生育治理:限縮的統計、身體與醫學知識(二)

召集人:施麗雯(台北醫學大學醫學人文研究所 助理教授)
主持人:范代希(台北醫學大學醫學人文研究所 助理教授)

生育與所有人息息相關,孕產照護的設計連結著每個個體如何來到世上,生養的方式也決定了親職的實踐,這些過程也都化為了國家的人口統計數字。但是在很多時候,生育常是被侷限在特定的性別和照護需求的想像下,特別是從官方資料庫的收集與統計資料呈現方式、醫療照護設計、和國家的相關政策即可看到。近年女性主義研究強調生育的多層次分析,將生育視為結合生理與社會的過程,並且看重身體過程、認同經驗、互動關係,以及社會文化體制等環環相扣的層次。換言之,「生育」不僅只於生殖(受孕、懷孕、生產等),還包含未(成功)生殖的身體;養育不只包含哺乳和育兒等,親職生涯調適與社會文化體制的相互形塑等,都必須納入探討。特別是生育中不同階段的性別異同下的主體經驗。在這些研究的啟發下,我們關切:過去台灣這一百年的生產敘事為何?生育在醫學知識的內涵又是為何?女性的身體又是如何被凝視?台灣的官方統計數字如何性別化生育?在走向生養與親職實踐間的落差有哪些?圍繞著生育治理的議題,本論壇關切這些限縮的統計、醫學知識與主體經驗,五篇論文,跨越不同時期、生育階段、性別,企圖從官方的人口統計、政策與醫學知識的生育論述和實作,針對台灣的生育現況提供整體的生育評估,鍵入多元化的視角與需求。

自然流產的醫學論述與台灣男女性的主體經驗

施麗雯、鄭芮欣(國立清華大學社會所 碩士、台北醫學大學醫學人文研究所科技部 研究計畫助理)、蔣承憲(台北醫學大學醫學人文研究所 碩士生)

本文將從科技與社會的研究取徑,探索自然流產在醫學知識中和個人的身體經驗的不同表述。懷孕作為生育的過程與要件,但並非所有的懷孕都可以順利生產。根據統計,約有11%-22%的懷孕是以自然流產結束;其中有超過80%的自然流產發生在孕期前12週。在台灣約有11%-18%的已婚女性自述曾有過自然流產經驗,男性約有8%-10%的自然流產經驗。換言之,自然流產的比例不低,但是在相關的社會科學研究討論卻不多。美國人類學家Linda Layne (1997)以「研究上的隱默」(studied silence)描述當代相關研究對女性流產經驗的疏忽。事實上,不只女性的自然流產經驗很少被討論,男性的經驗也很少。針對此,本文將分析醫學教科書中關於自然流產的知識與臨床實作,並透過訪談檢視女性在身體經驗上的差異;其次,本文亦將納入男性伴侶的自然流產經驗,探討自然流產的性別差異。本文的主要目的是探討身體連結的不同自然流產事實(reality),從這些身體經驗的分析中對比現代醫學實作中對自然流產認識論的單一想像和個人主體經驗的隱默。

Over/Under-Medicalization of Women’s Health: Exploring Women’s and Healthcare Professionals’ Experiences of Pelvic Examinations in Taiwan

Malissa Kay Shaw(Assistant Professor at Graduate Institute of Humanities in Medicine Taipei Medical University)

The intensive medical intervention in pregnancy monitoring and birthing practices in Taiwan has been well documented by social scientists. There has been less research, however, into the everyday medical management of and preventative screening for women’s reproductive health outside of childbirth. Despite government initiatives to augment certain women’s health preventative screening practices, specifically cervical cancer testing, quantitative studies indicate that testing remains irregular and underused by certain segments of the population. Furthermore, limited qualitative research exists on women’s experiences of routine gynecological examinations both in Taiwan and globally. To explore why this gap in women’s health exists, we conducted in-depth interviews with 19 Taiwanese and 18 foreign women on their experiences undergoing pelvic examinations at Taiwanese healthcare facilities. Semi-structured interviews were also conducted with nine gynecologists and seven nurses providing a more comprehensive understanding of the context of gynecological screening.
Women’s and healthcare professionals’ narratives indicated various reasons as to why pelvic examinations may be underutilized, the foremost being lack of knowledge and misconceptions about the examination. Many Taiwanese women in particular, and even some nurses, only talked about pelvic examinations in relation to pregnancy and labor. Furthermore, there were misconceptions and horror stories about the pain that accompanies such examinations, which contributed to some women postponing the exam. Various foreign women and some gynecologists felt that Taiwanese women only seek the help of a gynecologist as a last resort, and routine examination is rare. Yet, some foreign women recalled instances where gynecologists made them feel it was unnecessary to undergo routine examinations if they lacked symptoms. Such experiences reflect narratives from younger gynecologist about pelvic examinations being outdated and ultrasounds being more accurate, sentiments that were not shared by more experienced doctors. Moreover, some gynecologists mentioned limited appointment times and lack of training as reasons pelvic examinations may not be performed. Reproduction itself was also narrated as a barrier to pelvic exams. Many women felt that gynecologists’ focus on reproduction rather than other gynecological issues (e.g., birth control, heavy bleeding, etc.) resulted in inefficient treatment, and often in women seeking treatment elsewhere. Paradoxically, when speaking to women about their vaginal health experiences, many women told me about their pregnancy and birthing experiences. Some noted that such experiences were off topic, but nonetheless they related their pelvic exam experiences with reproduction, suggesting that not only healthcare professionals, but also women, commonly equate women’s health with reproduction.
These narratives suggest that the discrepancy in the over/under-medicalization of women’s health are both pushed for and detracted by healthcare professionals, women, and the healthcare system. Moreover, the equation of women’s health with reproduction may be both a product of and a catalyst for this over/under medicalization gap. Socio-cultural understandings of women’s health combined with higher value being placed on certain technologically-mediated medical interventions (e.g., ultrasound, genetic testing, assisted conception) suggest important implications for women’s health, in regards to both excessive intervention and limited care, as well as the focus of academic research.

An Anthropological Exploration of Postpartum Depression in Taiwan: Women’s Experiences and the Therapeutic Emplotment

許銘心(臺北市立聯合醫院醫師)

Postpartum depression (PPD) is seen as a critical health issue due to its potential adverse outcomes such as suicide and infanticide. While the estimated prevalence of PPD in Taiwan ranges from 21% to 40.3%, the number of women diagnosed with PPD at psychiatric clinics remains low. However, although the majority of women experiencing PPD never visit psychiatrists, they self-diagnose with PPD and use the term “PPD” to articulate their sufferings in real life or online. The above phenomenon raises interesting questions – What are the subjective experiences of women (self)diagnosed with PPD? Why do women adopt the term “PPD”? What is their perception of the term “PPD”? This research focuses on the knowledge gap regarding the subjective experiences of women who have suffered from PPD. The research data is collected through six semi-structured interviews with women (self)diagnosed with PPD and through in-obtrusive online data collection on the online discussion board “BabyMother”. I first illustrate that women adopt the term “PPD” to articulate postpartum distress that is too intense and cannot be minimalised or somatised through “the work of culture”. Then, I demonstrate that women who (self)diagnose with PPD define “postpartum depression” as a “reasonably abnormal state” rather than a biological dysfunction as in psychiatry. I argue that “defining PPD as a reasonably abnormal state” should be seen as a form of “therapeutic emplotment” that women use to comprehend their postpartum distress and support themselves in confronting the sociocultural factors that contribute to their postpartum distress. By exploring PPD from an anthropological perspective, my research complements psychiatric approaches and contributes to our understanding of PPD in Taiwan.