Abstract
This article examines how feminist politics are made to ‘stick’ to appropriated technologies in the context of a contemporary feminist women’s health clinic in the US. Feminist clinics such as ‘FemHealth’, founded as part of 1970s women’s health movements, put medical tools and knowledge into lay women’s hands, making the appropriation of medical technologies a centerpiece of their political project. In the process, they rejected the authority of physicians and gave new politicized meanings to the tools they claimed as their own. As lay healthworkers at FemHealth continued the project of appropriation, they also continued to negotiate their dependence on physicians to perform tasks that required a medical license. Drawing on participant observation and interviews with healthworkers, I argue that struggles over the role and authority of physicians in this clinic play out through debates over two similar and competing tools used in the abortion procedure: the single-tooth tenaculum and the cervical stabilizer. Many healthworkers invested in the stabilizer as ‘inherently feminist’ in hopes that it would maintain its politics even when passed into physicians’ hands. While appropriation depends on the ability of users to alter a technology’s meanings, actors may feel invested in the new politics taken on by appropriated tools and work towards making those meanings persist, or ‘stick’.
FemHealth 1 is a feminist women’s health clinic that provides reproductive health services in a large city in California. It was one of several clinics established in the early 1970s as part of a surge of feminist women’s health activism across the US. The broader women’s health movement(s), in multiple and varied local incarnations, pursued a radical transformation of mainstream healthcare by rejecting the authority of medical professionals and seeking to return control of women’s health to women’s hands (Kaplan, 1997; Morgen, 2002; Ruzek, 1978; Weisman, 1998). In feminist clinics such as FemHealth, this political project took the form of putting medical tools and knowledge into the hands of lay women, who would perform most (but not all) of the medical procedures involved in attending to women’s reproductive health.
As lay women claimed for their own use technologies intended for medical professionals, they challenged the legitimacy of medicine to define and control women’s reproductive health and healthcare. Feminist clinics made appropriating medical technologies a centerpiece of their political project; as they did so, they produced new knowledge and ways of knowing women’s bodies, and gave new politicized meanings to the medical tools they claimed as their own. However, although feminist clinics were founded on and organized around a fundamental rejection of physicians’ authority, legal requirements specified that certain medical procedures (in particular, abortions) could only be performed by licensed physicians, making clinics dependent on physicians if they wanted to operate legally. Clinics have pursued varying strategies to address the lasting tensions this paradox produces for the project of enacting lay woman-controlled healthcare. In this article, I examine the contemporary case of FemHealth, where lay healthworkers continue the project of appropriating medical tools as they negotiate their relationships with the physicians required for specific clinical procedures. Specifically, I focus on their attempts to stabilize the feminist politics of a particular tool, the cervical stabilizer, as a way to resolve tensions over medical authority.
The contours of this strategy became apparent in an interview with Liz, an experienced lay healthworker at FemHealth. Liz shared with me her thoughts about a debate in the clinic over two competing versions of a clamp used by a physician to hold the cervix in place while performing a surgical early abortion procedure. The prongs of the single-tooth tenaculum 2 curve to two sharp points that grasp the cervix by puncturing it, while the atraumatic cervical stabilizer 3 pinches the cervix between two blunt ends (see Figure 1). Most clinic staff and volunteers shared a clear preference for the cervical stabilizer, which they considered the ‘feminist’ version of this tool. They valued its feminist lineage and contrasted it with the ‘brutal’ tenaculum that was ‘against our feminist rules as a clinic’. However, one well-regarded physician at FemHealth consistently chose to use the tenaculum, saying that the stabilizer did not work well for her. Liz confirmed that she had witnessed the doctor’s difficulty with using the stabilizer and stated, ‘I’d prefer Beth use tenaculums … but some people seem to think that stabilizers are inherently feminist.’ Liz preferred that Beth use the tool she felt most comfortable with, the tenaculum, but this view was uncommon among the healthworkers I spoke with. Liz’s statement made clear that many at the clinic believed the cervical stabilizer to be ‘inherently feminist’, and that their investment in the stabilizer’s feminist politics animated debates over its use.
The single-tooth tenaculum and atraumatic cervical stabilizer. Illustration by Wes Terray.
Why were lay members of this feminist clinic invested in the politics of a particular technology – the cervical stabilizer? I argue that because lay women in the clinic cannot be the direct users of the stabilizer, they invest in the inherent politics of this tool as a strategy to guarantee that they are providing feminist healthcare, regardless of the politics of the physician using the tool. As a counterexample to the contested politics of the tenaculum and stabilizer, I examine the speculum, an icon of feminist health activism. I argue that the speculum’s politics ‘stick’ because it is used by lay women; it is the speculum’s sustained use in lay women’s hands that allows it to take on a feminist politics. To develop this contrast, I bring together the insights of the appropriating technology framework (Eglash et al., 2004) with the theme of ‘right tool for the job’ (Clarke and Fujimura, 1992), which expands our understanding of how actors work to stabilize the politics of appropriated technologies and of what the stakes might be in doing so.
Appropriated technologies are artifacts that are claimed by unintended users and altered or used in unintended ways, often in explicitly political actions (Eglash et al., 2004). While appropriation is based on the idea that users can alter a technology’s meaning, political actors may invest a new politics in a device and work to make specific political meanings persist, or ‘stick’. One way they can do this is by making the particular device the ‘right tool for the job’ (Clarke and Fujimura, 1992), thus stabilizing its definition along with that of the job with which it is associated. When such appropriated tools are passed to new users, one strategy for stabilizing their politics is to conceive of the particular politics as being ‘inherent’ in the appropriated artifact. But what happens when these tools fail to perform as expected, and their meanings must, inevitably, be actively negotiated in context?
Can a technology be inherently feminist?
The question of whether technology embodies particular social values and politics has been debated in the STS literature, at least since Langdon Winner (1980) argued that technological artifacts can be considered to ‘have politics’ because they are designed as solutions to particular social problems or their use requires particular social or power relations. Critics have countered that this approach does not acknowledge the extent to which the meanings and uses of any particular technology are always constructed and negotiated in particular contexts, independent of developers’ intentions (Clarke and Fujimura, 1992; Faulkner, 2001; Joerges, 1999; Saetnan et al., 2000; Woolgar and Cooper, 1999). Similarly, early feminist activists often rejected what they saw as the oppressive gender politics surrounding particular technologies, leading feminist scholars to question ‘whether the technology is in some sense inherently patriarchal’ (Wajcman, 1991: 13), or whether the problem was the gendered social relations within which technologies were developed and put into use (Faulkner, 2001; Saetnan, 2000). Recent scholarship develops the concept of feminist technology, drawing on theories of sociotechnical systems in order to attend to the gendered social relations and structures in which developers, users, and tools are all embedded (Layne et al., 2010).
A body of literature focusing specifically on the users of technologies examines how developers attempt to ‘configure’ users and limit the ‘interpretive flexibility’ of technologies by inscribing them with ideal users’ expected behaviors and identities in ways that both shape and reflect existing social categories (Akrich, 1992; Oudshoorn and Pinch, 2003; Woolgar, 1991). Studies of the ‘consumption junction’ emphasize how users can and do take up, transform, or reject the meanings inscribed in technologies as they use them (Cowan, 1987; Oudshoorn, 2003). Research on users highlights the tension between the constraints on users built into technologies through scripting and users’ ability to actively and creatively transform technologies through use.
By focusing specifically on the political implications of changing technologies through use, the appropriating technology framework theorizes how groups usually identified as consumers or users become producers of ‘vernacular science’. They do so as they ‘reinvent these products and rethink these knowledge systems, often in ways that embody critique, resistance, or outright revolt’ (Eglash, 2004: vii). Appropriation occurs to a greater or lesser degree, depending on the difference in social power between intended and appropriating users, and the degree to which technology is altered in its appropriation. Appropriation is most clear when the semantics, use, and structure of a technology all have been altered, as in reinvention, and least clear when the technology is altered at the level of meaning only, as in reinterpretation (Eglash, 2004: x–xii). Studies of appropriating technologies attend more to the question of how appropriation changes the meaning, use, and design of technologies along with the political implications of appropriation; they have attended less to whether new meanings and politics forged through appropriation persist and what steps actors can take to encourage them to ‘stick’. In order to shed light on these latter questions, I bring appropriating technology into conversation with scholarship on the construction of the match between ‘right’ tools and jobs, exploring how actors can work to stabilize the new, oppositional politics of appropriated tools.
In their introduction to the influential volume, The Right Tools for the Job, Adele Clarke and Joan Fujimura (1992: 5) argue that, ‘“tools”, “jobs”, and the “rightness” of the tools for the jobs are each and all situationally constructed … they are co-constructed, mutually articulated through interactions among all the elements in the situation’. Coherences between a particular tool and job are actively constructed and negotiated in an ongoing process (Pickering, 1989, 1990), with the result that tools also have ‘careers or trajectories’ over time. As they travel across disciplines, institutions, and users, tools accrue multiple political, intellectual, moral, and technical meanings, ‘becom[ing] meaning-laden entities to all those familiar with them for any reason’ (Clarke and Fujimura, 1992: 15).
My use of this framework focuses precisely on medical tools that circulate in FemHealth as ‘highly elaborated symbols’ with careers and trajectories that are intertwined with those of feminist health activism (Clarke and Fujimura, 1992: 15). I move the analysis of ‘right tools for the job’ out of the laboratory and away from the question of negotiating and stabilizing the appropriateness of technologies across clinical sites (Casper and Clarke, 1998; but see Moore, 2004). I ask how activists turn the process of making a tool ‘right’ for the job toward the purpose of stabilizing the new, oppositional meanings of appropriated tools. How can a particular technology come to be understood (and contested) as the ‘right tool’, not only for a particular medical procedure but also for a particular political project?
History of the women’s health movement and feminist clinics
Understanding FemHealth’s origins in the broader political projects of US-based women’s health movements of the 1970s provides the necessary context for understanding the continuing project of appropriation at FemHealth. The history of feminist clinics in the US, including their widely varying forms and concerns in different times and local contexts, has been covered extensively (Morgen, 1986, 2002; Murphy, 2004a,b; Ruzek, 1978, 1980; Simonds, 1996; Thomas, 1999; Weisman, 1998). Here I present a few elements of this history, which are salient to the case of appropriated technologies at FemHealth. In particular, I focus on the clinics’ rejection of physician authority, their appropriation of medical technologies, and the challenges posed by their dependence on physicians.
FemHealth was founded in the early 1970s as one of a network of feminist clinics. These clinics shared many traits, including the use of lay woman healthworkers, a non-hierarchical division of labor, and a concern with limiting physicians’ authority over both patients and lay healthworkers (Morgen, 2002; Ruzek, 1978). The goal of returning women’s health to women’s hands began with the self-help health groups that developed and practiced methods of self-examination and treatment. Some of these groups evolved into clinics that offered well-woman reproductive health services and performed abortions (Morgen, 2002; Murphy, 2004a; Ruzek, 1978; Weisman, 1998). These clinics were fundamentally organized around appropriating medical knowledge and technologies, which had been considered to be the purview of medical professionals, and thus they directly challenged the authority of physicians.
Despite this aim, clinics had to employ physicians for legal purposes, to provide certain procedures, such as abortions. Managing physicians posed an early and significant challenge for feminist clinics (Ruzek, 1978). Particularly in the 1970s, feminist clinics could not necessarily count on finding physicians who embraced – or were even sympathetic to – the project of transforming women’s healthcare (Gray and Tyson, 1976; Morgen, 2002). Physicians often resented the marginalization of their expertise, disliked having their authority questioned by non-professionals, and were perturbed at the prospect of patients diagnosing themselves and dictating their own treatment (Gray and Tyson, 1976; Joffe et al., 2004; Morgen, 2002; Watkins, 1998). Clinics took many steps in order to reduce physicians’ institutional and symbolic authority over both clients and healthworkers. For example, the paper ‘drape’ that hid the physician’s work from the patient’s view was removed, lay healthworkers and clients alike addressed physicians by their first names, and in many cases, physicians were asked not to address patients at all (Morgen, 2002; Ruzek, 1978). The goal was to undermine medical authority and reduce the physician’s role to that of a technician, who was necessary only to perform tasks that required a medical license.
This basic tension persists, and shifts in the medical profession over the past 40 years have complicated the issue. To a certain extent, feminist medical professionals have infiltrated the medical mainstream and are ‘beginning to confront the burdens of being “inside” biomedicine and attempting to change it from such relatively new and difficult sites of perception and action’ (Clarke and Olesen, 1999: 17). As the number of women physicians increased (in part due to in-roads made by the feminist movement) and feminist physicians came to work in the clinics, they found that they were marginalized and viewed as adversaries rather than allies (Morgen, 2002; Simonds, 1996). Further, the context in which present-day feminist clinics operate has also changed. While during the early years feminist clinics proliferated in varied forms across the US, their numbers have decreased substantially; those that remain often temper their political actions and adopt more conventional organizational structures (Morgen, 1986, 2002; Thomas, 1999). These shifts occurred especially in the 1980s and 1990s, when clinics struggled to secure licenses and insurance coverage, to become eligible providers in patients’ insurance plans, and to secure funding from states and private foundations (Morgen, 1986, 2002). During this time, clinics that provided abortions also faced increasingly difficult relationships with state-regulating authorities and (often violent) actions by anti-abortion groups (Joffe, 2010; Morgen, 2002; Simonds, 1996).
As feminist clinics shifted toward conventional healthcare delivery, they faced competition from mainstream healthcare providers that specialize in women’s health services and employ women health professionals or paraprofessionals (Thomas and Zimmerman, 2007). This is particularly true of the hospital-owned, often for-profit, ‘women’s health centers’, which mimicked the innovative practices of feminist clinics but did not take up their political challenge to medical authority (Kay, 1989; Thomas and Zimmerman, 2007; Weisman, 1998; Whatley and Worcester, 1989; Worcester and Whatley, 1988). Feminist challenges to mainstream medicine have significantly changed doctor–patient relationships, but this has not had the transformative effects imagined by activists. The goals of empowerment and autonomy have been translated into consumer ‘choices’ among medical services which, in the context of medical markets for health commodities, encourage women to actively participate in the greater medicalization of their bodies and lives (Conrad and Leiter, 2004; Thomas and Zimmerman, 2007; Watkins, 2007). It was in this changed context that FemHealth continued to pursue the project of feminist healthcare.
Clinic description and methods
Thirty years after its founding, FemHealth continued as an independent, not-for-profit reproductive health clinic. FemHealth offered well-woman reproductive health services (such as pap smears, contraceptives, testing and treatment for sexually transmitted infections (STIs)) and first-trimester abortions. The clinic was funded mainly through donations and payment for services, either directly from clients or through state (and, rarely, private) health insurance programs. 4 FemHealth was staffed almost entirely by volunteer lay healthworkers working alongside five to seven full- or part-time permanent staff, including the executive director, volunteer coordinator, bookkeeper, and office and clinic managers. 5 Although the number of volunteers fluctuated throughout the year, during the time when I conducted this research, there were approximately 35 volunteers spread across four to six clinic shifts per week (two to three for abortion, two for well-woman gynecology, one for the men’s STI clinic). Each clinic shift, or ‘day’, worked somewhat independently of the others, employing one doctor (for abortion clinics) or nurse practitioner (for gynecology clinics) and its own team of volunteers. Most volunteers worked only one clinic shift per week. Volunteers rotated their clinic duties, and new volunteers trained for all positions during the required, year-long volunteer training program. Beyond the formal training program, most volunteers learned ‘on the job’ by shadowing more experienced healthworkers.
Physicians worked only one shift per week; they received nominal payment and most had full-time employment elsewhere. When attending abortion clinics, they were only physically present at FemHealth for about half of the time that volunteers were present. Healthworkers prepared the clinic, took health histories from patients, and ran necessary lab tests before the physician arrived. There was little interaction between the physicians and most of the healthworkers outside of the procedure room, and some volunteers would not see the physician at all, depending on their duties in a given shift. Physicians also did not attend after-clinic meetings, when staff and volunteers reviewed and processed that day’s clinic and discussed the political aspects and implications of their work. These absences were not accidental, but rather reflected the deliberate exclusion of physicians from clinic operations beyond the technical tasks of performing abortion procedures. As a result, most volunteers knew very little about physicians’ beliefs and attitudes toward various aspects of the feminist model of healthcare.
I conducted 18 months of participant observation at FemHealth, volunteering as a healthworker for one gynecology or abortion clinic and often taking part in an additional administrative shift per week. I participated in the year-long training sequence and also trained incoming healthworkers in the gynecology clinic after I gained sufficient experience. Participant observation allowed me to experience firsthand the everyday practices and politics of providing feminist healthcare and to familiarize myself with the structure and dynamics of the clinic. 6 My extended presence and observations in the clinic provided essential background knowledge and were particularly helpful for developing my interview questions. This article is based on 12 semi-structured interviews conducted in 2006, at the end of my 18 months in the clinic. I interviewed three staff members and nine current volunteers, who had worked at FemHealth for periods of 2 months to more than 20 years. For confidentiality reasons, I did not interview doctors. 7 I transcribed and coded the interviews myself and used a modified grounded theory approach for analysis, coding recursively and allowing salient categories and themes to emerge from the interview data. This method of analysis allowed me to build a picture of the ongoing processes through which FemHealth volunteers and staff defined and provided feminist healthcare.
Demystifying medical knowledge and technology: Feminist healthcare at FemHealth
In interviews, healthworkers at FemHealth said that helping women cultivate knowledge about their bodies and health is the key to what makes feminist healthcare political, because obtaining this knowledge provides women with the increased control that enables them to challenge medical authority. Andrea, a healthworker at FemHealth, explained it this way:
The more generic version is women taking control of their bodies, right? That kind of sums it up, you know … women feeling empowered enough to make decisions on their own before having to see a physician for everything, you know, instead of having to see a physician for everything. I think feminist healthcare is doing that, is just bringing the power of women to take care of themselves, giving it back to them.
Providing knowledge and control enables women to understand their bodies and make decisions about when to seek medical treatment ‘before’ or ‘instead of having to see a physician for everything’. Liz, who had been involved with feminist healthcare for several years, said:
So much of the medical field is like you bring your body in to get worked on. And I think that part of feminist healthcare is teaching women that we do know about our bodies and we can know more. By doing that, actually, we can be the experts about our own bodies. A doctor that looks at our cervix once a year isn’t going to know as much as we do if we look at it more regularly.
Being ‘the experts about our own bodies’ meant encouraging women to produce and share knowledge about their bodies, developing an expertise about the body that is distinct from medical expertise (Davis, 2007; Murphy, 2004a). This orientation shifts lay women from being consumers of medical treatments who bring their bodies in ‘to get worked on’, to being producers of vernacular science who can ‘know more’ about their bodies than doctors.
However, feminist clinics do not reject medical knowledge wholesale in favor of an experiential alternative. Rather, lay women are encouraged to take up medical tools and knowledge as an integral part of providing feminist healthcare. Central to this process of appropriation is removing the mystique of medical knowledge as inaccessible to those without extensive professional training. Volunteers at FemHealth (and those who train them) repeatedly point out that the kinds of well-woman care provided in the clinic, and even the abortion procedure itself, are not ‘rocket science’, and that anyone can learn to do them. Institutionalized medical hierarchy is understood as a barrier to women’s ability to obtain knowledge about their own bodies. Offering medical training to lay healthworkers becomes a key feminist act that contributes to the rejection of physician authority. Maria described to me how being trained as a lay healthworker provided her first indication that feminist healthcare was different from mainstream healthcare:
In [the clinic], medical training didn’t come from this place of, you know, the typical medical hierarchy and the medical establishment being this untouchable science that no one else can understand and no one else can learn without a zillion years of schooling. They really invested in me because of my political passion … and just that act in itself dismantles the medical hierarchy and makes patients better able to conceptualize their own bodies and their own healthcare.
Through their training in medical knowledge and techniques, many of the volunteers experienced this demystification of medical technology as empowering in two ways. First, like Christie, some volunteers expressed amazement that they would have access to medical practices:
With a bit of training you can just do a finger prick [blood] test [for anemia], and that to me is the most technical test that the volunteers get to do [in the well-woman gynecology clinic]. The other options are a urine dipstick, test for pregnancy, or the blood pressure – which is not that big of a deal, you know. But then the blood – we actually get to draw body fluids. You have to wear protective gloves. You know, you’re dealing with blood. That’s a biohazard. And then dealing with sharps and all that, it’s really kind of high-tech. It’s low-tech, but it’s high-tech for people that are just lay people.
A fairly new volunteer at the time of our interview, Christie recognized that these tasks are usually off-limits to lay people, giving an aura of transgression to performing them and handling the materials involved – protective gloves, sharps, blood, biohazards. Volunteers get to perform medical tests, ranging from ‘not that big of a deal’ to ‘high-tech’, within a framework that affirms that these are appropriate tasks for lay women. The second way they feel empowered, after their healthwork training demystifies their past medical experiences, is that volunteers explicitly connect their learning to perform medical tests or handle medical tools with the political project of feminist healthcare. Pat told me:
I really like learning about – just silly things that seem so easy now, like doing a urine test or a pregnancy test. It’s stuff that I’m sure they’ve been doing at the doctor when I go for years. It always seems like this big thing that’s very distant from me, but now I’m realizing that it’s really simple and doesn’t have to be this monopoly of knowledge that other people have.
Directly experiencing the demystification of medical knowledge reinforces the importance of appropriating medical tools as a political act.
Specific practices in the clinic, such as the ‘rap session’, demonstrate that appropriation still forms a central part of providing feminist healthcare. The ‘rap’ is an interactive group information session held for clients immediately prior to the abortion procedure, in which a healthworker passes around examples of most of the tools used in the procedure and provides a step-by-step explanation of how and when each instrument will be used. Clients are encouraged to handle the tools and ask questions. Pat explained the importance of the rap session as a feminist practice:
Showing women the instruments that are going to be used when they’re going to have an abortion, so they can actually see and feel and touch and know what’s going on and not just be this passive recipient of whatever healthcare they’re receiving is so important, I think, for it being a feminist approach.
Not only do women get to see and hold instruments that normally would be familiar only to medical professionals, which gives the tools new meaning by moving them into women’s hands, but many volunteers also believe that the demystification that takes place in the ‘rap session’ drastically alters a client’s experience of the abortion procedure. As a way of explaining this to me, Maria contrasts women’s experiences at FemHealth to those at a non-feminist abortion clinic where she had briefly worked:
[Clients at this other clinic watched a] half-hour video of all the horrendous things that could happen, but nothing about what the instruments are, why they’re used, nothing about … anything about the procedure. So then they’re nerve-wracked. They get some Ativan or Vicodin or something, they go into the procedure and – I swear to god, for like a seven-week pregnancy, six-week pregnancy, super early pregnancies, you could hear women screaming through the corridors. Screaming! … It was amazing to me to come from a place of feminist healthcare where we do these rap sessions, and we only give people Ibuprofen. We don’t give them any narcotic medication, especially at [FemHealth]. And they’re fine, they’re really okay … I think the act of doing this kind of education is so empowering, much more than I ever thought it was until I had that experience of working there.
Maria explained her belief that the knowledge provided in the rap session fundamentally changes a woman’s physical and emotional experience of the abortion procedure. Contrary to arguments made by abortion opponents, there was nothing inherent in the procedure that produced the fear and pain of women at this clinic; rather, women experienced excessive fear and pain when they were not given information about what would happen during the procedure, other than frightening possible side effects. Working at another clinic proved to her that ‘the rap’ is not only more empowering, but also more effectively reduces pain than even the narcotics used at other clinics.
Maria clarified that it is not only the tools that need to be demystified, but how they will be used and what sensations they will cause in the body:
Demystifying technology is really important, also demystifying the sensations that the technology creates during the abortion, like specifically during the aspiration part when the uterus is being emptied. It feels really crampy. It feels like super-strong period cramps, maybe worse. But it’s pretty minimal, it’s about thirty seconds to a minute that the aspiration is actually taking place. But when people are feeling this cramping, and it’s just like this anonymous pain in their lower abdomen, it hurts like ten times worse. If you can tell the client, ‘What’s happening right now is that as she’s emptying your uterus, it’s slowly shrinking back to its pre-pregnant size. So the act of your uterus deflating essentially is what is creating that cramping, and the closer you are to being done with the procedure, the stronger your cramps are gonna get.’ Then you just know that means the emptier your uterus is and the closer you are to being done. People can visualize that. They’re relieved that they’re having cramping.
This form of demystification allows women to contextualize their subjective, bodily experiences and understand them in relation to the information they receive about the medical tools and procedures. Giving women knowledge about the abortion procedure, allowing them to handle the instruments that will be used, explaining to them how these instruments will be used, and explaining what sensations they will cause, make up key ways that volunteers enact feminist healthcare practice in the abortion clinic at FemHealth. By appropriating these medical tools and techniques as something that lay women (both volunteers and clients) can and should be familiar with, healthworkers claim a limited position as users of these technologies, moving lay women from being passive recipients to being producers of knowledge through interpretation that incorporates women’s subjective experiences into the tools’ meanings.
In line with the rejection of physician authority that has been fundamental to the feminist healthcare model, FemHealth attempts to delegate to lay women all procedures except for those that require a medical license. As Liz explained, the technical expertise and decision-making power granted to lay healthworkers marks the clinic as feminist:
Lay healthcare workers are in charge of the whole process besides the abortion, which I think is unusual. I’m the one who looks at the tissue after the abortion, not the doctor. That doesn’t happen in non-feminist healthcare centers, at all. Healthcare workers have a lot more decision-making power, and the doctor really plays a really minor role in the whole thing.
Maria stressed this point when she stated that volunteers have the technical capacity to provide medical services beyond what they are legally allowed to do:
We teach and train lay healthworkers to do everything possible that we can legally do without a license. Really the entire visit or session is conducted by the layperson, until we get up to the last moment when we can’t do a pap smear, we can’t perform an abortion, at least not legally. We obviously could do these things, because it’s not rocket science.
The idea that lay women can and should be able to perform all aspects of well-woman healthcare is fundamental to a feminist approach to healthcare; however, the lay healthworkers’ position as users of the knowledge and technologies they appropriate is unstable, as some tools must be ceded to the physician. This proves to be a central tension at FemHealth, one that plays out with reference to particular technologies. The crucial ‘last moment’, when specific tools must be placed into doctors’ hands, becomes the terrain on which the politics of feminist technologies are defined, enacted, and stabilized.
Stabilizing politics in feminist technology
In this section, I explore two cases of appropriated technologies at FemHealth to show how strategies to make appropriation ‘stick’ differ depending on whether lay healthworkers or physicians are the tool’s users. In the first case, the speculum is an iconic feminist technology; its politics are transformed when it is used by lay women in a project that reclaims both the tool and their access to and knowledge about their own bodies. In the second case, two competing tools – the single-tooth tenaculum and the cervical stabilizer – perform the same function in the abortion procedure, but one is considered a feminist technology while the other is not. Feminist healthworkers have invested significantly in the politics of the cervical stabilizer, but cannot be the end users of the tool. The stakes are particularly high for stabilizing the feminist politics of these technologies. The daily use of the speculum and the cervical stabilizer make them central to the ongoing work of providing feminist healthcare; the times when these tools were appropriated also represent key moments in the history and legend of feminist health activism. While the politics of the speculum are transformed through use by lay women, the ‘inherently feminist’ cervical stabilizer is asked to transform the work of physicians’ hands.
Transformed in women’s hands: The speculum
The speculum, as figured in feminist mythology as well as in day-to-day practice at FemHealth, symbolizes the transgression of taking medical technology from the hands of doctors (Davis, 2007; Haraway, 1997; Murphy, 2004a). In lay women’s hands, this tool provides access to a view of the body previously monopolized by physicians and enables feminist projects of self-discovery and knowledge-production. As a portable, non-threatening medical instrument that doesn’t require much technical knowledge to use, the speculum materializes the belief that women’s healthcare is not ‘rocket science’ and that anyone really can know and do the things that doctors do. In 1971, Carol Downer used a speculum to demonstrate cervical self-examination to a group of women at Everywoman’s Bookstore in Los Angeles, beginning the first of the feminist self-help health groups that eventually grew into feminist clinics (Morgen, 2002; Murphy, 2004a). The speculum and its use in cervical self-examination were central to the practices of women’s health self-help groups. By turning the speculum in on themselves, lay women in such groups turned self-discovery into new ways of seeing and producing knowledge about their own bodies (Davis, 2007; Murphy, 2004a).
At FemHealth, volunteers were often told of Downer’s demonstration, and they understood the clinic to be a direct descendant of those she founded in the early 1970s. The speculum was passed around in the rap session, and each client who visited the clinic was offered a plastic speculum to take home with her, along with self-exam instructions. The clinic also required volunteers to participate in cervical self-exam training as a part of the year-long healthworker training program. FemHealth volunteers drew on tropes of self-discovery (Davis, 2007; Haraway, 1997: 42) as they explained the continued importance of the speculum in enabling women’s access to their bodies.
According to volunteers, the speculum gives women access to valuable knowledge through self-exam and a sense of ownership over their bodies and healthcare. For example, Christie shared this anecdote:
My roommate said, ‘What’s that in the bathroom?’ And I said, ‘Oh, it’s a speculum. You know, like when you go to the gyno, you can look at your cervix and you can see.’ She said, ‘Why would you want to do that?’ I was like, ‘Because you don’t need to go to the doctor to see your body! You can figure out what’s going on. A lot of times you can see, you can just look yourself and figure it out. You don’t have to ask someone if you can look at your own body!’
Christie highlighted how owning and using the speculum affirms the central feminist tenet that women do not need permission to access knowledge about their own bodies. They do need the right tools, however, and thus lay women’s ‘ownership’ of the speculum can transform healthcare from something done to a woman into something she can ‘own’ through access to and free use of some of the tools involved, as Maria explained in her discussion of the speculum:
I think this act of offering them access to this kind of technology to take home makes it so that they literally own the [abortion] procedure. The procedure is something that’s accessible – it’s within their own reach. They get to take part of it home and do it on themselves in an effort to understand their bodies more. Like I said, most people don’t want to take one. But just the act of asking if somebody wants one, opens, I think, a doorway for them to be like, ‘Oh, it’s part of my body and of course I have the right to know about my body and discover it myself.’
Further, the speculum’s appropriation and use by lay women, and not the speculum itself, took on feminist political meanings:
I think the speculum itself has always been a pretty patriarchal tool. It’s like this phallic, weird, duckbill-shaped thing. … I think this instrument being the symbol of male-dominated gynecology, male-dominated women’s healthcare freaks people out.
Maria’s statement encapsulated how appropriation shifts the meanings of the speculum, but not the speculum itself, which persists as ‘pretty patriarchal’ and yet is transformed when owned and used by a woman to ‘discover’ her own body.
The oppositional meanings re-inscribed through appropriation by lay women ‘stick’ to the speculum, allowing it to stabilize as the ‘right’ feminist tool for the job of women’s self-knowledge and discovery, precisely because it can be used by lay women. Transformed when placed in women’s hands, the speculum can be claimed as unquestionably feminist in the clinic; other tools can be only briefly handled by lay women before being placed back into the hands of physicians. In the next section, I look at the cervical stabilizer, a tool appropriated and redesigned by feminists, but which cannot be used by lay women at FemHealth and must be returned to physicians for use.
Whose hands? Which tools? The atraumatic cervical stabilizer and single-tooth tenaculum
As noted earlier, struggles over the role and authority of physicians in this clinic played out through debates over the cervical stabilizer and the single-tooth tenaculum, two competing tools used by the physician in the abortion procedure. Lay healthworkers in the clinic were deeply invested in the feminist appropriation of the stabilizer, but could not use the tool themselves; instead, they worked to establish the device as the ‘right tool for the job’ by imbuing it with inherently ‘good’ politics, which would ensure that the procedures provided by physicians retained a feminist political charge. These attempts faltered when the stabilizer failed to perform in the hands of one particular doctor at the clinic, who consistently chose to use the tenaculum. In response, the lay volunteers and staff at the clinic confronted the physician and urged her to use the stabilizer. However, faced with a trusted doctor’s claims that the ‘right tool’ did not do its job well, a few argued that, rather than depending on the stabilizer to embody feminism, the clinic could recognize ‘their’ physicians as full participants in the political project of feminist healthcare.
As discussed above, the atraumatic cervical stabilizer and the single-tooth tenaculum are two types of forceps that clamp onto the lip of the cervix in order to stabilize the cervix during the abortion procedure. While the tenaculum grasps the cervix by puncturing it with two sharp points, the stabilizer pinches the cervix between two blunt edges (see Figure 1). In all other respects, the cervical stabilizer and single-tooth tenaculum are used in the same way (see Figure 2). What makes the stabilizer a feminist tool? Healthworkers claimed that the stabilizer was feminist because it was less invasive and because of its connection with the history of feminist health activism. Unlike the tenaculum, which was described as needlessly invasive and even ‘brutal’, the stabilizer does not puncture the cervix. One volunteer, Andrea, expressed this opposition to the tenaculum in experiential terms, saying ‘As a woman, I wouldn’t want to have my cervix pierced for no good reason. It would make me really upset if I knew that [had happened].’ Further, some volunteers said that the tenaculum actually scarred the cervix, leaving a permanent, visible mark that could clearly be read by future healthcare providers as proof of a woman’s abortion. One volunteer, Sarah, told me:
We had a woman from Mexico speaking on it, and tenaculums leave a scar on your cervix which stabilizers don’t. When the woman went back to Mexico after she had a procedure, her gynecologist could see the scar on her cervix and knew she’d had an abortion and was treating her like shit and was horrible to her. So there actually are possible repercussions.
Abortion procedure using a cervical stabilizer. Used with permission; from A New View of a Woman’s Body by the Federation of Feminist Women’s Health Centers. Illustrations by Suzann Gage.
Because it is less invasive and leaves no lasting mark as evidence of a stigmatized procedure, healthworkers considered the stabilizer to be the feminist tool.
Further, the stabilizer was a feminist tool because feminist health activists had appropriated and redesigned it. Feminist lore, as recounted at FemHealth, held that the cervical stabilizer was invented as an alternative to the tenaculum by Carol Downer and Lorraine Rothman, prominent feminist health activists, during their cross-country, women’s health self-help educational tour in the early 1970s. They wedged the points of the tenaculum in the joint of a pipe on their RV [recreational vehicle] and hammered the ends until the points were worn down. Lynn referred to this feminist lineage of the stabilizer in her description:
Coming out of the self-care and self-help model, the women who in my interpretation of history helped develop the abortion procedure threw out the tenaculum and were like, ‘This is a horrendous thing that doesn’t look like it should be near anyone’s cervix ever.’ – Which is kind of a valid point.
For lay healthworkers at FemHealth, the feminist lineage of the cervical stabilizer proved just as important as its effects on the body for defining the stabilizer as a feminist tool.
While it is difficult to know whether this origin story is accurate, a stabilizer or tenaculum is listed among the supplies used in menstrual extraction (ME), a method developed by Lorraine Rothman and Carole Downer for removing the contents of the uterus at or around the (expected) start of a women’s period (which would also result in an early abortion if she were pregnant) (Chalker and Downer, 2003: 142–143; Murphy, 2004b). Downer and Rothman demonstrated ME on their self-help tour and it is possible that the re-invented cervical stabilizer was meant specifically for use in ME. The stabilizer may have been used by lay women in self-help groups practicing ME and only later ceded to doctors, once abortion had been legalized and placed securely in the purview of licensed physicians. An ME group studied by Denise Copelton in the 1990s used the tenaculum but later rejected it, citing both the invasiveness of the tool and fears that marks left on the cervix by the tenaculum would lead to ‘discovery by unsympathetic outsiders … who might report the group’s activities to the police’ (Copelton, 2004: 153–155). It is unclear whether this ME group knew about or would have been able to obtain the cervical stabilizer.
Present-day lay healthworkers at FemHealth, unlike feminist self-help groups practicing ME, inevitably reached the ‘last moment’ referenced by Maria above, ‘when we can’t perform an abortion, at least not legally’. At this point, lay healthworkers must hand the stabilizer to the physician for use. Lay healthworkers at FemHealth worked to solidify the stabilizer as the ‘right tool for the job’ of providing feminist abortions by claiming use of the ‘feminist’ stabilizer as what made FemHealth a feminist clinic, institutionalizing the preference for the stabilizer, and challenging the physician’s choice to use the alternative tool.
First, the stabilizer was imbued with feminist politics to the extent that its use was seen as one thing that made the clinic, and the healthcare provided there, feminist. Andrea explained what, for her, was at stake in allowing doctors to use the tenaculum, saying that ‘[t]his is against our feminist rules as a clinic. The fact that we’re a feminist clinic is what is setting us apart from the rest of the world, and so we really need to hold true.’ The stabilizer was asked to stand in for FemHealth’s feminist approach to healthcare. In this vein, Liz said:
The feminist thing to say, supposedly, is that you use cervical stabilizers instead of tenaculums. … And, in fact, some people in the rap say the feminist reasoning behind why that is, and that something that makes us different from other clinics is that we use cervical stabilizers instead of tenaculums, because they [tenaculums] are more brutal.
Liz expressed her sense that using the stabilizer was seen by many as essential to maintaining FemHealth’s feminist identity. The stabilizer not only embodied their feminist approach to healthcare, it retained its feminist politics even when returned to physicians’ hands and therefore had the power to transform physicians’ work.
Another way that staff and volunteers tried to make the stabilizer cohere as ‘the right tool’ was by embedding its use in everyday practices at the clinic. Volunteers consistently claimed that, according to clinic protocol, the cervical stabilizer should always be used in the surgical abortion procedure, but that physicians had discretion to use the tenaculum in situations where they found it necessary. While FemHealth’s clinical protocol documents did not actually specify that the cervical stabilizer should or must be used for a surgical procedure, 8 the room in which the procedure was performed was set up to make it inconvenient for physicians to use the tenaculum. When preparing for an abortion, healthworkers wrapped and sterilized a set of instruments to be used for the procedure. Prior to each procedure, the set was unwrapped and placed on a tray for the medical assistant to pass each instrument to the physician when needed. These ‘AB sets’ did not include the tenaculum, which was wrapped and sterilized separately. If the physician wanted to use a tenaculum in place of the cervical stabilizer, she had to ask the medical assistant to get one for her. Although volunteers told me that they would always get a tenaculum for the doctor if she or he requested it, they said that making the physician ask for it was an important safeguard that provided some control over doctors’ use of the tenaculum. Further, FemHealth owned many fewer tenacula than stabilizers, anticipating that there would be a limited number of times when the doctor would choose the tenaculum. This meant that the doctor could not choose to use the tenaculum frequently; once they had all been used, there was not enough time to sterilize more while the clinic was in progress. In these ways, lay healthworkers institutionalized the stabilizer as the ‘right tool for the job’, leveraging their control over stocking and preparing the clinic and reducing the physicians’ control over these decisions. Concretizing the feminist, lay-driven approach to healthcare in a specific tool offered a guarantee that this project could continue even for phases in which lay healthworkers were excluded.
Lay healthworkers invested in the stabilizer as inherently feminist in hopes that the tool would retain its feminist identity even when passed back into a doctor’s hands. What happens, though, when the stabilizer cannot be counted on to perform its feminist politics by being the less-damaging tool? When Beth explained her choice to use the tenaculum, because it did a better job than the stabilizer of holding the cervix in place during abortion procedures, some healthworkers countered that she had not put in enough work to improve her skill with the stabilizer because she was used to using the tenaculum at her other workplace. However, what seemed to be most troubling for many who opposed Beth’s use of the tenaculum was that she was considered to be both highly skilled and otherwise completely ‘on board’ with the feminist project – the ‘best’ of the doctors, in many healthworkers’ opinions. As one volunteer said, ‘the doctor that does it is wonderful, but it’s just a method that’s against what we believe in as feminists’. Many in the clinic expressed this same conflicted admiration of Beth, combined with disapproval of her use of the tenaculum. The clinic director ordered new stabilizers for the clinic, in case wear on the tools was causing them to not work for Beth as well as they should. Sarah, another volunteer, told me, ‘[w]e’ve been talking about whether it is worth the fight to make Beth use the stabilizer, when she can actually do faster procedures with the tenaculum because that’s what she’s used to and good at.’
One reaction to Beth’s repeated use of the tenaculum was to confront her directly to encourage her to use the stabilizer. Some volunteers noticed that Beth did not use the tenaculum as frequently when the clinic director worked as her medical assistant for procedures,
9
and they brought this pattern to the director’s attention. From that point forward, when Beth would ask for a tenaculum with the director in the room, the director would speak directly to the client. Describing these confrontations, Jackie said:
Our tack now is that every time that she pierces a woman’s cervix, we say in the room ‘The doctor is using a different instrument because of your special circumstance. She’s unable to use the atraumatic stabilizer and is going to use a more invasive method.’
By calling the client’s attention to Beth’s choice, clinic staff used their relationship with the patient to disrupt the tacit legitimacy of the physician’s choice. Jackie described this approach as a matter of struggling with, rather than against, good doctors. However, this mode of confrontation recreated an oppositional relationship between physicians and lay healthworkers and denied the possibility that physicians could work as feminists to rescript the tenaculum.
While many volunteers were highly invested in the appropriated stabilizer as a feminist tool, and counted on it to enact and express a feminist transformation of physicians’ work, this investment in the stabilizer’s politics could not guarantee that it would always do a better job of holding the cervix in place during a procedure. Confirming Beth’s claims, Liz, who often worked as medical assistant for Beth, stated that the stabilizer did not live up to the claim that it was the less damaging tool when used by this particular doctor:
I’ve seen Beth do procedures with a stabilizer and it is much more brutal. It rips off [of] the cervix every time. I don’t know what it is about her technique that differs from others’. … I’ve seen stabilizers rake across people’s cervixes and, ugh, it seems so much worse. I’d prefer Beth use tenaculums… but some people seem to think that stabilizers are inherently feminist.
These volunteers acknowledged the established feminist status of the stabilizer, but they agreed that the stabilizer did not work for this doctor and suggested that her preference ought to count for something. They based their argument in favor of allowing Beth to use the tenaculum on the stabilizer’s failure to perform its feminist job, and expressed a belief that some doctors could be counted on to work in feminist ways.
If the ‘inherent feminism’ of the stabilizer could not be counted on to automatically transform a physician’s work, then perhaps (certain) physicians could be folded in as feminist actors who could participate in the appropriation and re-inscription of the tools of mainstream medicine. Lynn noted that ‘sometimes our doctors feel much more comfortable and feel like they have a much better ability to give people quality healthcare when they can use a tenaculum that they perceive to be a better stabilizer of the cervix during an abortion procedure.’ She also raised the question of whether the doctor’s preference ought to be an important aspect of feminist care, particularly for doctors already committed to working in a feminist clinic:
I think also it’s a matter of what the doctor feels most comfortable doing is also what’s going to provide the best healthcare – I mean for our doctors, anyway, not as a blanket statement, clearly! But our doctors who we know and trust, who at least have heard our interpretation of what intent we have for people at clinic and have an understanding of the feminist politics that build that intent. Whatever’s going to make them feel like they have the ability to provide service and see someone’s uterus best or stabilize the cervix best is going to produce a good outcome.
Those who supported Beth’s use of the tenaculum argued for the ability of some physicians to be feminist actors, rather than opponents, and to re-script technologies – expanding both the understanding of who can appropriate and which tools are open to appropriation.
In this section, I have argued that the debate over the stabilizer and tenaculum centers on two conflicting resolutions to the enduring tensions surrounding the role and authority of physicians in the project of feminist appropriation of medical technologies. On the one hand, if the stabilizer coheres as a feminist tool, the ‘right tool for the job’, it can possibly resolve the tension between the rejection of medical authority and the clinic’s dependence on physicians. If the stabilizer is inherently feminist, it can remain so even at the moment when feminist healthcare must be placed back into the hands of physicians. However, if the stabilizer does not perform its feminist function in the physician’s hands, if it does not do its feminist job of being the less damaging alternative, then the clinic staff must face the question of how it might be possible for a physician to perform a better, or more feminist, abortion using the non-feminist tool. Thus, like STS theorists, volunteers and staff at the clinic must contend with the construction of an artifact’s politics in the context of use, rather than its inherent politics.
Conclusion
For more than 30 years after its founding at the height of the women’s health movement in the US, feminists labored at FemHealth to envision and enact a form of healthcare that would keep control of women’s reproductive health in lay women’s hands. They continued to negotiate the role and authority of physicians within feminist clinics, especially in a changed context where ‘their’ physicians might be counted on as feminist allies, while mainstream medicine had co-opted feminist innovations to provide comfortable care and expanded choices to well-informed and well-insured healthcare consumers. They also continued to engage with technologies that had been appropriated and reshaped by the activists who set this strand of feminist health activism in motion. The feminist politics of some appropriated tools, like the speculum, had solidified through continued lay use as the ‘right tool for the job’ of women’s empowerment through self-knowledge. Other tools that had been claimed as feminist, such as the cervical stabilizer, could not be used by lay healthworkers at FemHealth. Consequently, these women sought to institutionalize the stabilizer as the ‘right tool’ for the job of providing a feminist abortion by investing it with an inherent feminism that would perform its politics even when it was passed from lay healthworkers’ to physicians’ hands. The project of appropriation turns on the flexible politics of technologies and the construction and negotiation of their meaning through use; and yet, in this case we see that some actors invested the stabilizer with inherent political meaning as a feminist tool, so that its politics traveled with it when it was passed to new users’ hands.
My analysis offers two contributions to the literature. First, this research contributes to new scholarship on ‘feminist technologies’. In a recent volume, Linda Layne and colleagues (2010) introduce and elaborate the concept of feminist technology and argue that we need criteria for designing and assessing feminist technology. They argue that this is necessary despite the challenges posed by feminists’ multiple political stances and varied social positions and the contingency of the politics of technologies on their contexts of use. My analysis of appropriated technologies at FemHealth, particularly the example of the ‘feminist’ stabilizer, demonstrates how difficult it can be to specify such criteria. Even with a tool designed by feminists, offering a clear improvement to women’s lives (no damage to the cervix during the abortion procedure), and employed in the context of an explicitly feminist political project, the stabilizer cannot always perform its feminist politics. Even the most careful considerations and intentions of designers cannot determine that the tool will fulfill its feminist function in all possible contexts of use. Situated, empirical analysis of feminist political activism involving the development, design, and appropriation of technology would enrich the literature on feminist technology. It is not the case that ‘the very idea of feminist technology at all is a result of the intellectual and academic critique of technology’ (Gorenstein, 2010: 203), and there is much to be learned from feminist activists’ engagements with technology.
Second, this research opens up new avenues for analyzing the politics of artifacts by bringing together the insights of two frameworks: appropriating technology and ‘the right tool for the job’. Doing so provides new theoretical insights into how political projects are instantiated in and through particular technologies. Expanding our understanding of how and when actors seek to stabilize the new, oppositional politics attached to appropriated technologies opens new avenues for investigating the deployment in other social movements of technologies of resistance. In particular, it opens up one possibility for exploring the tensions between appropriated and appropriate technologies – those that are claimed by less powerful groups and transformed into technologies of resistance and those that are designed to conform to or work around existing inequalities.
Afterword
In 2009, FemHealth closed its doors. In an open letter, the clinic cited repeated delays in payment from the state’s insurance programs, which caused the clinic to fall behind in rent payment and lose their lease. FemHealth was one of the oldest feminist clinics in the country, and the only one in this California city. FemHealth’s closing highlights the practical and fiscal challenges facing feminist clinics in their efforts to maintain a radical political approach to women’s healthcare.