Jolien Gijbels and Kaat Wils*
In 1875, the entrance of women to the medical profession was discussed in the Belgian parliament. Along with discussions within medical societies, this public debate is an important source to study gendered views about women’s involvement in medicine. About three- quarters of a century before women’s suffrage was fully granted in Belgium, it was evident that women were not allowed at the negotiating table. Such public discussions thus pose a meth-odological challenge for historians who study the intersections of gender and medicine and aim to give women a voice. Due to a scar-city of personal documents and publications by female healthcare professionals and feminists, it remains a challenge to work with a corpus of sources in which men’s voices dominate.
The parliamentary debate of 1875 took place in the aftermath of international developments in favour of women’s access to medical studies; the American Elizabeth Blackwell being the first woman who, in 1849, obtained a medical degree. In the margin of a debate on a bill that was to regulate the awarding of aca-demic degrees, the liberal deputy Eudore Pirmez suggested to offer women access to at least some branches of the medical profession.
Pirmez’s plea consisted of different types of arguments. He started by referring to the natural capacities of women to fully devote themselves to the care for others, a degree of dedication that men rarely attained. The availability of women physicians would also lower the barriers for women to consult a doctor when confronted with intimate medical issues, as concerns with indecency would no longer be at play, Pirmez argued. At the end of his plea he referred to the American situation, where more than three hundred women doctors proved to be talented and successful practitioners.
‘Physicians will agree with me,’ he continued, ‘that there are no anatomical or physiological differences between American and
Belgian men and women, and hence no reasons to continue to organise the medical field in a different way.’1
Parliamentary opinions on Pirmez’s proposal were divided and it was decided to ask the four Belgian universities and the Royal Academy of Medicine for advice. Responses were mainly negative.2 The most elaborate arguments against women’s entrance in the pro-fession came from the Academy. In a lengthy discussion in which in fact all participants agreed, Pirmez’s three main arguments were reversed. Women’s nature was indeed inclined to care for others, but it was precisely her nature that made her physically, intellectually and emotionally unfit for both the studies and the hard profession of medicine. Women’s bodies and minds were mainly, and naturally so, determined and preoccupied by the heavy demands of menstru-ation, reproduction and lactation. Their nervous system was much more delicate than that of men, as the exclusive occurrence of hys-teria among women made clear. In order to become a physician, masculine qualities were needed. The rare woman who by accident succeeded in becoming a doctor, could no longer be considered a woman – she would be ‘a virago’, a ‘monstrous being’.
Academy members also countered Pirmez’s argument that women doctors would lower the barrier for female patients to con-sult a physician. Wasn’t it telling, they stated, that while lower- class women relied on female midwives to deliver their babies, more distinguished women, who could not be suspected of having less modesty, all preferred male doctors? Problems of indecency would arise when female students were being exposed to male bodies in the anatomical theatre. And who wanted female students to have to study sperm and syphilis together with male students? Pirmez’s reference to the situation abroad was equally turned down. The so- called emancipation of women had indeed advocates in Germany, England, France, Russia and the United States, but should not be seen as a model, on the contrary. Belgium had so far been spared of such aberrations. It was no coincidence that the few women who had applied for an authorisation to exercise the medical profession in Belgium were ‘fanatics’ from abroad.3
The debate of 1875 not only offers an excellent insight in prevailing male opinions on the issue, but it also constitutes a good introduction in the many ways in which gender, health and medicine have been intertwined over the past two centuries. In a first, very
explicit way, the discussion dealt with the social division of medical labour. Power relations within the medical field have indeed been structured along class and gender lines, and the definition of both the internal and the external boundaries of the medical profession has often been informed by cultural representations of men’s and women’s roles and their so- called nature. In the case of the 1875 debate, physicians’ elaborate argumentations on the physical and mental inferiority of women point to a second pattern: medical knowledge, medical practices and medically informed discourses have always been gendered. Specific cultural representations of men and women have indeed informed medical knowledge. While nineteenth- century physicians constructed hysteria as a typically female disease associated with women’s supposedly natural emo-tionality, men’s mental problems were related to ‘manly behaviour’
such as violent experiences or sexual excessive activity. Inversely, an apparent gender neutrality could result in inequalities when research, for instance, tended to concentrate on diseases that occur more in men than in women, or when medication was tested exclusively on men. These often invisible but structural historical inequalities have been laid bare by feminist scholars such as Londa Schiebinger and Ilana Löwy; they remain a topical issue within contemporary health research and theory.4 The explicitly feminist engagement of many scholars points to a third issue, which was also apparent in the 1875 debate, where fear of female emancipa-tion was so obvious. Since the nineteenth century, feminists indeed have included questions of reproduction and health in their social activism. While medicine has often functioned as an instrument of male power over women’s bodies, it has also functioned as a space where both women and men could gain more control over their bodies, and the ways in which biological sex and gender relate to each other.
These three interrelated themes – the social division of medical labour, the gendered character of medical knowledge and prac-tice, and feminist activism to claim and redefine the body – will structure this chapter. On each of these themes, an extensive body of literature has appeared since at least the 1970s – and in fact earlier. Substantive studies on, for instance, the history of female physicians did appear as early as 1900.5 Globally, this historiog-raphy has moved from a focus on the underestimated role of women
in the field of healthcare to more structural analyses of the gendered nature of knowledge, scientific cultures and medical practices.
While path- breaking studies such as Ludmilla Jordanova’s Sexual Visions (1989) and Alison Bashford’s Purity and Pollution (1998) demonstrated the interrelatedness of these questions, new and exciting research on more ‘classical’ topics such as women surgeons in the nineteenth century continues to be done.6 Here as elsewhere in the field of medical history, scholars based in the United Kingdom and the United States have played an important role in the devel-opment of the field.7 Their studies, which often privilege English- speaking regions, depict historical evolutions which also occurred in Belgium, albeit at a different pace and with different accents, given the long- standing dominance of Catholicism, the slow pace of women’s political emancipation and the major role of ideological pillars in the organisation and financing of healthcare. On the con-trary, within Belgian historiography there hardly exists a tradition of historical research on intersections of gender and medicine in which these recent historiographical insights and perspectives are incorporated. Whereas female medical practitioners mainly figure in histories of medical professionalisation and medicalisation, the doctoral dissertation of Tommy De Ganck on nineteenth- century gynaecology in Brussels is one of the sole examples of historical scholarship on medicine’s role in the production of gendered cul-tural representations.8 Feminists’ activism to legalise birth control and abortion in Belgium – the third and last theme of this chapter – has received most historical attention, yet their medically informed views remain largely unexplored.
The division of medical labour
In the Southern Netherlands – the region that would become Belgium in 1830 – childbirth was women’s work. Officially recognised mid-wives mainly operated in cities, while unlicensed birth attendants assisted at deliveries in villages. In Belgium, as elsewhere, the medicalisation and professionalisation of midwifery coincided.
International historiography has traced how physicians in Europe and the United States increasingly gained control of traditional female birthing practices in the nineteenth century.9 Early- modern
attempts of doctors and surgeons to control (il)legal birth deliv-eries having been unsuccessful, it was under Dutch rule (1815– 30) that medical supervision on the medical practice of childbirth was installed in the Southern Netherlands (see Chapter 5, pp. 177–9).
The legal framework of 1818 established the education and practice of midwifery for the nineteenth century. The royal decree of 1823 further determined the organisation of two years of training. Female students mainly had to follow practical courses at an important maternity ward in their province.10 Similarly to French laws but unlike in the United States and Britain, Dutch legislation recognised midwifery as a distinct field of medical practice.11 The second part of the nineteenth century witnessed further calls for the improve-ment of midwifery training. In 1884 these attempts resulted in a royal decree that established stricter admission requirements and a broadening of the curriculum. At a time when the number of official midwives had increased in such a way as to – at least theoretically – replace non- official birth attendants, the sterner requirements for student midwives now slowed down a further growth in an age in which the number of doctors continued to rise.12
The professionalisation of midwifery was intertwined with the development of gendered hierarchies limiting the competences of female birth attendants vis- à- vis their male counterparts. The Dutch law of 1818 differentiated between three groups of obstetric practitioners: the doctor of obstetrics, the male midwife and the midwife. Unlike male practitioners, midwives had to confine their practice to ‘normal births’ that did not require specialised instruments. When confronted with difficult deliveries, they had to call a doctor or a male midwife.13 Taking such restrictions for midwives into account, historian Karel Velle has argued that the declining social role of midwives almost points at a process of
‘deprofessionalisation’.14 Throughout the nineteenth century the majority of doctors in the Academy of Medicine and in the provin-cial medical commissions, which supervised medical practice and advised the government on matters of public health, continued to defend such a gendered division of labour. The medical debate in the Belgian Academy in the 1870s on a proposition introduced by the physicians Hyacinthe Kuborn and Louis Mascart is exemplary in this respect. The proposition put forward the authorisation for mid-wives to use forceps when confronted with an emergency situation
and an absence of doctors. Both physicians mainly argued that such an extension of midwives’ competences was necessary since mid-wives often stood alone in the countryside. It would, moreover, be an effective means to combat illegal birthing practices that mainly took place outside the cities. Most doctors disagreed, among other things arguing that midwives were ignorant and disposed of weak intel-lectual capabilities. Finally, in 1879, the proposition was rejected by the majority of academy members and midwives’ access to the forceps was formally prohibited.15 In 1908, a law that replaced the law of 1818 confirmed the supposedly limited competences of midwives.16 Recurring arguments about women’s ‘ignorance’
and medical debates about midwives’ insecure financial position make clear that social inequality was constructed on the intersec-tion of gender and class hierarchies. Recently, however, historians have argued that studies privileging these medical sources have exaggerated the precarious social status of midwifery. Research into the social background of female birth attendants in Belgium has shown that while midwives operated within local communities of poor people, they themselves often originated from and married within the social environment of skilled laborers.17 Moreover, the fees midwives charged for a delivery were not necessarily different from what a doctor received for a delivery and were equivalent to what a day labourer earned in two to four working days.18
While male doctors solidified their dominance over the nineteenth- century domain of childbirth, nursing was an almost exclusively female domain consisting mainly of women religious (see Chapter 2, pp. 69–71). The first training programmes emerged in the context of tense ideological debate in the 1880s on the nursing competences of women religious. Early initiatives for lay nurses in the liberal settings of Liège and Brussels were followed by Catholic training programmes after 1900. Historians and feminists have often explained this gendered division of labour by underlining the hierarchy between caring and curing. Caring tasks of nursing were traditionally associated with ‘female’ maternal qualities, while the responsibility of curing patients belonged to the male- dominated field of medicine.19 In Belgium, as elsewhere, representations of the profession of nursing were indeed peppered with gendered notions of maternal care, altruistic dedication and female compas-sion.20 Recently, however, historians also challenged these gendered
notions of care by paying more attention to the practices and discourses of male nurses who were most clearly visible in psychi-atric hospitals.21 The Belgian mental institutions of the Brothers of Charity, for instance, were almost all- male spaces, both in terms of patients and nurses. A first exploration of the Brothers of Charity’s journal for nurses has shown that existing gender ideals informed the construction of a professional identity. ‘Male’ characteristics such as discipline and physical strength were associated with the care for mentally ill patients. At the same time, however, male nurses were also described as ‘mothers’ who cared for their chil-dren: the – equally male – patients.22 Outside psychiatric settings, male nurses were present as well. About 30 per cent of the first generations of qualified nurses were men.23 The gendered discourse on these nurses awaits research.
In the twentieth century, the position of Belgian independent midwives who assisted at home deliveries was increasingly threatened by the rapid professionalisation of nursing, on the one hand, and the medicalisation of giving birth in hospitals, on the other. The first process was accelerated by the development of mid-wifery as a specialisation within the nursing training programme as of 1951.24 The medicalisation of birth comprised the isolation of birthing women in hospital delivery rooms, the introduction of new medical technologies and the increasing use of anaesthesia during deliveries.25 In most countries – the Netherlands being a notable exception – the medicalisation of childbirth implied an increasing employment of midwives in hospital settings, where they were put in a subordinate position to physicians.26 A Belgian law of 1944 promoted deliveries in maternity clinics by offering mothers a com-pensation for all costs within the first ten days of a hospitalised stay, while home deliveries by midwives were not covered. Shortly afterwards, independent midwives were allowed to assist at deliv-eries in maternity departments. As a result, midwives preferred a paid employment in hospitals above poorly paid self- employment.
From 2,513 independent midwives in 1900, there remained around 80 in 2000.27 The profession of midwifery remains a remarkably stable ‘feminine’ domain. In contrast to the domains of medicine and nursing, very few men practise midwifery at present. In France, for instance, there has been an increase of male students since the profession was opened to men in 1982, yet the actual number of
male practitioners remains limited. In Belgium, male midwives also form a minority. In 2017, about 1 per cent of the qualified Belgian midwives were men.28
Testimonies of midwives themselves complicate the dominant narrative of medicalisation. In contrast to France, where historians have been able to integrate the professional experiences of mid-wives into their work,29 Belgium disposes of only a couple of oral and written testimonies of female birth attendants and their family members in the nineteenth and twentieth century.30 The few avail-able testimonies display a more balanced view of being an inde-pendent midwife in the countryside before, during and after the Second World War. Their socially vulnerable position – low wages, hard work and stressful situations – was definitely an important facet of their lives. Yet, the testimonies also show expressions of commitment and a high internal motivation. Midwives took pride in the many roles they fulfilled and for which they were recognised and appreciated in their community. Those who worked among large poor families, for instance, did additional tasks as social workers by providing them with material help and advice. Midwives in rural territories hardly ever called upon doctors, except when medical intervention was necessary.31 Moreover, recent research based on witness statements of unqualified midwives in the context of court cases on infanticide and the illegal practice of medicine suggests that in urban contexts collaborations between doctors and (unqualified) midwives sometimes occurred until the beginning of the twentieth century.32
Since the 1990s, the existing power hierarchies between physicians and midwives have been challenged. In 1994, a European law determined that midwives were qualified to assist deliveries autonomously and decide whether it was necessary to call a doctor. At the same time Belgian midwives adopted new roles in counselling future parents. They opened the first birth centres, providing for prenatal consultations, workshops, specific courses and information sessions. There, they offered their ser-vices by giving parents information and care before, during and after home deliveries.33 For the setting up of these birth centres midwives looked for inspiration abroad – the Netherlands, Scandinavia, Britain and the United States – where home deliveries were more common.34
In contrast with the professions of midwifery and nursing, the field of medicine was for a long time closed to women. From an international perspective, Belgian medical education opened up quite late. Medical schools in Switzerland and France admitted women early on in the 1860s. The first woman to receive a French medical degree was the British Elizabeth Garrett, who had been unsuccessful in her attempts to enter a British medical school.35 In Belgium too, Isala van Diest had been denied access in Leuven in 1873. She went to Bern, where she took her degree in 1877 (Figure 1.1). Garrett and Van Diest fit in a broader pattern of the first generations of female students who studied abroad.
Around the same time, an initiative offering a minimal medical education to women was launched by the Brussels doctor Constant
Figure 1.1 Painting of Isala van Diest by Pierre- Joseph Steger, ca. 1855.
Crommelinck. In 1875 he opened a ‘free school of medicine’ that offered female students a two- year elementary training in ‘natural medicine’ consisting of weekly conferences.36 This initiative was, however, short- lived and remained marginal vis- à- vis mainstream medicine. In 1880, the right of women to enter academic studies
Crommelinck. In 1875 he opened a ‘free school of medicine’ that offered female students a two- year elementary training in ‘natural medicine’ consisting of weekly conferences.36 This initiative was, however, short- lived and remained marginal vis- à- vis mainstream medicine. In 1880, the right of women to enter academic studies