The Pennsylvania State University The Graduate School Department of Human Development and Family Studies THE EMPOWERMENT OF WOMEN IN REPRODUCTIVE SERVICES: A POSTSTRUCTURAL FEMINIST CASE STUDY OF TWO WOMEN’S HEALTH CENTERS A Thesis in Human Development and Family Studies by Ayse Dayi © 2005 Ayse Dayi Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy May 2005 The thesis of Ayse Dayi was reviewed and approved* by the following: Edward A. Smith Associate Professor of Human Development and Family Studies Thesis Co-Advisor Co-Chair of Committee Phyllis K. Mansfield Professor of Women's Studies and Health Education Thesis Co-Advisor Co-Chair of Committee Robert L. Burgess Professor of Human Development and Family Studies Clancy Blair Associate Professor of Human Development and Family Studies Craig S. Edelbrock Professor of Human Development and Family Studies Professor in Charge of the Graduate Program in Human Development and Family Studies *Signatures are on file in the Graduate School iii ABSTRACT The purpose of this study was to investigate the legacy of the Women's Health Movement (WHM) in the 21st century, especially in relation to the concept of empowerment of women in the reproductive arena. An important line of research evaluating the legacy or impact of the WHM on women's (reproductive) health care involves the study of women-controlled (or feminist) health centers. Except for Simonds (1996) and Thomas (2000), the studies that assessed the WHM's legacy through feminist health centers had their primary focus on the changes in organizational structures as a result of external and internal pressures. Such accounts include discussions of feminist care; however the changes in care (or models of care) are not as systematically discussed as the changes in organizational structure. Furthermore, except for Thomas’ (2000) study, the concept of empowerment itself is not opened up. Including Thomas' work (2000), when empowerment (or empowering care) is evaluated, it is done so from the perspectives of women's health activists and workers, not the individual women who receive the services. In order to address these needs, in the present research, I investigated the legacy of the WHM in the 21st century through studying two women-controlled agencies with a focus on how women clients define and experience empowerment and how their experiences are affected by agency (organizational), community, and societal factors. The specific research questions that guided the study were: (1)What is the current meaning and experience of empowerment for women clients of reproductive services? (2) What are the agency and societal factors that mediate women's experience of empowerment? (3) How do the two agencies differ in enabling empowerment? In order to address the previous questions, I visited two women’s health centers in the Northeast region of the United States, staying two weeks at each site. The data collected from both sites consisted of: (a) semi-structured face to face interviews with staff and clients (clients of birth control and abortion services), (b) observations of pre-abortion counseling sessions, and iv gynecological visits, (c) field notes on staff-staff and staff-client interactions, on protesters, spatial arrangement of the centers, and conversations with staff, and (d) a review of agency forms and archival materials. The design of the study was a feminist case study with ethnographical components and poststructural influences. Feminism guided all the stages whereas post- structuralism guided mainly the data collection and analysis. The feminist and poststructural framework essentially led to rejecting objectivity and neutrality, and emphasizing instead personally and politically engaged, accountable research, where I claim to present only a partial (historically and temporally situated) truth about empowerment in reproductive health in two clinics. I used the Grounded Theory Approach to qualitative analysis to analyze the data (with the help of the NUDIST software to organize the data). The theory reached was that the current generation of women experience (and define) empowerment as safe and humane care, where care is mediated by agency and community factors and by the politics of reproduction. For women receiving birth control and abortion care, safety and respectful humane care was at the core of empowerment. Safety had both physical and emotional dimensions: being safe from anti-abortion violence, and not feeling vulnerable, judged or cajoled. Humane treatment meant receiving dignified, egalitarian, individualized, and holistic care. Women's experience of empowerment (seeking safe and humane care) was affected by community, agency, and societal factors. Agency factors were the agency atmosphere (security measures and homey atmosphere), staff characteristics (age, gender, race, and childbearing status), staff beliefs and motivations, the medicalization and psychologizing of services, and the business aspects. Community factors referred mainly to the interactions between the agency and community (people, schools, churches, other providers, feminist organizations, hospitals and individual doctors) that occurred in an anti-choice climate, and reflected the isolation and integration of the centers in their respective communities. Social factors referred to the norms and institutions that influence v reproductive services, which I called the “politics of reproduction.” The findings were discussed in the light of the definitions of empowerment, empowerment models, and within the history of the Women’s Health Movement (its aims, accomplishments, and challenges). This study contributes to revitalizing the awareness (in public and academic scholarship) of the contributions of the WHM to women's health care. The present study also provides a more current evaluation of the WHM, its present challenges and the strategies applied by women- controlled centers in navigating these challenges, contributing to the growing research on social movements and movement organizations. Although not a full ethnography (due mainly to the limited time spent at the sites), the present study is a case study with ethnographical components taking its place alongside of Simonds and Morgen's feminist ethnographies with in-depth, multimethod and multilevel investigation of empowering care. Finally, as different from Morgen's and Simonds' ethnographies, the present study is the first feminist ethnographical research of clinics from a post-structural framework. vi TABLE OF CONTENTS LIST OF FIGURES ................................................................................................................. xiii LIST OF TABLES................................................................................................................... xv ACKNOWLEDGMENTS ....................................................................................................... xvi CHAPTER 1 INTRODUCTION ......................................................................................... 1 Purpose and significance of the study ............................................................................... 1 Conceptual framework ...................................................................................................... 7 Feminist epistemologies (feminist ways of knowing) ................................................ 7 Postmodernism and poststructuralism........................................................................ 9 Poststructural feminism .............................................................................................. 10 CHAPTER 2 LITERATURE REVIEW .............................................................................. 13 Part one: The Women’s Health Movement....................................................................... 13 The origins .......................................................................................................... 13 Women's Health Movement's critique of health care ................................................. 15 Problem areas....................................................................................................... 15 Feminist critique of medicine .............................................................................. 19 Strategies for change applied by the Women's Health Movement ............................. 24 Reducing the knowledge differential between patient and practitioner ............... 24 Education ....................................................................................................... 25 Selective utilization........................................................................................ 26 Self-help gynecology ..................................................................................... 26 Challenging the license and mandate of physicians and reducing professionals' control and monopoly over related goods and services........................................ 27 Altering the size of the profession relative to clientele ........................................ 29 vii TABLE OF CONTENTS (continued) Transforming the clientele from an aggregate into a collectivity......................... 29 Feminists clinics as movement organizations............................................................. 30 Organizational changes in feminist clinics from 1970s-1990s............................. 34 Changes in the Women's Health Movement between 1970 and 1990s ...................... 39 Medicine .........................................................................................................