences in the biological consequences of pregnancy (Colb). Women immediately recognized the blatant double standard this reproduced, and expressed their discontent. Their efforts invoked change – in 1998, Congress passed a law that extended health coverage for federal employees to contraceptives. In the 20th century, sexuality remained a more valuable and appropriate characteristic of men. Methods to allow women to freely express their sexuality are currently in developmental stages (i.e. the emergency contraceptive pill) and will certainly face new challenges in the legislative and legal arenas. Until efforts are made to improve male forms a birth control, contraception will most likely remain a woman’s responsibility.
     As crusades to cease mass availability of birth controlled gradually ceased, abortion eclipsed birth control as the most controversial reproductive topic in American politics. By the beginning of the 20th century, all states prohibited abortion at any stage of pregnancy. The Catholic Church’s views played a significant role in reversing many state laws that previously allowed abortions before quickening (Sapiro 424). Until 1973, only wealthy women possessed the option of a legal abortion due to the expense of traveling to another country where abortion laws were more lenient. In 1973, the much debated Roe v. Wade trial ended with the Supreme Court reversing previous antiabortion laws. Because of this law, women have the right to an abortion due to her constitutional right to privacy; the court also implied that a fetus is not a citizen and is not entitled to constitutional rights. Many subsequent trials have redefined the rulings of Roe v. Wade in determining the time at which states can reserve the right to restrict abortions, the required consent before an abortion, and keep records of abortions. Women retain the right to an abortion without spousal consent in the first-trimester, parent consent, and amniocentesis (Sapiro 425-426). Many women view abortion as a moral catastrophe for religious reasons, but many women view abortion as a woman’s inherent right to control her reproductive proceedings. Pro-choice activists emphasize a woman’s right to choose if and when she becomes pregnant. They challenge the traditional double standard of sexuality because they claim that women posses the intrinsic entitlement to the command of her body and therefore must have the freedom to express her sexuality, since men enjoy this right without the risk of pregnancy.
     Abortion remains a politically charged issue due to the moral/religious content interwoven within the rulings, but economic and racial concerns also complicate the abortion situation in the United States. Abortions, while legal, remain expensive and economically beyond the financial means of many women stricken by poverty. In the 1970s, both individual states and the U.S. Congress passed laws that prevent Medicaid funds from monetarily supporting abortions (Sapiro 427). Therefore, women as a whole obtained access to legal abortions with the rulings of Roe v. Wade, but poor women continue to endure unwanted or unplanned pregnancies due to their economic disadvantage. It is important to distinguish this inequity to expose flaws within the women’s rights movement that create racial and class barriers; when women gain legal rights that allow women to make decisions about one’s own body, discrimination based on race and class prevents all women from gaining access to equal benefits, especially within the health care system. 
     The process sterilization also exposes sexism within today’s health care structure. In the 1970s, women exposed a dark secret about sterilization that highlights women’s lack of power over their own fertility. It became widespread knowledge that poor women, especially African American, Latina, and American Indian women were “forced to undergo sterilization, sometimes without their consent, sometimes under considerable pressure to consent, and sometimes without their knowledge” (Sapiro 421). Doctors urged poor women on welfare or those who could not afford medical treatment to undergo sterilization (as if they became pregnant solely on their own accord); some doctors even refused to deliver babies to women who, in their opinion, should stop having children and refused sterilization. This bias against impoverished women explicitly demonstrates how lack of access to information about birth control disempowered women.
     As surgical procedures to sterilize men and women became safer and more effective in the 20th century, some men and women opted for permanent infertility. However, many couples are not informed that male sterilization, where the vas deferens tubes are cut and sealed, is both reversible and 99% effective (Levay&Valente 342). Female sterilization, colloquially known as “tube tying,” clasps the fallopian tubes to prevent sperm from reaching the egg; this surgery is much more invasive, not reversible, and is less effective. Yet, more females than males continue to undergo sterilization (Levay& Valente 279). Male sterilization can be considered emasculating (and therefore damaging to a man’s psychological health) to those who believe that masculinity is fundamentally linked to fertility and sexual vitality, hence, this procedure is less popular. However, little regard is given to women and their concerns with ceasing their reproductive capabilities.
      Menstruation persists as a relatively taboo subject. New studies demonstrate bias within observations about menstruation. There are recent “scientific”  studies that modern women “menstruate ‘too much’: based on studies of hunter-gatherer societies in which women were frequently pregnant, lactating, or insufficiently nourished to menstruate, it has been suggested that menstruating each throughout adulthood is ‘unnatural’” (NWSA Journal). These setbacks in progressive thought inhibit women from drastically transforming society into accepting women’s bodies as they are and appreciating the biological processes that ultimately contribute to reproduction. Many women overcome the embarrassment of menstruation and embrace it, but society lags far behind in this progressive nature of thought. Further research will hopefully correct sexist observations and observe menstruation and other female-specific biological processes in a reasonable, unbiased context. 
     The shift in women’s location of delivery, from homes to hospitals, functions as another model where women were guided into procedures that are not particularly beneficial or sensitive to women’s needs. Before WWII, women usually delivered their babies at home in the company of a nurse midwife or the family doctor. At the end of the 1970s, 99% of women decided to deliver in a hospital rather than at home, thereby also opting for assistance from mostly male doctors rather than mostly female trained nurse midwives (Sapiro 183). Women tend to focus on the positive aspects of hospital delivery including: decrease infant mortality in cases of emergency due to new technology and anesthetics. However, many subtle clues depict women’s subjugation within the birthing process.
     Firstly, the routine position for birthing, the lithotomy position, exemplifies how women are “transformed into ‘patients’ and are treated, and expected to act, as though they are sick people – that is, not normal” (Sapiro 183). This position makes it easier for the doctor, not the woman, to deliver a baby. Also, information about current procedures for hospital deliveries fails to reach women’s attention before and during childbirth. Surgeries such as episiotomies (the cutting of a woman’s vagina to enlarge it) are performed in the majority of births in North America, but recent evidence indicates that this procedure does not usually prevent the problems claimed to justify its use and it may even create more serious complications. Anesthetics may relieve some of the pain of childbirth, but developed into a routine request instead of an emergency procedure. Women rarely know that it “diminishes women’s ability to use their voluntary muscles, making it difficult for them to participate actively in childbirth and making surgery more likely” (Sapiro 183). Childbirth can be one of the most painful, but exciting times in a woman’s life – women deserve the right to know about all potential surgeries and consequences before she goes into labor to assert control over her body. 
     Although women no longer undergo intolerable treatments such as the rest cure and many more women are entering the field of psychology, women still encounter biases in regard to psychological treatments. More psychotropic drugs are prescribed for women than men (Sapiro 186). Also, physicians subconsciously are influenced by drug advertisements. Studies show that in the psychiatric journal the ratio of females to males was 5:1, and 10:0 in a general medical journal. Therefore, it is not surprising that many physicians (who receive an enormous amount of exposure to gender-biased ads) believe that women are “more vulnerable” and “need drugs more” (Sapiro 186-1870). As more women enter the medical and psychological fields of study, it is possible that gender-biased diagnosis will disintegrate and allow for the development of treatments that do not discriminate based on the sex or gender of an individual.
     One of the most obvious disparities between women and men’s current access to quality health care rests in the androcentric health care research process. Most medical research has been performed on men because “researchers worried about the effect of ‘abnormalities’ of women’s bodies, such as menstrual cycles and pregnancy, and because women do not die as young as men, so their problems are not seen as being as serious as men’s” (Sapiro 187). Also, drug testing primarily used only men for research, but all findings (without regard to biological differences) immediately accounted for women as well. White men may be considered the norm in the patriarchy, but it is dangerous to women’s health to assume that men and women’s bodies behave and react in exactly the same way.
     A critical example that highlights sexism is heart disease research. In the 1980s, a study researched the impact of aspirin on cardiovascular disease and the avoidance of heart attacks and formed the basis for cardiovascular treatments today. Yet, this study only involved male participants (Saprio 188). Consequently, “virtually all information on the prevention, recognition, clinical manifestations, therapy, and prognosis of coronary heart disease is derived from studies conducted predominantly or exclusively in middle-aged men” (Carnes 15). Women suffered a serious disadvantage with the assumption that treatments for white men are applicable to all people. Still, one in three primary-care physicians do not know that cardiovascular disease is the leading cause of death among American women and many still do not discuss the risks and symptoms (or, more importantly, female-specific risks and symptoms) of cardiovascular abnormalities (Sapiro 187). It is tragic to think of all the women’s lives that have been lost due to androcentric assumptions.
     Until only recently, medical experts have begun to fund compensating research for women. In 1986, the National Institutes for Health adopted a policy that required women’s participation in clinical trials. Also, in 1992, the Office of Research on Women’s Heath became a facet of the NIH. Furthermore, the Women’s Health Equity Act has pressured medical experts to study women’s health concerns, such as breast cancer and women’s cardiovascular disease (Saprio 188). Women’s groups also have acknowledged that men’s bodies are the used as the norm in medical school and have worked to change this inequity in medical school curricula (Carnes 17). Many changes need to occur within the current health care system to remove gender biases from research, diagnosis, and treatments. Many improvements are underway because those “actions towards improvement parallels the increase in the number of women in powerful policy-making decisions” (Carnes 19). A more diverse representation in leadership positions is required to break down the patriarchal structure of the health care system, but it is completely necessary. Millions of lives are at stake.
     Lastly, women also experience discrimination with regard to cancer treatments. Mastectomies (complete removal of breast tissue) and lumpectomies (removal of tumors) are common procedures in hospitals due to a higher rate of diagnosis for breast cancer. By modern day standards, these procedures are labeled as “drive-through” because of their swift protocol. By 1996, 78-88% of women that underwent a lumpectomy were sent home without staying in a hospital overnight (Schaller)In contrast, or prostate cancer, as well as other “male” cancers, average hospital stay was 3 days to 2 weeks (www.cancer.org). Also, an increase of out-patient mastectomies (a more invasive procedure) exhibits the “‘concern that the gains in health care savings may be at the expense of health care quality,’” expresses Claudia Steiner, M.D., M.P.H (Schaller). Women, unfortunately, bear the brunt of this inequality.
     The biases within the health care system reflect the ingrained sexist establishments within society and the injustices women face due to their lack of knowledge and power within the current system. The increase in the number of women doctors and women’s health clinics serves as a stepping stone towards health care equality, but these women are often kept out of the decision-making process. Similarly, women’s lobbying groups continue press for more funding and research, but often face setbacks that encumber legislative funding. A rise in conservative political thought under the Bush administration also poses a threat to American women’s rights to choose medical treatments, such as abortion. However, access to unbiased knowledge provides women with the key tool to dismantle the current patriarchal health care system, and with an increasing number of women in political, social, and educational fields, an unbiased health care system is not an impossibility.
     Women must continue to claim responsibility over their own body and fight for the inherent legal rights that women possess in regard to their health. To achieve equality, the global tradition of patriarchy must recognize that the women’s health movement involves serious issues that attempt to redress the disparities between men and women’s health and invoke necessary changes that promote the health of every human being. After all, the health of every person begins with the health of their mother – would most people consciously subject their mother to second-class health care? Or their wife? Or their sister? Most people would not. Treating women’s health as a secondary priority negatively affects everyone.


REFERENCES

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