A Brief History of the Speculum

L0035255 Speculum auris, made by John Weiss, 1831 Credit: Wellcome Library, London. Wellcome Images images@wellcome.ac.uk http://wellcomeimages.org Speculum auris, made by John Weiss, published 1831. Plate XVII from ‘An account of inventions and improvements in surgical instruments made by John Weiss …’ Text to Plate XVII reads: The speculum auris. To open the blades of this instrument, turn the handle from left to right. Engraving and text An account of inventions and improvements in surgical instruments / made by John Weiss … with a selection of cases wherein they have been … employed John Weiss Published: 1831 Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/

The above image, dating from 1831, is a diagram of a vaginal speculum designed and manufactured by John Weiss, a well-known maker of surgical instruments in London in the 18^th and 19^th centuries. The company in fact still operates to this day. Intended for direct vision of the cervix via the vagina, the first vaginal specula were used by the ancient Greeks and Romans.[1] However, the invention of the ‘modern’ speculum that is familiar to us today is largely credited to the American James Marion Sims, a well-known gynaecologist in the 19^th century.

Specula vary in their design and the material used, depending on their intended use, whether it be in the operating theatre or in the examination room. The most common style of speculum that is used in the vagina is the bivalved speculum, in which the two blades are hinged and are ‘closed’ when the speculum is inserted to facilitate its entry and ‘opened’ in its final position, where they can be held open by a screw mechanism, so that the user’s hands are free to perform other tasks.[2] While perhaps more heavy and industrial-looking than their modern-day counterparts, these mid-19^th century specula appear to be based on similar basic design principles to 20^th and 21^st century versions. Perhaps the most striking difference, however, is that modern versions usually have two blades, not three. Also, according to the description of the version pictured above, one should turn the handle in order to open the blades of the instrument, rather than there being a screw mechanism to do so.

Thomas R Mitchell, author of Practical remarks on the use of the speculum in the treatment of diseases of females, which was published in 1849, describes several different variations on specula design that were available at the time, of which ‘some are very ingenious’.[3] He describes, for example, one design which ‘consists of five blades, which are made to dilate by means of a string attached to a central peg’,[4] and another ‘furnished with an air cushion of bladder or the crop of a fowl, to facilitate its introduction’.[5] Described in the front matter of the book as a Fellow and Licentiate of the Royal College of Surgeons in Ireland and as a lecturer in midwifery, Mitchell considers the speculum to be nothing short of revolutionary in terms of its impact on the sphere of women’s health. He writes, ‘I look upon the introduction of the Speculum into general practise, as one of the greatest improvements in the treatment of disease since the discovery of the stethoscope’.[6] Indeed, he implies that the speculum is nothing short of life-saving since, prior to its invention, he writes, ‘many went to the grave with the seat of disease undiscovered’.[7]

However, for many of Mitchell’s contemporaries, the potential to preserve life was far outweighed by the moral implications of the instrument’s use. The anonymous author of The speculum: its moral tendencies, writes that he believes ‘the workmanship of the Creator to be as perfect now as of yore, and that the modern and multitudinous disorders attributed to the uterine system are wicked inventions, put forth to sanction unnecessary interferences’.[8] For some, the idea of men being allowed to view women’s vaginas in any capacity was a social abomination that was symptomatic of a morally degenerate society. The author of Hints to husbands: a revelation of the man-midwife’s mysteries, for example, deplores the practice of ‘man-midwifery’ and aims in his writing to ‘fearlessly unveil and drag into the light its indecent mysteries’.[9]

In taking such a tone of outraged morality, these two authors transgress the perception of the clinician as an objective observer. The implication is that men are deriving private enjoyment from viewing female genitalia, under the guise of performing medical examinations. This view completely subverts the ideal of the ‘clinical gaze’ as described by Michel Foucault. Foucault writes of the attempts ‘on the part of clinical thought to define its methods and scientific norms’,[10] over which ‘hovers the great myth of a pure Gaze that would be pure Language: a speaking eye. It would scan the entire hospital field, taking in and gathering together each of the singular events that occurred within it.’[11] This gaze would be ‘turned into speech that states and teaches; the truth’.[12] In short, this speaking eye ‘would be the servant of things and the master of truth’.[13] If the clinical gaze is to be realised, for the benefit of medical and scientific knowledge, then the physician – who, in a historical context was usually male – must in a sense become an impassive observer, immune to sexual desire when viewing a woman’s genitalia. In effect, the female patient must become an object to the male observer (the physician). The speculum facilitates this transition since, by its appearance it is clear that the instrument is, first and foremost, designed for the doctor’s easy access, and less concern is given to the patient’s comfort. It enables the user to directly view and examine inside the vagina without the need for digital insertion, distancing the physician from the body of the patient and transforming it into a clinical specimen. The benefits of this to the progression of women’s healthcare are clear, however, the ‘clinical gaze’ as described by Foucault rouses some problematic issues relating to the operation of medical culture within patriarchal society.

If the clinical gaze in one sense is beneficial for women in removing a layer of morality from the observation of their bodies and allowing hitherto ‘hidden’ disease to be uncovered, in another sense it can be understood that the ‘medical gaze of the professional, taken to be the true source of medical knowledge, has consistently been privileged over the voice of the patient’.[14] This suggests that the power resides with the physician, rather than the patient. This view can be seen as stemming primarily from the fact that medicine is a male-dominated profession, therefore, in an gynaecological examination setting, it is likely to be a male doctor observing a female patient. A pure Foucauldian ‘clinical gaze’ may debatably be the ideal in attempting to advance medical science, but in practice it can be argued that in the patient examination setting, the clinical gaze merely upholds the power imbalance between the genders that underlies patriarchal society. Taking the speculum as symbolic of this, we can see that the instrument’s usefulness and value lies in its ability to increase men’s knowledge of women’s bodies. As Kaspalis writes, the speculum is another example of male power over women, making ‘visible the inner recesses of the female body, just as the telescope enabled a view of the outer depths of space’.[15] In Kaspalis’s view, ‘the speculum was like a compass in that it helped guide the physician into this unknown terrain. In this rhetorical construction, the female body is metaphorically produced as raw natural territory awaiting discovery and cultivation by the hands of male medical culture.’[16] The implication of this is that the examination of women’s bodies by men serves only the purpose of increasing men’s knowledge and therefore power, reducing the female patient’s body to a passive resource awaiting exploitation.

The speculum as an historical object is interesting in that it raises a number of questions around issues of women’s health and the fact that, worldwide, this is still an area where more research and knowledge is needed, particularly in some developing countries. It is true that many lives have been saved through the use of the speculum, particularly in detecting cervical cancer through the introduction of cervical screening programmes, which are part of many healthcare systems in countries in the west. However, there are wider cultural and social issues at play that make the issue more complex. First, in the tone of moral outrage adopted by some commentators in the 19^th century who saw the use of the speculum as indicative of a morally corrupt society. It is notable that, in both examples presented (The speculum: its moral tendencies and Hints to husbands: a revelation of the man-midwife’s mysteries) the authors are both male, again reducing the female patient to a silent, passive object. Second, the imbalance of power in the examination setting between the doctor and patient can be seen as reflecting the gender imbalance in society at large. In effect, the speculum represents an object that perpetuates gender inequality in its intended use as a means by which to view the female as an object, thereby facilitating the ‘clinical gaze’, which by default equates to the ‘male gaze’. As an object of historical interest, therefore, the speculum carries the weight of complex social and cultural concerns, making its an analysis crucial to an understanding, not only of the history of medicine, but to the advancement of women’s healthcare in the future.

[1] Ralph Jackson, ‘Roman doctors and their instruments: recent research into ancient practice’, Journal of Roman Archaeology, 3 (1990), pp. 5–27 (p.9)

[2] Marion Edward Clark, Diseases of women, (Democrat Print, Kirksville, 1901), p. 68

[3] Thomas R Mitchell, Practical remarks on the use of the speculum in the treatment of diseases of females, (Fannin, Dublin, 1849), p. 13

[4] Mitchell, p. 13

[5] Mitchell, p. 13

[6] Mitchell, p. 11

[7] Mitchell, p. 12

[8] A Fellow of the Royal College of Surgeons, The speculum: its moral tendencies, (Bosworth and Harrison, London, 1857), p. 5–6

[9] George Morant, Hints to husbands: a revelation of the man-midwife’s mysteries, (Simpkin Marshall & Co, London, 1857), p. 5

[10] Michel Foucault, The Birth of the Clinic, (Taylor and Francis, Oxford, 1989), p. 140

[11] Foucault, p. 140–141

[12] Foucault, p. 141

[13] Foucault, p. 141

[14] Kirsti Malterud, Lucy Candib, Lorraine Code, ‘Responsible and responsive knowing in medical diagnosis: the medical gaze revisited’, Nordic Journal of Feminist and Gender Research, 12.1 (2004), pp. 8–19 (p.8)

[15] Terri Kapsalis, Public privates: Performing gynecology from both ends of the speculum, (Duke University Press, Durham and London, 1997), p. 39

[16] Kapsalis, p. 39

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Bounty should be banned from maternity wards

Commercial organisations should not be allowed access to vulnerable women and newborn babies on hospital wards. Back in 2013, the Guardian published an article calling for Bounty to be banned from maternity wards and a petition was started, but this has since closed and the situation remains changed . Bounty reps are still allowed free rein among the hospital beds of new mothers. A 38 degrees petition was recently launched to raise awareness of the issue once again.

The government argues that the £90,000 it pays each year to Bounty to allow it to distribute Child Benefit forms is justified because that way they will reach 97% of new parents. Bounty itself insists that its reps play a crucial role in getting information to parents. It also argues that most parents are happy to talk to its reps and to receive the free goods and vouchers in its Bounty packs.

There is a high level of commercialisation around women’s health, and the areas of maternal health, fertility and childbirth are particularly affected. Under the guise of offering support to complete the form, Bounty reps are taking the details of new mothers with a view to passing them onto third-party organisations who then bombard women with marketing spam. Child Benefit forms can be freely obtained online or in hard copy form and these could easily be handed out by a registrar or midwife, eliminating the need for the presence of a commercial company. Additionally, new parents have reported that the reps do not behave appropriately on the ward, often invading privacy and refusing to take ‘no’ for an answer. These reps exploit women when they are at their most vulnerable and anxious to give their newborns the best start in life. They are allowed access outside of visiting hours, and frequently open curtains and enter the private spaces of new mothers, who may be recovering, sometimes from caesareans, or breastfeeding, or trying to snatch some much-needed rest.

A frustrated and upset new mum describes her experience on a mumsnet forum: ‘[the Bounty rep] arrived originally before breakfast turned on the lights and opened curtains waking me and the other Mum up, then continued to talk over the peadiatrician [sic] who was checking my [daughter] over.’ Apparently without regard for anything but commercial gain and her own concerns, the rep ‘eventually […] sulked off but apparently came back when I was asleep (how dare I?) Last time she came back as I’d just settled [my daughter] and was eating lunch which had just arrived. I said No photos at the minute thanks she got most insistant [sic] that its for security reasons?? (I’m going home today) and said she’d just lean round and take them, [my daughter] was asleep on my lap in a v pillow whilst I ate. I said again, not right now I’m eating she left brochures and went off muttering quite loudly.’ The thread below this post is full of similar accounts from other mothers, making it clear that this woman’s experience is far from isolated.

Not only is it unethical and downright invasive to allow strangers who are not medical professionals access to hospital wards, this issue is symptomatic of a much larger issue around the commercialisation and commodification of childbirth and maternity. From conception, women are bombarded with information and ‘advice’ – on pregnancy, how and where to give birth, and how to look after their babies – from commercial organisations selling goods and services. Under the pretence of offering valuable services and information, Bounty not only patronises but exploits and bullies new mothers with the sole goal of achieving commercial gain.

In a thought-provoking piece entitled, ‘Why Birth is a Feminist Issue’ the question is posed, ‘Why is the culture of childbirth saturated in fear? Why not trust women to make their own informed choices about their bodies and their babies?’ These choices can only be made when they are unclouded by fear and by the influence of the kind of marketing and commercialism that is currently state-sanctioned in our publicly funded hospitals. By allowing Bounty to stalk our maternity wards, the government is allowing the sacred space of birth and new motherhood to be debased and exploited.

The sound of the food police

I’ve been thinking a lot about food consumption and body image recently, which is obviously not a new topic in feminist discourse and has been written about extensively, from Fat is a Feminist Issue (it still is) onwards. In this post I have found that the issue of food consumption as a feminist issue is intertwined with issues relating to class and race, and that the modern food industry is at the heart of a political and cultural conflict in which the human body, and specifically the female human body, is the emblem of a war on obesity that has been wholly invented and perpetuated by the patriarchy.

A woman who openly enjoys food is regarded with suspicion and disapproval. My partner and I recently overheard two teenage girls on the bus, fat-shaming an absent friend who always ordered pudding because, she just ‘really likes food’; apparently this makes her a freak. It got me thinking about the restraint I impose on myself, and have done for decades, when I am eating with a group of women. No one wants to be the one being spoken on the bus like that and I believe this comes from a fear, not so much of being seen as greedy, but of standing out, of not conforming to expected behaviours and restricting food intake, as women are expected to, in order to maintain an acceptable body size and shape. The woman who shows that this is not at the forefront of her mind when consuming a meal is seen as strange or weak. This is the reason a woman will often go for a salad or ‘healthy option’ if the other women at the table are shunning chips (which are what she would really order if she was alone).

This kind of self-restraint can become endemic throughout a woman’s life, as explored by Lily Myers in her poem Shrinking Women, in which she compares her mother’s shrinking form (who, she says, drinks wine from a measuring glass) with her father’s (whose ‘stomach has grown round with wine, late nights, oysters, poetry, a new girlfriend…’). It’s not just food the that the mother is denying herself, the implication is that she is missing out on life experiences, the enjoyment of rich food, of staying up late drinking with a lover. Her shrinking body is a symbol of her fading existence without a man to make her ‘real’, while her father’s corpulent form is evidence of his rootedness in existence, his lack of fear to carry on after the decline of his marriage.

The image of a woman enjoying food is sometimes seen as evidence of urban decay. The Facebook group, Women Who Eat on Tubes (WWEOT), which came to the media’s attention a few months back, drew a lot of attention and accusations of misogyny. I would argue that the fact the project was carried out on public transport and seems to focus particularly on women eating fast food, that there is a class issue here as well. Considering the type of food being consumed, where it is being consumed and who by (women, who in the patriarchal view should act as keepers and ambassadors of a society’s moral values to draw a veil over the behaviour of its men), the author seems to be suggesting that these images encapsulate societal decline.

If we consider food and consumption to be a site of intersection between class and gender equality issues, it is appropriate to mention the subject of the obesogenic view of society (the idea that a person’s environment is to blame for making them obese). Berlant said: ‘Obesogenic accounts open the door for interventionist, paternalistic policies targeted at curbing consumption, always with an eye toward poor communities and communities of color, and often yoked to nationalist discourses of security and progress.’¹ We can see this kind of attitude at play in WWEOT. By attempting to shame women who eat in public, the author is playing a paternalistic role, attempting to put a halt to the constant consumption that is the sign of a society that is never satisfied.

‘Fat represents modernity gone awry’, Yancey wrote.² Modernity has gone awry, this means, insofar as we have moved away from having our diets shaped by nature, from living off the land and eating seasonally. We no longer fear starving to death in the West. Instead we are at risk of eating ourselves to death. We now have cheap ways of producing a constant supply of processed food full of sugar and synthetic ingredients, with no nutritional value. It seems we have opened a Pandora’s box of exponential cheap food production, with our self-destruction through overeating being the consequence. But the individual risk is not equal across society. While a proportion of us live in so-called ‘obesogenic environments’, and are actually exposed to, and seduced by, cheap food to attain temporary fulfillment, others actively fight against this environment (i.e. the middle-classes, who eat and shop healthily to distinguish themselves from poorer consumers). At the top are those (the state, the media) who see it as their responsibility to police the obesogenic environment, issuing health advice while allowing the food industry as much leeway to maintain the fine balance between ensuring that profit is made, and ameliorating the consequences of consumption to ensure they do not put a burden on the public purse by overwhelming the health service. (To digress slightly – I speak only in the context of an as-yet not completely privatised health service as it is in the UK. Once it is fully privatised I can only assume that the rhetoric of the ‘food police’ will disappear and consumers be left to fund their own treatment for obesity-related disease, or die if they cannot afford it. Look to the USA as an example of what is likely to happen. High obesity; privatised healthcare. Coincidence?)

Why it is specifically the issue of women being fat that ‘seems to magnetize fears around living and dying, life and death, liveliness and … deathliness’?²

References

1. Lauren Berlant, “Slow Death (Sovereignty, Obesity, Lateral Agency),” Critical Inquiry 33 (2007): 754.
2. Yancey et al, “Obesity at the Crossroads: Feminist and Public Health Perspectives,” Signs 31.2 (2006): 426.

Gender equality: the picture in Latin America

On 6 March 2014, as part of UCL’s Lunch Hour Lecture series, Professor Maxine Molyneux, from UCL’s Institute of the Americas, presented her research on the impact of global policy on women in Latin America, to mark International Women’s Day.

Molyneux has been involved for many years in the issue of policy involvement in the area of women’s rights. Her interest is in effective policy interventions: what policy environments produce positive impacts on women’s lives in developing countries?

The MDGs

The Millennium Development Goals are eight international development goals that were established following the Millennium Summit of the United Nations in 2000. The third MDG is ‘To promote gender equality and empower women’ and Molyneux’s research focuses on the Latin American region, monitoring the progress that has been made, the obstacles that women still face in achieving greater equality and justice, sexual and reproductive rights and measures to tackle violence against women in the Andean region and in Mexico.

The MDGs represent the first time there has been a full global consensus of this kind. However, there is scepticism around whether themeasures put in place are reaching those most in need. Molyneux posed the question: do the gender equality frameworks established in response to MDG3 reach the very poorest in those areas and do they make a difference? Governments can be reluctant to use resources and can be selective about which measures they adopt. But, on a global scale, significant advances have been made as a result of the MDGs. For example, there has been a fast reduction in poverty globally. Child death rates have also fallen by at least 30% and deaths form malaria have fallen by 25%.

So significant gains can be attributed to the MDGs. But the figures must be put into context. Poverty reduction in India and China may be due to economic growth, but in Latin America, active efforts to reduce poverty that have contributed to the drop. And when it comes to gender equality, this was behind target for 2010. However, progress has been made since then, thanks to renewed efforts.

Latin America

Latin America is a very diverse region, with a middle-sized income. However, its 20 countries vary in terms of size, population and size of territory. There are also huge variations within countries and regions, in terms of wealth. In 2002, the richest 10% had 40% of the total income, while the poorest 20% received only 4.7%. The disparity is echoed in global terms: still, the top 5% richest have 80% of the global wealth.

According to figures from the 2012 GI Ranking, the top performers when it comes to gender equality are Chile, Uruguay and Argentina, who were ranked around 40. The worst performers were Guatemala, Nicaragua and Honduras, ranked at around 110–120; to put this into context, the UK is ranked around 26.

In fact, on a global scale, Latin America ranks around the upper middle in gender inequality, above Africa, the Middle East and Asia, but below Europe and the US and, in the global south, Latin America is the region that has made the most progress in terms of women’s rights. This is partly due to economic reasons; there is more money to spend on policies favouring women, but Molyneux cautioned that GDP alone is not an indicator, for example, in Gulf countries in the Middle East, wealth is high, but life for women is not so good.

Political factors

There are political reasons for progress in gender equality in this region. The Latin American policy environment favours human rights agendas. There is widespread democracy across the region, and a proliferation of left-of-centre political parties in government, headed by leaders such as Chavez and Morales, whose left-wing policies are aligned with social and women’s rights movements. The politicization of these movements also means that women were able to gain positions of power and use their influence to empower women. Figures such as Michelle Bachelet (the former head of UN Women, who has just been elected President of Chile for the second time), who is active on a global scale, have been pivotal in foregrounding the implementation of the MDGs in Latin America.

The seeds of change in the region were sown long ago. From the mid 1980s, Latin America has benfitted from favourable political conditions and democratic, sympathetic governments who adopted international women’s rights frameworks, creating a context in which those frameworks could begin to be part of the political agenda.

MDG3

The third MDG promotes gender equality and the empowering of women. These are basic but important goals, Molyneux said. Targets set for Latin America were: to eradicate the gender gap in education, improving the ratio of girls to boys and raising literacy levels among women; waged employment of women in the non-rural economy; and a greater share of women in positions in parliament.

The outcomes of these targets are that, in Latin America, girls now outperform boys in school; there has been a reversal in the gender gap in terms of education. However, this does not carry through to rural, poorer areas, where women and girls are disadvantaged through poverty, and often drop out of school to marry, or they get pregnant.

There is a similar ambiguous picture in terms of employment; although women have been entering the workplace since the mid 1980s, and women now make up an average of 52% of the workforce, there has been an overall decline in waged work. So people are being paid less, meaning more women have to work to support their families. Often, these jobs are in the informal sector where women work in precarious, low-paid jobs in predominantly the service sector, in which they have no social rights. Currently there are 12 million domestic workers, 90% of whom women, and most of these women are from racial and ethnic minorities.

The pay gap between men and women is also wide, and women are often not in jobs commensurate with their education level. The care economy is also borne by women; it still falls to women to care and work within the home.

In politics, the average proportion of women in parliaments is 25% (2013), (better than the UK!). Opinion polls in Latin America reveal that, although the people often want a man as their leader, they place more trust in women in parliament. In fact, since 2000, six women have served as presidents in Latin America.

Maternal mortality is still a problem, and rates of maternal mortality are especially high in Peru, Bolivia and Ecuador. Reproductive and sexual rights are also still an issue, with around four million risky terminations being carried out, and a lack of knowledge and use of contraceptives, which has a big impact on overall.

Post-2015

Looking to the future, will the post-2015 agenda do better? Global consultations have taken place and the top priorities are to eradicate extreme poverty; there is a need to go beyond earlier MDGs to reach the poorest but the targets are still vague.

In the new framework there will be more focus on violence against women. Violence in general is a huge problem in Latin America, where 30% of homicides take place. There is also a need to tackle the phenomenon of femicide, which has swept through countries such as Mexico and Guatemala. There are also calls to end child marriage, to ensure equal rights for women to own property, sign a contract, register a business and to open a bank account.

Summing up, Molyneux said that, ultimately, progress for women is contingent on much bigger issues that affect everyone and go beyond specific targets, concerning what development model governments will pursue. The MDGs hint at the bigger issues but the question is, will the post-2015 framework be enough? Recent protests in Chile and Brazil show that the question is in the minds of the people.

Fertility and the media – unravelling the hype

Each week in the UK, news and feature pieces on fertility, pregnancy and childbirth proliferate in the mainstream media, in tabloids and broadsheets alike. Stories based on results of clinical studies on topics such as advances in fertility treatment, practices to ensure a healthy pregnancy and so on appear on a regular basis. But how accurately is the science being interpreted, how much is being omitted and how misleading are some of the headlines?

Headlines such as ‘1 in 3 will be infertile in 10 years’ (Daily Mirror, June 2005) and ‘Babies given Calpol and other forms of paracetamol are more likely to develop asthma’ (Mail Online, November 2012) certainly grab readers’ attention, but they also cause fear and anxiety in parents and prospective parents, who may not have the relevant medical knowledge to be able to look objectively at the evidence presented. (For those who are aware of it, the NHS does a valiant job of combating some of the inaccuracy and misinterpretation of clinical evidence in these stories with its Behind the Headlines section of the NHS Choices website.)

The commodification of fertility and childbirth  

It is a sad fact that there is a high level of commercialisation around women’s health, which has undeniably increased in recent years, as health services become privatised. The areas of maternal health and fertility treatment are particularly affected. Vicky Garner wrote recently of seeing sales reps from a commercial ‘parenting club’ lurking on maternity wards handing out child benefit forms. Under the guise of offering support to complete the form, they were taking down the details of new mothers with a view to contacting them to market their services. She argues that the reps exploit women who are at their most vulnerable and anxious to give their newborns the best start in life; an anxiety that is heightened by the scare-mongering headlines we see every day.

When it comes to fertility treatment, it is easier to see where there are opportunities for profit to be made by private companies, given that fertility treatment is not universally available on the NHS (eligibility depends on where you live and other criteria). It therefore falls to private clinics to offer IVF treatment, and they can market and advertise their services as they wish.  However, as Miriam Zoll wrote in an op-ed in the New York Times, ‘marketing and advertisements’ play their part in selling hope to ‘customers who are at their wits’ end, desperate and vulnerable’. Zoll speaks of the ‘debilitating trauma’ associated with failed IVF cycles and treatments, highlighting that, though fertility clinics offer, advertise and market services to paying customers as if they were any other for-profit company, when treatment fails it takes a significant psychological and emotional toll.

Hype and hope

A recent event at City University, London, looked at the intersection between science, the media and public engagement, in reporting advances in fertility treatment. The meeting, entitled ‘Hype, Hope and Headlines: How Should Breakthroughs in Fertility Treatment be Reported?’ questioned where responsibility should lie for accurately reporting advances in fertility treatment. Speakers Prof Simon Fishel, Managing Director of the CARE Fertility Group, who was part of the original team whose work produced the world’s first IVF baby in 1978; Prof Nick Macklon, Professor of Obstetrics and Gynaecology at the University of Southampton, and Director of the Complete Fertility Centre; and Dr Hannah Devlin, Science Editor at The Times, discussed the issues around this controversial topic.

Ahead of the meeting, Profs Fishel and Macklon and event organiser Connie St Louis spoke on BBC Radio 4’s Woman’s Hour. St Louis said that PR teams at IVF clinics often put out ‘overblown’ press releases, and she cautioned science journalists to be wary when producing stories based on clinical trials, particularly when a study is being publicised by the organisation that funded it. She also pointed to the lack of balanced argument in healthcare stories, and said that journalists should seek out a range of expert opinions in order to include different voices in stories on IVF.

On the other side of the argument, Fishel, though he agreed with the need for robust reporting of results and for peer review, cautioned that the best must be done to push the science of the field forward via mainstream media.

The City University event following the Woman’s Hour discussion was organised by the Progress Educational Trust (PET), an independent charity that aims to raise awareness of embryo and stem cell research, genetics and assisted conception and to engage with policymakers and medical professionals to inform debate. Fiona Fox, Founder and Director of the Science Media Centre – a charity that improves public trust in science by persuading scientists to engage more effectively with controversial science stories in the media – chaired the meeting.

Media engagement

Fishel stated his position on the debate topic, saying that information on developments in reproductive technology must be accessible to patients as and when it becomes available. As the pace of reproductive medicine moves so quickly, he said, it takes time for cutting-edge technology to filter through the medical profession, meaning that GPs and even some specialists do not understand or appreciate the breadth of the work done in fertility research. He pointed out that even the National Institute for Health and Clinical Excellence (NICE) can be too slow to issue guidance when seen from the perspective of a couple seeking new, improved therapies. When looking for clinical evidence to recommend a fertility treatment procedure, it is problematic to consider randomised, double-blinded, controlled trials to be the ‘gold standard’, he said. Because of their lengthy duration (15 years), by the time the results are available it will be too late for many couples, he argued, suggesting that other types of trials, such as cohort observational studies should be considered.

It is not always easy for journalists or the public to grasp that all scientific knowledge is provisional, he said. In other words, science is progressive, with improvement and advances being made all the time; however, the time in which a couple want and are able to have a baby is limited and they should be able to be access information on all current treatment options. The key lies in responsible communication to the media, he argued, so it is up to trial investigators, clinics and press officers to accurately communicate their evidence to the media and it is up to the media to look at the evidence before reporting.

False hope

Presenting a contrasting view, Macklon argued that when a couple see a headline proclaiming breakthroughs in fertility research, there is a danger of giving false hope that they will not only be able to access this new treatment, and that it will be successful. A relationship with the media is necessary to raise awareness and encourage funding of potential new treatments, he acknowledged, but if the relationship between clinics and the media is ‘too cosy’, this can lead to false hopes being raised. Macklon, in his argument, reminds us that there is a third party, the potential patient, who stands to lose out financially and emotionally, when ‘unproven technology’ is being offered in IVF clinics for profit. The patients are the ones paying the price for uncertainty, he said.

Devlin countered Macklon’s argument by accusing him of being ‘patronising’ to potential patients. She acknowledged that, as a journalist, IVF stories are always welcomed as the science is ‘easy to follow’ and is relevant to everyday life, encapsulating controversy, morality, life-changing events and they can be illustrated with ‘cute baby pictures’. Agreeing with Fishel, she posited that it is the job of journalists to filter out anything that might give false hope to patients, but that all developments, no matter what stage they are at, should be reported. She also highlighted that there is pressure from editors to cover stories reported by the majority of most national papers, to maintain competitiveness.

Considering responsibility

In the discussion following the speakers’ presentations, there was clearly a split in the audience between where it was felt that ultimate responsibility should lie for the accurate communication of clinical results to the public. One commenter suggested that patients seeking fertility treatment would not go to a medical journal to seek out the original research, thereby placing emphasis on the newspaper/journalist to offer balanced and accurate information. Another questioned the role of the PR or press officer in drafting a press release free of language and phrasing that might appear to sensationalise the facts. Concern was also raised over not withholding or omitting information and the need for the wider debate to move forward.

It was also emphasised that other expert opinions should be presented in a story and this would be the journalist’s responsibility to present alternative viewpoints. Macklon pointed out, however, that some doctors may have a vested interest in recommending a particular treatment (or, conversely, in not recommending it).

Does knowledge empower?

Fertility treatment is unlike any other area of medicine in many respects. Being largely provided in private practice, there is the market and, therefore, the finance available to plough into technological development; however, this means that the availability of evidence from (the so-called ‘gold standard’) randomised, controlled trials cannot keep up with the pace of development or the demands of the consumer/patient.

From the speakers’ presentations at the City University event and the discussion that followed, it seems clear that a collaborative approach is needed in order to responsibly and accurately communicate developments in the field of fertility treatment. Perhaps, as one commenter highlighted, this all points to the need for better-quality are more accessible patient information in the UK. But in lieu of this it would seem that it is the responsibility of all involved – press officers, journalists, and clinicians to communicate accurately and put in context any available information. Mutual trust, it would seem, is crucial when communicating science to the public.

Conclusions

The argument that knowledge is empowering for the patient certainly has merit, but it is important to bear in mind that both the media and the clinic stand to make commercial gain from the publishing of fertility stories. And as long as treatment remains in the private sector, there will remain a ‘cosy’ relationship between the media and the provider, however well hidden; the danger is that the patient, who should be at the centre of the discussion, will be open to exploitation.

Women’s health: the patriarchal paradox

‘Health – bounding saucy health – is the fountain from which all true beauty springs.’¹

This quote, from The Girl’s Own Book of Health and Beauty, sums up the perception of girls’ and women’s health in the late 19^th and early 20^th centuries. A woman’s health was never just about her physical condition, but was related to her mental health and, most importantly, her appearance.

The commonly held view, propagated by ‘experts’ such as Dr. Henry Maudsley, was that girls had a finite store of energy, which needed to be reserved for the processes of pregnancy and childbirth. Any woman who was too active before marriage would exhaust this supply of energy, making for a weak, frigid and mentally deficient adult.

Some medical professionals and social commentators used this popular belief as an argument to petition against women’s education, for example, Maudsley, who wrote of the ‘excessive mental drain as well as the natural physical drain’ caused by school or college study.² For women to reach the ideal of motherhood, therefore, and produce many strong and healthy children, the safest and most healthy pre-marriage lifestyle involved remaining in the home, inactive except when engaging in sedentary, non-intellectual pastimes.

The ‘New Girl’

In the post-First World War era, however, the ideal image of female health and beauty underwent a radical revision and the ‘New Girl’ emerged. Sport and outdoor activity were encouraged and beauty was linked with physical strength and the shapeliness that comes from regular exercise. Bodily beauty was linked with sexual attractiveness, and the role of the wife as a sexual partner, rather than as a mother, was emphasised, placing value on youth and women’s responsibility for their own lives and winning a husband.

The link between health and sexual attraction persists in our current popular culture. Newspapers and magazines promote diet and exercise, primarily in order to achieve a desirable body.  Even in supposedly health-focussed publications, physical shape and appearance, not intrinsic health, is the real subject of the advice, as a recent blog piece on the magazine, Women’s Health, points out.

Despite the more than 100 years that have passed since Gordon Stables published The Girl’s Own Book of Health and Beauty, we are still transfixed by the idea that health is linked with appearance. In the media, women promote health products to other women through their appearance; we should be attractive, active, always striving for self-improvement and always, always thin (yet still constantly engaged in an on-going effort to lose weight). Furthermore, we are also responsible for each member of our family’s health. Possibly the only indulgent product women are ever seen to promote is chocolate, which is represented as a guilty, sexualised pleasure to indulge in secretly (see every Galaxy ad ever made).

However, while women are placed as instigators and protectors of their own and their family’s healthy eating habits, advertising aimed at men encourages indulgence in laziness and greed through the consumption of unhealthy drinks, snacks and junk food.  But despite the preoccupation with women’s health in the media, it is the bad eating habits in men promoted by such gender-specific marketing that have been blamed for a far greater cancer risk in men than women. Yet the stereotyped images persist.

Doctor knows best

The late 19^th century saw the development of obstetrics and gynaecology as discrete specialisms, opening a new market in the medical landscape. The effect of this was that doctors now had even greater control of women’s bodies, administering questionable and barbaric treatments for disorders such as epilepsy and ‘hysteria’. For example,  genital massage and the development of the vibrator for the treatment of hysteria, or Dr. Isaac Brown Baker, who claimed success in treating epilepsy and other nervous disorders in female patients by excising the clitoris. In the case of the development of the vibrator, as Rachel P. Maines highlights, ‘Doctors were a male elite with control of their working lives and instrumentation, and efficiency gains in the medical production of orgasm for payment could increase income.’

At this time, the female anatomy was shrouded in mystery. As Maines points out, Thomas Laqueur says that physicians writing of anatomy ‘saw no need to develop a precise vocabulary of genital anatomy because if the female body was a less hot, less perfect, and hence less patent version of the canonical body, the distinct organic, much less genital, landmarks mattered far less than the metaphysical hierarchies they illustrated.’ Therefore, treatment for women was much more fluid, experimental and ambiguous; for the female patient it all came down to trust in the physician’s knowledge and methods.

The image of the doctor as profit-focussed businessman, who capitalises on the lack of knowledge of his patients is reflected in the recent case in Bluegrass Women’s Healthcare Centre, where the owner pleaded guilty to misbranding non-FDA approved forms of birth control. In addition to the immorality and illegality of this action, the fact that these were intrauterine devices adds an extra level of violation. Women, against their will had had a potentially dangerous object placed inside them by someone they should be able to trust.

The paradox

Women’s health, therefore, has always been a strong preoccupation for patriarchal society. The womb is seen as public property and the health of its owner crucial to the that of the society as a whole. Though we are now somewhat more scientifically informed, many of the beliefs around women’s health of the late 19^th and early 20^th centuries persist today. We still equate women’s health with sexuality, and place the responsibility for the wellbeing of the family, and therefore society as a whole, on women’s shoulders.

Yet, ironically, it is often women that suffer the most when it comes to cuts in health services. Take this open letter from a resident of Ravalli county in the US, in which commissioners voted to eliminate funding to women’s healthcare. To these commissioners, the woman writes, ‘somewhere down the road you may meet a woman who has no hair and less hope due to an advanced breast cancer that, if you had voted differently, could have been caught earlier’. And elsewhere in the US, politicians have been accused of backing policies that are anti-women’s health.

In the UK, a discussion on the BBC’s Woman’s Hour on NHS funding for IVF revealed that 50% of those polled believed that, as a non-emergency treatment, the NHS should not fund IVF at all. Of course, access to IVF is not something that solely affects women but this is another area in which women can be attacked and made to feel guilty about their health. By taking away the universal right to fertility treatment (even just by raising the question in discussion), the message is sent that if you cannot conceive naturally your health must be at fault and you must live with the consequences. The technology that has been developed that could help you can only be accessed by the elite.

This shows that, when it comes to women’s health, there has really been very little progress made since Victorian times. Evidence shows that, when and where there are resources and a market in which to make a profit, women are made to feel their health is imperative, and that there is something inherently unstable in being a woman that makes her mind and body vulnerable to disease, which must be remedied with medicine without question. However, when resources are scarce, it is women’s healthcare that is the most dispensable.

References

1. Gordon Stables, The Girl’s Own Book of Health and Beauty, London: Jarrold and Sons, 1891.
2. Henry Maudsley, ‘Sex in Mind and in Education’, Fortnightly Review, 15, 1874, 466–83.

I can dream …

So much has has happened in the world of gender inequality (that is, the actual world) during this blog’s lengthy hiatus, it would be foolish to attempt to cover everything.

I long to say how glad I am that, since I last posted, we now live in a culture where women who have campaigned to get a female face on an English banknote aren’t systematically targeted with death and rape threats, and that when they are, they are taken seriously by the police; or that female prime ministers are not publicly attacked with sexist abuse; or that it is regarded as just plain weird that magazines full of near-naked women would sit on supermarket shelves next to Peppa Pig magazine and the New Scientist; or that topless women were not compared with vegetables by tabloid newspapers in a sad attempt at wit. I wish I could be glad that statistics were not manufactured and misattributed by lazy journalists attempting to victim-blame and underplay the impact of a serious crime (as journalist Peter Lloyd did in a recent Daily Mail article, attributing a statistic to UK charity Rape Crisis that ‘almost 1 in 10 rape allegations are fake’ – a completely incorrect statement for which Rape Crisis has demanded a retraction and apology). I wish I could be happy that we live in a country where council cuts haven’t caused the destruction of essential services, meaning that the lives of women and children are put in danger.

But sadly I can’t.

Feminism is a utopian issue

The creepiness and inaccuracy of Caitlin Moran’s recent comments on rape have been widely discussed. In an interview, Moran said, ‘I know there’s a woman coming who I could rape and murder, because I can hear her coming up the street in high heels’. As the F-word post points out, these comments are hugely unhelpful, unsisterly and downright inaccurate, adding to the culture of victim-blaming that prevails currently. It’s pretty much common knowledge that only a small percentage of rapes are committed by a ‘stranger in the bushes’ waiting to pounce on lone females walking home in the dark, and her comments perpetuate this myth.

The other big issue here is that of class, and particularly how it relates to feminism. In the same interview Moran comments, ‘No billionaire heiresses are ever abducted and raped and murdered, because they are just being put into a taxi or have their driver waiting around a corner for them. Again, it’s not just a feminist thing, it’s a class thing.’ Aside from the implication that ‘not wanting to be raped’ equates with ‘feminist’, this is misleading; the fact is, rape happens because some men cannot control their sexual impulses and to use class division as an argument for the existence of sexual offences is not helpful and is far too simplistic.

She also seems to advocate passivity in her comment, ‘while we’re waiting for society to change, there’s just certain things you have to do [to be safe from rapists]’. I don’t believe that gender equality is something that we should wait to happen after society has been ‘sorted out’. It should be an integral part of effecting social change and is something that society as a whole will benefit from. As Millicent Fawcett said, ‘men will never be truly free so long as women are held in subjection’. Effecting equality is about the strengthening of society as a whole, not about class warfare or gender warfare.

Making people feel that they have a place in society and therefore some ability to change it comes down to a question of representation, whether it be in terms of gender, race, class or sexuality. In the recent Fawcett Society debate, Caroline Lucas, Green Party MEP, said that there will be a greater chance of people engaging with the political process if there were more women in power. Because we live in a society where democracy is not representative currently, anyone who is not white, male and middle-aged feels alienated. If we are not represented by people who look like us, Lucas said, then there is more of a chasm between political parties and people. This can also be extrapolated out to the general media and to various workplaces where women are under- or misrepresented.

On a more theoretical level, I’ve been reading recently about utopian ideology, of which gender equality is a key feature (for some utopian writers, anyway). In her article, ‘Looking for the blue: the necessity of Utopia’, Ruth Levitas writes that, in order for the concept of Utopia to be incorporated into political and cultural thought, it needs to be ‘understood as a method rather than a goal, and accompanied by a recognition of provisionality, responsibility and necessary failure.’ Marcuse, another utopian writer, suggests that much remains to be done of a critical and diagnostic nature in examining the various ways in which our society represses the utopian principle and the utopian imagination. The key word here is ‘imagination’. If we can imagine living in a society where rape is not viewed as an inevitable consequence of a woman walking alone down a dodgy street at night, it might help us realise the ultimate goals of an equal society.

28 Too Many and FGM in the UK

I recently went to a South London Fawcett Group meeting, where Ann-Marie Wilson, Founder/Director of 28 Too Many spoke about the work of her charity. With a background in corporate HR, she went in 2005 to West Darfur to do some aid work, where she first came across the practice of female genital mutilation (FGM), meeting a young girl who had undergone the procedure at the age of five. This girl was then raped at the age of 10 and became pregnant. This, Wilson said, was a wake-up call and she returned to the UK to find out what anti-FGM work was being done. She found it was virtually nothing and so founded 28 Too Many. The 28 refers to the number of countries that practice FGM in Africa. However, it takes place many other countries such as Russia, Belarus, UK, Netherlands and Canada.

FGM takes place in a complex and emotive cultural context. FGM has been going on for 2000 years, is pre-Christian and pre-Islamic. In 2003, Wilson said, 140 million women had had FGM done to them. Perhaps one of the most difficult aspects of FGM to accept is that this is a woman on woman practice. It is seen as a rite of passage; if women do not have it done they have no chance of marrying, which is the only way for a woman to be valuable in certain societies.

There are three different types of FGM. The first is a clitoridectomy, where the clitoris is cut out entirely; type 2 is clitoridectomy plus the removal of the labia minora; type 3 includes both clitoroidectomy, removal of labia minora plus the labia majora, leaving a large open wound that is stitched with catgut. A tiny orifice is left for menses, copulation and birth. Menses are therefore often retained, causing infection and infertility. The type and prevalence of FGM practiced varies depending on the country. In some countries, nearly 100% of the female population have FGM, Wilson said.

FGM normally takes place in children at the age of nine or 10, but it can be done on babies as young as eight days old. Around three million girls a year undergo FGM and around 10% of these will probably die from haemorrhage or infection. This equates to 300,000 FGM-related deaths a year, or one every 10 seconds. The procedure is often done using cultural instruments, which could be a used or new razor blade, or could be a knife or a piece of glass, which obviously has implications for infection such as septicaemia, haemorrhaging and death. No anaesthetic is used. Aside from the physical pain, Wilson highlighted the psychological trauma this must cause in children who don’t know what has happened to them, only that they have been cut and that this is seen as a good thing for them and their family.

Wilson said that originally FGM was done to protect the value of slaves, who would be sold intact as a virgin so the slave master could have them as a virgin and also, being virgins the girls would not be pregnant and therefore could work longer. Wilson emphasised that the practice is not just a Muslim practice and in fact does not occur in Iran or Iraq. Christians and Jews across Africa also practice FGM, however, it is mostly done in Muslim communities. Although the Qur’an does not specifically mention FGM as a necessary practice for Muslim women, illiterate women are often told by men that it is. Furthermore, the myth perpetuated is that women are oversexed. Considering girls in their early teens are often married to much older men who may have other wives already, it begs the question, who is really oversexed?

In some areas, the procedure has been medicalised and is performed by a qualified health practitioner, meaning the risks of infection and haemorrhage are minimised. However, the complications of obstruction in labour and retained menses still occur, aside from the fact that this is a waste of the healthcare professionals’ time and resources, is against accepted medical ethics, and leads to FGM being legitimised and institutionalised. In fact, a third of the 28 countries do have anti-FGM laws, a third have laws around the prevention FGM, but a third have none at all.

The rationale for FGM in many communities is that it is the price of beauty, and in countries that are fixated on chastity and virginity, there is an aesthetic aspect, the clitoris being seen as a remnant of maleness and the ideal to have a flat, smooth area (scar tissue). But in childbirth the vagina needs to dilate 10 centimetres to give birth, meaning that scar tissue is constantly opened and restitched when women undergo multiple childbirths. The social importance of FGM means those who have not undergone FGM are considered ‘girls’, who cannot undertake the work of women, ie drawing water, attending rituals and preparing food. The husband might not be able to work, which has implications for the whole family. Other complications include the time it takes to urinate, which can take 15 minutes, meaning girls miss out on classroom time, affecting their education. There is also the risk of false pregnancies due to retained menses, meaning the girl’s abdomen swells, leading her family to believe she is pregnant.

FGM takes place in the UK. In the past, girls would go to Africa to be cut during the long summer holiday, but the increasing awareness of UK authorities means that now it is more usual for the ‘circumciser’ to be flown into UK, where ‘cutting parties’ are held. Areas of the UK where this occurs include in Bristol, parts of London and Rochdale. The UK has had an FGM Act since 2003, making it illegal to aid and abet any UK resident to have it done. However, there have been no convictions as yet, although three people have been arrested under these laws as a result of a Sunday Times report. The problem is that FGM is complex issue affecting a minority group in the UK, where there is lack of money, voice and literacy.

It is difficult to get young women to speak against their families. Wilson cited an example of girl who refused to join a swimming class at school, giving as a reason the fact that she had recently been cut. The school then contacted the girl’s family, and the child withdrew her case. In fact, the UK is seen as softest European nation regarding anti-FGM measures. In France girls are examined routinely (although there are question marks over the ethics of this) and in Scandinavia girls have a right to be inspected at airports. As with many cultural traditions, such as the wearing of the veil, the practice of FGM is often kept alive when families move to UK, as a way to maintain a connection with the culture of their home country.

As part of the work of 28 Too Many in the UK, Wilson has held talks with school nurses in areas such as Haringey, to educate them about the practice. She has also held conferences, inviting Mulsim clerics and other religious leaders to try to influence their teachings.

One problematic aspect Wilson addressed is that there is also contradiction inherent in that labiaplasty is legal in this country, as in many Western cultures but FGM is not, and this is an interesting point, especially if a boyfriend has put pressure on girl to undergo labiaplasty to conform to the ‘ideal’ look of female genitalia seen in pornography.

So what can be done to combat the practice of FGM? The approach taken by Wilson and 28 Too Many is based on establishing hard facts, mapping rates of FGM in different countries to see where prevention is working and where not, establishing benchmarks to form the basis of research and subsequent education. The aim is also to build networks with other charities working in this area.

Wilson cited the example of footbinding, which ended in China within 16 years after 1000 years of practice. Hopefully, Wilson said, in three generations the same could be achieved for FGM. To do this, she said, courage and drive are needed.

The Duchess of Malfi, White Bear Theatre, Kennington

Themes of silence and concealment run through The Duchess of Malfi, by John Webster.  In the tiny venue of the White Bear Theatre, Kennington, Eyestrings Theatre’s production was visceral, stripping back the play to expose the frailty and brutality of the characters.

A pervading sense of unease began at the outset when the cast, already seated on chairs at the front as the audience came in, suddenly broke into wide, forced, almost deranged smiles, turning to the audience and making eye contact with individual audience members, which was unsettling, and provoked a fair amount of nervous laughter in the audience.

The Duchess of Malfi is a young widow, who is forbidden from marrying again by her brothers, the Cardinal and Ferdinand. The reasons for her brothers’ not wanting her to remarry may be attributed to a wish not to share their inheritance with her but there are other, more complex reasons at play, as there always are in Jacobean tradegy. By marrying Antonio, who is a steward, the Duchess shows that her motives for marriage are not political or strategic, but based on love and sexual attraction and it seems that this is one cause of her brothers’ chagrin. In the world of the play, female sexuality is threatening to men, something to be suspicious of, Ferdinand referring to her disdainfully as a “lusty widow”.

Is the Duchess a feminist figure? Perhaps her motives, which are simply to be happy, to marry and have a family, would not be seen as particularly feminist now, but it certainly takes courage to rebel against her brothers’ wishes. “I through frights and threatenings will assay/This dangerous venture,” she says, determined to get what she wants in spite of them. In the context of the play, she is asserting her sexuality and subverting the ideals of power and class by marrying, in secret, beneath her, and against her male relatives wishes, which makes her a fairly radical figure by contemporary standards. Furthermore, her “crime” is thrown into sharp relief against the hypocrisy of the Cardinal, a man of the clergy who is involved with a married woman, Julia.

The brothers fear the Duchess’s power should she remarry, as a woman, alone, chaste and silent, is not threatening to them. Kelly Hotten, who plays the Duchess, cut a slight figure in a close-fitting grey gown, emphasised at times by her drawing in her shoulders, making her appear bird-like and fragile. In contrast, Ferdinand, played by Orlando James, is muscular and, in his final scenes, appears without a shirt, as if to emphasise his masculinity. However, by this point he has shown himself to be fragile is in his mind, as he succumbs to madness through his guilt, finally being murdered by Bosola, the servant he had commissioned to murder the Duchess. This physical strength/mental fragility of Ferdinand contrasts nicely with the Duchess’s physical frailty but strong mindedness. In contrast to Ferdinand’s mad ranting at his end, the Duchess is calm and quiet. As Bosola says of her, “Her silence, methinks, expresseth more than if she spake.” Also, her death is a kind of symbolic silencing, as she is strangled, she says, “Go tell my brothers, when I am laid out,/They then may feed in quiet”. As well as the Duchess herself being silenced, so is Julia, who is murdered by the Cardinal to prevent her from revealing the fact that the brothers order the murder. Also, Cariola, the Duchess’ maid is murdered mid-plea for her life, almost in mid-sentence.

The only male in the play who does not wish the silence of women, and the Duchess in particular, is Antonio, “You only will begin then to be sorry when she doth end her speech,” he says at the beginning of the play. However, being direct about her desires as a woman is difficult. When she declares her love for him, she speaks of her frustration that as women, “we/Are forc’d to express our violent passions/In riddles, and in dreams.” Female sexuality is a taboo subject in this play and the Duchess is the sole figure to rebel against this and act on her desires. As she says to Antonio, “This is flesh and blood, sir/’Tis not the figure cut in alabaster”.

The Duchess of Malfi is on at The White Bear Theatre, Kennington, until 30 September.