On women's right to experience their sexuality free from illness. (Reflections).

In this presentation I will address the challenge of developing a feminist reflection on women's right to experience their sexuality free from illness. Without abandoning my perspective as a physician, I will make use of the contributions provided by the feminist study of bioethics to question our role in the situation of women who become ill through exercising their sexuality. Bioethics is a new discipline which believes that it has incorporated moral diversity as a regulatory principle of moral conflicts (Diniz, 1999). Indeed, we perceive that the situations of diagnosing and treating STDs result in a moral conflict.

In the countless studies which address this issue, certain basic premises emerge. The first is that in the field of health and sexuality, three domains converge: sexuality, gender and health (Gogna, Ramos, 1999). Any intervention that seeks to have an impact on health must take this reality into account. The second premise is that the social representations of sexually transmitted diseases are radically different for men and women. And finally, without detailing the epidemiological data, I would like to stress the high rates of these illnesses among women, including the resurgence of syphilis and the serious problem of AIDS, particularly in relation to women and the poor.

In regards to ethics, we human beings may belong to several moral communities. In each of these communities, we fulfill various moral obligations which often enter into conflict with each other. On the other hand, these moral obligations and our private commitments may be incompatible. Frequently, these situations generate dilemmas, and the most common solution is the incorporation of another, new set of morals which serves to replace the previous problematic and uncomfortable ones. Even if some moral tribunal existed to establish increasingly difficult moral obligations, this dilemma would never be resolved (Rorty, 1997). Such assertions are sure to find resonance in the personal lives of each of us, as we have seen in the frequency and diversity of the moral conflicts that we experience daily as physicians.

Living together and tolerating our different sets of morals implies another ethical challenge. The tendency to ignore our differences stems from an intolerance of anything that we identify as other. And although we may take comfort in the impossibility of validating the range of values and subjectivities of either a single person or of an entire culture, there is no universal recipe for unraveling or rewinding this complex skein, even though we can try. We may doubt, but never ignore, the limits we establish for truth because they force us to act. Reestablishing these limits of truth is the objective of our analysis, illuminated by the beacon of feminism and Rorty's proposal of solidarity.

In the context of post-modernity, marked by the crisis of essentialism, feminists have tried to deconstruct women's status and analyze in greater depth the numerous aspects of gender relations. We have challenged the idea that biological differences between men and women are solely responsible for women's subordination and oppression. Instead, we believe that in our society the social attributions designated to each sex are determined by their biology. As a result, we argue against the naturalization of women's sexual and social asymmetry which stems from gender relations.

As physicians, we have intervened in women's bodies and health, transplanting and disseminating new values and meanings, which often involve creating new needs. The result is the medicalization of women's bodies, of the pains of life and of the physiological and reproductive phenomena which occur in women. To cite just one example, tubal ligation as a method of birth control is today a consecrated cultural value, a product included in the life plans of Brazilian families. More recently, but no less effectively, we promote hormone replacement therapy as essential for replacing something that the body lacks, something that it no longer produces, in order to give back to women lost years of life. Not only is the universalization of this indication abominable, but we are losing yet again an opportunity for establishing relations between physicians and women which would encourage women's confidence and self-esteem. The recognition of women's need for information about what is happening to them, about the countless side-effects of this therapy and the real limits of its action, should be an established part of offering hormone replacement therapy.

Feminist intervention in the health-care field continues to systematically criticize and confront interventionist and moralizing medical practice on women's bodies. Feminists also denounce the asymmetrical power relationships inherent in this situation and its contribution to women's submission.

A Hierarchical Model of Morality

In regard to sexually transmitted diseases, the imposition of norms through the power of physicians--"standard medical prescription," in other words--has not resulted in concrete changes in attitudes or behaviors that could reduce risks related to these illnesses. We can thus infer that physicians are "communicating" very little with the women they treat. This is still more evidence of the yawning chasm that separates women and their physicians, two very different moral communities. In the classic physician/ patient relationship, the physician's morality predominates, based on the supposed power of medical knowledge, which makes him/her the unquestioned moral authority.

In this hierarchical model of morality, the physicians' moral values based on their knowledge of the body, illness and life usually are transferred to the women who are uninformed about these processes. By negating the value of the other, our medical practice prevents women from recognizing, nurturing and identifying their own moral values. In a way, this practice hides an "innocent" tendency towards essentialism, innocent because it is based on the belief in the efficacy of the medical moral, essential since it stems from the moral authority, i.e. the physician.

However, our real experience as physicians confirms our suspicion that, just as there is no human essence, neither is there an essential moral perspective. In fact, a secular rationale--based on the negation of the gap between moral perspectives--has been the basis of classic medical ethics. Engelhardt, a contemporary bioethicist, disabuses us of this innocent illusion when he asserts that "the aspiration was to discover, through use of reason, a common morality that would unite all and provide a foundation of perpetual peace.... It became clear that this was a false hope" (Englehardt, 1996:29).

We physicians always maintain a trace of the hero. An anti-tragic hero, to be sure, since by dealing in certainties and truths we eliminate the possibility of tragedy from our practices. What's more, we deny the very existence of tragedy (Diniz, 1999). Thus, we are transformed into privileged guardians of morality; our medical moral is sanctified. And such greatness removes us from our human condition, granting us the status of demigods. The enjoyment of this grandeur obscures reality, shaping it and making it comfortable.

Let us consider more closely our medical practice as physicians treating a woman with a sexually transmitted disease. Once the illness has been identified, the physician faces various dilemmas: whether or not to clarify the origin of the illness and thus produce doubt regarding the fidelity of the husband or partner, or to keep the woman ignorant of her own life, based on the conviction that this ignorance would protect her. At least three different actors--with three distinct moralities--are directly implicated in this situation: the two partners and the physician.

Since sexual relations imply a relationship between two people, STD prevention and treatment inevitably--by action or omission--include both members of the couple (Gogna, Ramos, 1999). However, the common-sense action of the physician reinforces and strengthens gender stereotypes and avoids provoking conflicts between the partners. The moral dilemma of the situation described permits us to contemplate individual medical practice, but also hints at a more ambitious undertaking, which implies the adoption of policies and strategies for the reorientation of health-care services.

STDs affect women and men differently. Biologically, women show fewer symptoms and signs than men. On the other hand, from a cultural perspective women are always labeled as vectors that spread these illnesses and are often punished. But in fact, this guilt is related to the association of women with sin and is not supported by solid facts. As Dixon-Mueller and Wasserheit explain, "It is more likely for a uninfected woman to acquire an STD from an infected partner than the reverse; it is also more likely that she will suffer more serious long-term consequences, including pelvic inflammatory disease, ectopic pregnancy, cervical cancer, chronic pelvic pain or infertility." (as quoted in Gogna, Ramos, 1999)

Nonetheless, many men believe that merely knowing someone and subjectively evaluating their hygiene is an effective form of protecting themselves against sexually transmitted diseases. Such behavior reflects the many social representations of vulnerability and risk related to these diseases and how our failure to recognize these representations distances us to such a degree that dialogue is impossible: it is the inefficient dialogue between two different moral communities.

In light of this impasse, any attempt to improve health by changing peoples' behavior must be based in the development of a critical awareness of the circumstances surrounding the lives of each individual. Thus, interventions in the health-care field should aim to bring about these changes by promoting an awareness that empowers people to think critically (Gogna, Ramos, 1999), rather than passively internalizing generally accepted images, norms, systems and values.

Women's vulnerability results from the combination of biological aspects and situations rooted in the asymmetry between the genders. This vulnerability is especially reinforced when love enters the scene, making the adoption of the so-called safe sex practices practically impossible (Martin, quoted in Barbosa, 1999). Penetrating the complex dimensions of the practices of prevention and sexual negotiation implies dissecting the very basis for partnership and the experiences of love; it implies a profound discussion of the relations between the partners: it is therefore a threatening situation. The horror of knowing the truth comes from the certain cruelty that this awareness implies, the intrinsically painful and tragic nature of reality. On the other hand, by going beyond the limits of tolerance of this cruel reality, the human being has the possibility of experiencing a privileged moment of clarity, the perception of reality in general and one's own reality in particular, which would permit the reconstruction of the self based on new meanings.

Thus we see that morality does not, in any way, censure what is immoral, unjust or scandalous, but what is real--the unique and true source of all scandal (Rosset, Clement, 1989). In other words, it is immoral to reveal the truth--to anyone--when this truth is unpleasant; in other words, the truth is only admissible to a certain degree of cruelty, beyond which it is prohibited (Rosset, 1998). Moral agreements have made physicians our "protectors from reality."

For married women--a group that is particularly vulnerable to STDs, especially AIDS--the adoption of the practices of protection and prevention collide with the need to confront the painful reality of their private lives. Adopting methods of prevention means admitting the inadmissible--infidelity. Experiencing this tragic horror may be unbearable and lead to the abyss of insanity.

The idea of sexual negotiation, a strategy for encouraging the use of preventive practices and methods, demands some basic influence which impedes its transformation into a moralizing and inefficient medical discourse. Sexual negotiation should presuppose the recognition of the different sexual desires of each of the sexual partners, the satisfaction of these desires and the conditions resulting from the tendency towards domination between them (Barbosa, 1999).

Nonetheless, sexual negotiation as an STD/AIDS prevention strategy among women and men can be seen in a different light if we understand sexuality as belonging to social subjects inserted in networks of meaning and values which shape behaviors, attitudes, desires and fantasies that can be given new definitions and new meanings (Barbosa, 1999). This is the opportunity for women to benefit from the possibility of an ironic transformation that doubts and thus reinvents (Rorty, 1997). It is this condition that permits the reconfiguration of the physician's role and manifests her/his potential contribution. This would demand a re-orientation of her/ his work and necessarily include discussion with the women regarding their concerns about sexuality while simultaneously encouraging improved self-esteem and critical awareness regarding the status and submission of their gender.

While recognizing that any confrontation between moral differences demands caution and tolerance, it is necessary to penetrate the contexts of these different moralities and thus identify the situation or situations in the confrontation that result in inequality and humiliation for one of the parties involved. We must question our own tolerance of the submission and humiliation of the other. It is this response that should illuminate and redefine our objectives as professionals, encouraging our solidarity with those who are vulnerable (Rorty, 1991). In this fashion, the practice of medicine becomes an instrument allied with women's empowerment.

This perspective recognizes the existence of an evolution of morality, leading towards greater human solidarity. But, as Rorty warns, this solidarity is not envisioned as the recognition of a central "I"--the human essence in all human beings, as in the Christian model where the search for moral perfection imposes equal treatment for all sinners, regardless of their individual history. Rather, this solidarity is perceived as the ever-increasing ability to place less importance on traditional differences (of ethnicity, religion, gender, race, customs, etc.) and emphasizes the similarities of pain and humiliation. It is the ability to have compassion for people who are very different from us, but who are included in that sphere of "us."

The process of extending this "us" must be based on the discovery of those we perceive as "them." We must attempt to discover the similarities that we share with these people and create a more all-encompassing sense of solidarity than we have today (Rorty, 1997).

References

Barbosa, R. (1999). "Negociacao sexual ou sexo negociado? Poder, genero e sexualidade em tempos de AIDS." In Sexualidade pelo Avesso- Direito, Identidade e Poder. Regina Barbosa and Richard Parker, eds., Rio de Janeiro: IMS/UERJ, Editora 34.

Diniz, D. (1999). Da impossibilidade do tragico: conflitos morals e bioetica. Ph.D. thesis, Anthropology Department, Universidade de Brasilia.

Engelhardt, H.T. (1996). Fundamentos da Bioetica. Sao Paulo: Edicoes Loyola.

Gogna, M. and S. Ramos (1999). "Crencas leigas, estereotipos de genero e prevencao de DSTs." In Sexualidade pelo Avesso- Direito, Identidade e Poder. Regina Barbosa and Richard Parker, eds. Rio de Janeiro: IMS/UERJ, Editora 34.

Rorty, R. (1997). "Solidarity or objectivity." In Objectivity, Relativism and Truth, Philosophical Papers, Vol. 1, Cambridge: Cambridge University Press.

Rosset, C. (1988). Le Principe de Cruaute. Paris: Les Editions de Minuit.

A Brazilian physician specializing in public health, Dr. Costa is an expert in social policy. She coordinated the team that developed Brazil's "Women's Comprehensive Health-Care Program" (PAISM) and was the national coordinator of this program in the Ministry of Health. Dr. Costa is currently completing a Ph.D. in Health Science, at the Department of Health Science in the Universidad de Brasilia, where she originally presented this article.