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PALGRAVE STUDIES IN PUBLIC HEALTH
POLICY RESEARCH
Analysing Gender
in Healthcare
The Politics of Sex
and Reproduction
Sarah Cooper
Palgrave Studies in Public Health Policy Research
Series Editors
Patrick Fafard, Global Strategy Lab, University of Ottawa, Ottawa,
Canada
Evelyne de Leeuw, Liverpool Hospital, CHETRE, University of New
South Wales, Liverpool, Australia
Public health has increasingly cast the net wider. The field has moved
on from a hygiene perspective and infectious and occupational disease
base (where it was born in the 19th century) to a concern for unhealthy
lifestyles post-WWII, and more recently to the uneven distribution of
health and its (re)sources. It is of course interesting that these ‘paradigms’
in many places around the world live right next to each other. Hygiene,
lifestyles, and health equity form the complex (indeed, wicked) policy
agendas for health and social/sustainable development. All of these, it
is now recognized, are part of the ‘social determinants of health’.
The broad new public health agenda, with its multitude of competing
issues, professions, and perspectives requires a much more sophisticated
understanding of government and the policy process. In effect, there is a
growing recognition of the extent to which the public health community
writ large needs to better understand government and move beyond what
has traditionally been a certain naiveté about politics and the process of
policy making. Public health scholars and practitioners have embraced this
need to understand, and influence, how governments at all levels make
policy choices and decisions. Political scientists and international rela-
tions scholars and practitioners are engaging in the growing public health
agenda as it forms an interesting expanse of glocal policy development
and implementation.
Broader, more detailed, and more profound scholarship is required at
the interface between health and political science. This series will thus be
a powerful tool to build bridges between political science, international
relations and public health. It will showcase the potential of rigorous
political and international relations science for better understanding
public health issues. It will also support the public health professional with
a new theoretical and methodological toolbox. The series will include
monographs (both conventional and shorter Pivots) and collections that
appeal to three audiences: scholars of public health, public health practi-
tioners, and members of the political science community with an interest
in public health policy and politics.
Sarah Cooper
Analysing Gender
in Healthcare
The Politics of Sex and Reproduction
Sarah Cooper
University of Exeter
Exeter, UK
Palgrave Studies in Public Health Policy Research

ISBN 978-3-031-08727-1 ISBN 978-3-031-08728-8 (eBook)
https://doi.org/10.1007/978-3-031-08728-8
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2022
This work is subject to copyright. All rights are solely and exclusively licensed by the
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of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on
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retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc.
in this publication does not imply, even in the absence of a specific statement, that such
names are exempt from the relevant protective laws and regulations and therefore free for
general use.
The publisher, the authors, and the editors are safe to assume that the advice and informa-
tion in this book are believed to be true and accurate at the date of publication. Neither
the publisher nor the authors or the editors give a warranty, expressed or implied, with
respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps
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This Palgrave Macmillan imprint is published by the registered company Springer Nature
Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Contents
1 The Politics of Sex and Reproduction 1

Inclusivity in ‘Women’s Health’ 5
Analysing Gender in Healthcare 12
Structure of the Book 17
References 18
2 Understanding Outcomes 29
Beyond Binary Service Delivery 32
Structural Adaptations 36
Shaping Outcomes 50
Conclusion 55
References 56
3 Sexual Health 67
Sex Education 68
Priming Cost-Effectiveness 76
Uptake, Lockdown and the ‘Other’ Vaccine 90
Conclusion 100
References 101
4 Abortion 119
Clinical Control of Patient Experience 121
The Distrusting Minister 128
Pandemic Pills by Post 143
Conclusion 152
References 153
v
vi CONTENTS
5 Assisted Reproductive Technologies 169

Legislating Infertility 171
Commissioning Motherhood 181
The Pandemic Pause 196
Conclusion 199
References 200
6 The Future of Gender-Related Healthcare 215
A Wider Analytical Toolkit 218
Strategies for Success 226
The Corona Context 229
Conclusion 234
References 235
Index 241
CHAPTER 1
The Politics of Sex and Reproduction
Addressing the clinical needs of the population is a principle concern for

national and international regulatory bodies the world over, and is the
bedrock of the modern democratic state. With a steady lengthening of
life expectancy, and proliferation of high-burden medical conditions, it
is a matter that also shoulders a plethora of financial responsibilities and
resource requirements, with the global health bill weighing in at a size-
able US $8.3 trillion in 2018 and topping 10% of global GDP (Vrijburg &
Hernández-Peña, 2020). Furthermore, this figure was predicted to reach
a heady US $15.4 trillion by 2030 (IHME, 2018), and is now subject to
the additional care costs and resource use demanded by the COVID-19
pandemic (e.g. Bartsch et al., 2020) and the emerging global economic
crisis. Sitting amongst this extensive list of varying economic pressures is
the matter of traditionally termed ‘women’s health’, which creates a very
specific and complex set of demands from any health programme, that in
turn requires sizeable funding. The contribution of such gendered care to
the aforementioned global spending is vast; $713.3 million in funding was
provided to the United Nations Population Fund (UNFPA) in 2017, for
instance, with the specific remit of reproductive health, family planning
and newborn and child health (IHME, 2018). The challenges to fully
meet the needs of patients, however, should not be viewed exclusively
© The Author(s), under exclusive license to Springer Nature 1

Switzerland AG 2022
S. Cooper, Analysing Gender in Healthcare,
Palgrave Studies in Public Health Policy Research,
https://doi.org/10.1007/978-3-031-08728-8_1
2 S. COOPER
as a concern for restricted resource settings, and the cost of medicine

is a worldwide consideration. The price of health is now outpacing the
expansion of the economy globally, with high-income countries expected
to stretch to US $9019 in medical care per person by 2040 (Dieleman
et al., 2016). Within this rapid growth, women account for 56% of health
spending across the OECD countries (OECD, 2016). The domestic
perspective here in the UK similarly demonstrates a significant impact on
wealth; amounting to 12.8% of the state’s GDP, the total expenditure on
UK health in 2020 was £269 billion (ONS, 2021).
The term ‘women’s health’ encompasses wide and diverging areas
from birth control to the menopause, ovarian cancer to osteoporosis and
menstruation to heart disease. The substantial price tag hung around
sexual and reproductive clinical care specifically is broadly triangulated
between therapeutic burdens, sex-contingent risks and gender relations.
First, reproductive capabilities alone establish a biological necessity for
recognition in the clinical sciences, and the management and treatment
of stages such as hormonal development, the menstrual cycle, pregnancy
and infertility, are an inevitable focal point of any healthcare system. As
just one result, maternity care established to cover the rising number
of births in England, recorded as 640,370 in 2019 (ONS, 2020) has
driven a £127 million financial boost to increase staffing, clinical develop-
ment training and neonatal cots amongst other initiatives (NHS England,
2022). Furthermore, fatality figures for women during pregnancy and
childbirth globally in 2017 reached levels of around 230,000 (IHME,
2018), with the UN’s ‘World’s Women’ report highlighting this aspect of
reproduction as one of the leading causes of death in young women in
developing countries (UN, 2020). In turn, sex-contingent healthcare risks
again create a discernible impact upon mortality rates, with the greatest
burden in fact attributable to non-communicable diseases (Peters et al.,
2016). Breast cancer, for example, is posited as the fourth most common
cause of cancer-related death in the UK, standing at a figure of around
11,500 every year; men only accounting for approximately 95 of those
cases (Cancer Research UK, 2021). Finally, a UK study in 2014 found
that the cost of intimate partner violence against women is more than
13.5 billion euros, with gender-based violence against women almost 28.5
billion (Walby & Olive, 2014).
Personal costs associated with this area of healthcare are also high, with
a survey conducted by Public Health England (PHE) in 2017 revealing
that 31% of women experience reproductive problems, with an even
1 THE POLITICS OF SEX AND REPRODUCTION 3
higher 35% reporting heavy menstrual bleeding and a further 12% having
taken time off work due to symptoms associated with the menopause
(PHE, 2018). Within this context, ‘women’s health’ thus comprises a
large proportion of all healthcare consumption, but it is importantly
reported that the complex clinical needs and concerns associated with
this category are often unmet (Luce et al., 2015), leading many to urge
the focus of further efforts in this regard (Regan, 2018). Benchmarks
for improvements in this arena are certainly not easily reached and esti-
mates submitted by the WHO in collaboration with UNICEF, as just
one example, highlighted that the UK has some of the lowest rates of
breastfeeding (UNICEF, 2018). Certainly, the literature recording the
premature death of women purely because of their sex now prolifer-
ates (e.g. Freedman & Maine, 2018; Ginsburg et al., 2017; Plümper
et al., 2018), and strategies to manage and combat these trends are the
interwoven product of multi-level governance, reaching beyond solely a
clinical approach, with national and supranational influences creating a
melting pot within which a contemporary approach to women’s health
constantly reacts, adapts and matures across all regions.
Specialist clinical attention in this area of healthcare is therefore unsur-
prising across such a pressing statistical landscape, with an abundance
of programmes and initiatives proliferating across the UK. In 2017, for
example, £2 million charitable money was awarded to establish a ‘Barts
Research Centre for Women’s Health’ with the objective of fostering
landmark research before, during and after pregnancy, and with a defined
focus on matters such as conception and successful IVF treatments
(BARC, 2021). Similarly, declining rates in cervical screening for female
cancers has become a fixture on the government’s agenda for decades,
and PHE has poured resources into considerations to make the procedure
more accessible (PHE, 2017). Of perhaps greater revelation, however, is
the relative infancy of the specialism in healthcare. Despite the forma-
tion of the Royal College of Obstetricians and Gynecologists (RCOG)
in 1929 in response to the historical management of women by women,
often in the form of unqualified midwives, the area has arguably long
lacked a broader holistic appreciation of the gender-based inequalities
in health outcomes. With the acceptance of the activity in professional
practice closely tied to ‘man-midwives’ or ‘accoucheurs’ (Goodell, 1876),
the feminisation of the subfield has only really been discussed in scholar-
ship from the turn of the twentieth century onwards (e.g. Drife, 2002).
As a result, the collaborative activity of knowledge gathering around
4 S. COOPER
the social determinants of health and gender-based disparities has only

recently gained popularity, with the groundbreaking Marmot Review in
2010 (Marmot et al., 2010) and followed by initiatives such as the BMA’s
symposium, and subsequent publication of briefing papers, on unmet
needs in women’s health (BMA, 2010). This is not just the nature of
chronological development at this domestic level, however, and stories
from across the pond mirror such insights. In the case of the US, for
example, it was not until the 1990s that the ‘Office of Research on
Women’s Health’ (ORWH) was in part established upon the observa-
tion, and corresponding concern, voiced by scientific, congressional and
advocacy groups, of a discernible lack of systematic representation of
female results in clinical trials (Pinn, 1994). This delayed acknowledge-
ment of the omission of female representation in data gathering tasks can
arguably be attributed to the inevitable political interpretations that infuse
this field, and convincing elites that an interest in this specific popula-
tion of health consumers could be to the clinical benefit of both men
and women was a difficult task (Pinn, 2004). With clear hurdles for
the recognition of appropriate individual healthcare faced, therefore, it
has instead been the democratic value of focusing on women’s health in
recognition of the predominate role of the primary decision-maker, or
‘linchpin’ in the family, that has gained traction in extolling the bene-
fits for the wider population (Glynn et al., 2016). Although undeniably
an important step in appreciating women in healthcare, these develop-
ments are increasingly outdated and are currently struggling to move
beyond conservative observations. Granted, significant efforts to date
have coalesced around the challenge to traditional female roles in the
home, the movement from reproduction into production and adaptations
to the division of labour across the sexes (e.g. Bianchi & Milkie, 2010;
Doyal, 1995; Paolisso & Leslie, 1995), but rejection of a heteronormative
and cisgendered preoccupation is scare despite notable societal shifts.
The provision of care in this domain has indeed now moved
beyond solely fiduciary concerns of sex-contingent risks and reproductive
inevitably to present a thoroughly modern puzzle for healthcare manage-
ment of gender across the globe. It is an area rife with complex scientific
developments inextricably linked to ideological context, and intimately
connected to the political environment. As such, it is often the mainstay
of presidential electoral campaigns, as so fiercely demonstrated in 2016.
Hilary Clinton’s pledge to Planned Parenthood to support the organisa-
tion against anti-abortion politicians and rhetoric, highlighted the breadth
of the debate beyond economic issues, to be, as she stated, a matter

of family and justice (Badanes, 2016). Heavily countered by President
Trump, however, on just his fourth day in office he signed an execu-
tive order to reinstate the ‘global gag rule’, an instrument preventing
foreign organisations in receipt of American international family planning
funds from providing information, referrals or services for legal abor-
tion or advocating for access to abortion services in their country (Starrs,
2017). Although this contentious and divisive rhetoric is not experienced
and relayed to the public in the same manner in the UK, the typically
British silence on the matter should not be mistaken for apathy, and deci-
sions concerning the design and implementation of women’s healthcare
are a web of opposing consideration and battles. In recognition of the
contemporary push for an intersectional approach to public health (e.g.
Bowleg, 2012), recognising racial and ethnic factors (Williams, 2002),
in addition to sexual minorities (e.g. Phillips et al., 2012), therefore, and
taking much inspiration from the utility of the paradigm in understanding
diversity in health outcomes (e.g. Hankivisky et al., 2009), this opening
chapter establishes the progressive empirical parameters of research into
this complex vicinity of healthcare that no longer appears appropriately
constrained to the term ‘women’s health’.
This introduction is organised into three substantive parts. First, the
expansion of this category to simultaneously include the clinical needs
of transgender, gender non-binary and sexual minorities, is first outlined.
Next, the research puzzle, and tackling the analysis of gender in health-
care, is made palatable through the outline of three nested points of
inquiry. To close, the empirical foci of the project, as comprising three
case studies of sexual and reproductive needs, is outlined and the structure
of the book is submitted.
Inclusivity in ‘Women’s Health’

Transformed expectations of the roles for women, along with attrition
to binary and heteronormative understandings of gender and sexuality,
and developments in biological capabilities, drive an increasingly complex
politics of sex and reproduction and is the core rationale for this book.
A definition of the reconstituted parameters of ‘women’s health’ is thus
a vital first task when identifying the population both affected by, and
in turn capable of influencing, policy outcomes. Mindful that there still
remains a palpable default position inherent in our group thinking of
6 S. COOPER
this form of clinical care, the privileging of the prominent image of the
married pregnant woman, as just one such instance, harmfully fails to
reflect the full spectrum of health considerations. We have instead entered
a more complex reality of personhood that encompasses a rich tapestry
of identity and sexuality, with the fluid boundaries of gender, in addi-
tion to more recent developments around sex characteristics, which all
challenge a now limited categorisation of just men and women. Impor-
tantly, this progression should not be viewed exclusively on a sociological
level and is equally matched by scientific developments. First tracing the
cultural history of women-centric medicine therefore, this section, under
the broad rubric of gender, outlines considerations of gender identity, sex
and sexuality across contemporary patients in the field of sex and repro-
ductive healthcare. The historical narrative that results illuminates the
medical profession’s initial positive distinction between sex and gender,
and its calls for greater respect for these differences, alongside technolog-
ical advances, has established a range of modern pragmatic demands for
the health policy network to address.
Challenges to gender stereotyping and strides towards women’s
equality have shaped the demands of women’s health. The sex has long
surpassed a one-dimensional child-bearing function, and in a liberated
twenty-first century, the rejection of gender-based norms has grown
ever more pronounced and now pervades multiple spaces in society.
This may be in the form of grassroots movements initiated on social
media that challenge binary labelling of toys for children and encourage
gender-neutral marketing, including the campaign ‘Let Toys be Toys’
(Grindberg, 2015), to more formal challenges such as the continuing
debates concerning the vagaries of the UK’s employment law and the
rights of employers to demand women wear heels to work (Macey, 2018).
These often, subtle actions are important nods to female progression
and one that has its roots in a long-fought battle for equality with
the ambitions of the women’s movement expanding beyond suffrage
(Buechler, 1990), to tackle the nuances of contemporary society and
demand equality on a broader front. The natural progression from child-
hood into puberty and beyond is not impervious to cultural influence,
however, and an important recognition of the distinction between phys-
iological differences and perceptions of roles is a necessary starting point
for the study of women’s health.
Ill health, therapeutic need and treatment are all multifarious issues
that expand beyond the reaches of scientific evidence and incorporate
broader lifestyles and choices. This has led some scholars to talk of
a social construction of medical knowledge (e.g. Jordanova, 1995), in
which ideas, infused by societal and cultural understandings, can result in
significant interpretations within the clinical sciences that influence under-
standings (e.g. Wright & Teracher, 1982) and extract knowledge from a
vacuum-like state. This observation can certainly be levied at women’s
health, and the history of medicine is a burgeoning field of academia
that uncovers, amongst its many trends, the environmental experience
female patients have had with their bodies across the centuries. Shorter
illustrates this point well when describing a wife’s limited control over
sexual activity in previous centuries, her conjugal rights heavily contin-
gent on the wishes of her husband. As a result, she continually ran
the risk of pregnancy and would bear an average of six live children
(Shorter, 1984). In a similar vein to maternity, temporal considerations
must also be applied to the understanding of reproductive cycles more
generally; although the term ‘premenstrual tension’ was first coined back
in 1931, it has, over the decades, been at the centre of disagreement
over the extent of physical, emotional and behavioural changes it can
incite and is indicative of the influence of cultural beliefs in the produc-
tion of medical knowledge (Rodin, 1992). Anthropological literature, for
example, traces ‘menstrual taboos’ back to primitive times (Delaney et al.,
1988) and medical approaches of old viewed the ‘reproductive apparatus’
as a limitation upon daily activities (Vertinsky, 1987). A now heavily dated
medical text from the 1920s detailed a study undertaken across 1200
school girls, for example, that found that many were ordered not to play
games when experiencing their period and thought the taking of baths
during that time would be dangerous (Clow, 1920). By way of contrast,
we are now inundated with advertisements for vaginal hygiene items
that demand women to be ‘clean and fresh’ (Jenkins et al., 2018) and
have experienced a steady depiction of menstruating women as ‘dynamic,
energetic and always functioning at their optimal level’ from the 1970s
onwards (Havens & Swenson, 1988). This development heavily illus-
trates a gendered approach to the understanding of menstruation; the
physiological understanding of the process is deeply engrained with the
perception of a female role.
To characterise the understanding of medicine as solely a social
construct, however, would be to overlook an important distinction that
is extolled in this policy domain. A steadfast delineation between gender,
in the patterns observed above, and sex as a biological fact, has long been
8 S. COOPER
endorsed by the medical profession. The latter is clinically defined as an

individual male or female based on ‘chromosomal complement and phys-
ical characteristics’ (Pinn, 2004) and manifests in primary sex characteris-
tics in birth—namely testes, ovaries and external genitalia—compounded
by secondary characteristics during puberty such as the development of
sex-specific hormones. Gender, by way of contrast, refers to the grouping
of feminine and masculine traits, and is closely tied to an individual’s ‘sub-
jective experience’ (Bowman et al., 2022). Moving beyond the formal
remit of biological differences that any healthcare system is required to
address, however, clinicians have increasingly promoted the importance
of recognising the differences between social and biological health risks,
and called for projects that aim to reduce inequalities across the male
and female divide by encouraging both to ‘challenge gender stereotypes’
(Craft, 1997). Certainly, the once ‘hidden burden’ (Heise et al., 1994)
of violence against women (VAW), for example, is now readily accepted,
and the detrimental health consequences for women of intimate partner
violence as just one subset (Campbell, 2002) is accepted as a sizeable
problem (Garcia-Moreno et al., 2006).
The separation of a bank of culturally contingent risk factors from
biological differences was therefore an important contribution of the
1990s to combat gender-based inequity in health (e.g. Bird & Rieker,
1999; Lee, 1998) and was manifested in several important initiatives of
the time. A core principle underpinning the Platform for Action of the
Fourth World Conference on Women in Beijing in 1995, for example,
was the targeting of a gender bias inherent in public healthcare and an
acknowledgement of the necessity of sharing disproportionate responsi-
bilities such as family caretaking (World Conference on Women & United
Nations, 1996). Further following suit, a global appreciation that the
social construction of female roles risks the perpetuation of discrimina-
tion in third world countries through situations such as a lack of female
autonomy over reproductive health, early marriage exposing women to
potential complications from young pregnancies, and an emphasis on
child-bearing capabilities (Okojie, 1994) has gained both academic and
media attention. Coupled with an appreciation of the exposure of the
gender to an array of environmental health hazards from chemical deter-
gents in the home (Habib et al., 2006), to occupational diseases (Kilbom
et al., 1998), in addition to more ‘silent’ trends that have a discernible
female impact such as suicidal behaviour (Shahmanesh et al., 2009), a rich
appreciation of the expectations and lived experiences of women is being
cultivated. Arriving at this point of understanding, however, has been a

tumultuous journey and extrapolating gendered rationale from explana-
tions of a woman’s health has taken time, with a problematic mix of the
two across diverging areas of academia submitted and justified in decades
previous. Examples included ‘body fatness’ (Cureton et al., 1979), a
greater trust in the capabilities of males in protector roles such as the
police (Remmington, 1983), and the higher demands upon women for
physical fitness to perform their duties in the military (Sharp, 1994). Clin-
ical progression towards a more nuanced understanding of sex and gender
differences is therefore invaluable and is a trend increasingly encouraged
and mirrored in society. Attrition to the archetypal gender role has indeed
occurred and the cultural boundaries of femininity have been expanded
and reconstituted over the years, with rises in the socioeconomic status of
women in work and government (Giele, 1978), rebalanced family time
management (Higgins et al., 2000) and improved higher educational
opportunities (Becker et al., 2010).
Extracting gender traits from sex characteristics, and the demysti-
fication of harmful assumptions, was an important first step in the
empowerment of women. With the growing acceptance of gender non-
conformity, however, we enter into a new phase of understanding that
progresses past this cisgendered perspective, to appreciate transgender.
Here this term takes guidance from advocacy groups and is asserted in
this book as an inclusive umbrella that covers binary trans people, non-
binary people and people who cross-dress (LGBT Foundation, 2021).
Gender-affirming medical intervention has a sizeable history, with ‘mas-
culinisation surgery’ recorded as far back as 1882, but researchers warn
that the cultural history of clinical practice should not be viewed as long
enlightened, and instead hosts a legacy of binary enforcement (Vincent,
2019) and ‘two-gender medicine’ (Snelgrove et al., 2012). Indeed, the
medicalisation of trans healthcare long persisted with the male and female
categories (Dolgin, 2017) with a dominant medical model emerging that
heavily associated gender non-conformity with a psychological condition
(Romeo, 2004). Moves towards de-psycho-pathologisation were heavily
driven by calls from the World Professional Association for Transgender
Health (WPATH) that expression past stereotypical binary should not
be viewed as inherently negative. This in part instigated change in the
conceptual framework for the delivery of healthcare from a mental health
solution, to the recognition of a durable biological component that
10 S. COOPER
cannot be externally manipulated (Safer, 2019). Despite these develop-

ments, significant hurdles persist today and contribute to a reluctance
amongst the population to disclose, a lack of provider experience and
resources, and both structural and financial barriers to access (Roberts &
Fantz, 2014). A patient-centred approach additionally appears far from
grasp, with 61% of trans people surveyed in the UK submitting that
they felt they had to go out of their way to educate health professionals
themselves (McNeil et al., 2012). As a cumulative result of this real or
perceived stigma (Safer et al., 2016) trans people tend to be less healthy
(Vermeir et al., 2018) and will often turn to online resources that may
be limited in their accuracy (Augustaitis et al., 2021). This staggered
history, coupled with this disengagement, requires responses from the
healthcare community and is further problematised in the country by
excessive waiting times (Carlile, 2020) with the combined patient list of
the 11 NHS gender identity clinics is at least 5000 (Barrett, 2016), and
with vulnerabilities made significantly worse by COVID-19 (e.g. Gava
et al., 2020).
Appreciation of the limits of binary categorisation is additionally recog-
nised in the naturally occurring variation in humans that some persons are
born with reproductive or sexual anatomy that does not fit exclusively in
the ‘male’ and ‘female’ boxes. Correspondingly, the term intersex is used
to refer to such persons with a combination of these sex characteristics
and in the UK, it is estimated that 130 babies born each year require
investigations before their sex can be assigned (Monro et al., 2017). The
legitimacy of medical intervention to ‘correct’ such situations predates
acceptance of trans-responsive healthcare, with historians noting cases
of fictional intersex narratives utilised to access gender-affirming surgery
(Vincent, 2019). As with the aforementioned medicalisation of trans
healthcare, however, this cannot be viewed solely as positive, and the need
‘to fix’ has had worrying implications for identity and informed consent,
and has been at the heart of intersex activism from the 1990s (Grif-
fiths, 2018). Nevertheless, growing ‘rhetorics of healing’ (Hester, 2006)
appeared to gain clinical acceptance in the controversial 2006 Chicago
Consensus Statement which introduced the term ‘Disorders of Sex Devel-
opment’ (DSD) (Feder, 2009). This ‘nomenclature’ was welcomed in
some quarters for its useful classification of the causes of DSD (Hughes,
2008), whilst opposing voices, questioning why treatment is necessary at
all, feared its full medicalisation of intersex conditions (Feder & Karkazis,
2008), and open discussion concerning the full implications of surgery on

ambiguous genitalia has been called for (Melissa, 2002).
This attrition to the traditional dividing lines of male and female roles,
in addition to acknowledgement past a cisgendered lens and inclusive
of transsexual, and intersex, identity is further encouraged by the adop-
tion of a queer perspective to sexuality. By critiquing fixed categorisation,
and challenging the ‘normalisation of heterosexual institutions and prac-
tices’ (Manalansan, 2006), the additional deconstruction of conventional
societal labels in line with a more fluid spectrum of sexuality is driven.
The first wave of this awareness is undeniably attached to the decrim-
inalisation of homosexuality in the UK in the 1950s, and later by the
medical profession’s response to the specific needs of the patient popu-
lation throughout the AIDS crisis and a mainstreaming of the disease in
professional circles (Berridge, 2000). Although much criticism can still
be levied at the healthcare community’s dominant paradigm of hetero-
sexual consumers (e.g. Burrow et al., 2018; Enson, 2015), and this will
certainly feature in later chapters, sexual orientation has become a feature
of contemporary medical care. It is appreciated amongst the scholarship,
however, that binary gender beliefs can nevertheless still be exhibited
both implicitly and explicitly in research into homosexuality (Drescher,
2015). Indeed, the homosexual/heterosexual division established over
the preceding decades does not alone fully encapsulate the intricacies of
sexual orientation today, but rather through its heteronormative lens it
posits homosexuality as the binary opposite to the natural norm (Valocchi,
2005). In reality, non-straight/non-gay sexualities such as ‘pansexual’
and ‘heteroflexible’ is a more appropriate landscape as encapsulated by
borderland theory (Callis, 2014), and is an important recognition for
an inclusive healthcare environment. Sexuality therefore, as importantly
distinguished from sex here, is inextricably linked to the perception of
gender roles both in medicine and society. This intersectional appreciation
of the experiences of LGBTQ+ communities alongside demographics of
race, class and gender is gaining traction in health user research (e.g. Fish,
2008) and requires similar recognition in the analysis of power in policy-
making. This urgency is now further exasperated, however, by scientific
developments in the biological capabilities of sex.
Far more than purely a feature of the welfare state and traditional
considerations of resource allocation, therefore, matters of sex and repro-
duction encompasses a series of interwoven ‘moving parts’ that include
12 S. COOPER
the dynamic societal understandings and acceptance of gender and sexu-

ality, and advances in sex-based biological division and capabilities. This
necessary intersectional appreciation of clinical need beyond ‘women’s
health’ is importantly adopted throughout this book.
Analysing Gender in Healthcare

The result of these reconstituted boundaries of ‘women’s health’ is an
array of complex regulatory conundrums for policymakers. The reaches
of publicly funded UK provision in response to such demands, and the
government and societal linkages shaping policy outcomes in this clinical
subset, is therefore of central concern to the book, and is an endeavour
that can be broken down into three nested research questions outlined
here.
How is Sexual and Reproductive Healthcare Provided in the UK?

The critical movement away from culturally defined categories of gender,
sex and sexuality (Kuper et al., 2019) and clinical appreciation of trans-
formed roles, gender dysphoria, expansion of the transgender community
and the adoption of non-binary identities elaborated above cause attri-
tion to conventional understandings of healthcare management. This first
research question’s historical inquiry therefore provides a vital first step
in understanding the evolving context of service delivery across gendered
healthcare in the UK. When selecting treatment areas of analytical interest
to comprise the case studies of this book within this now broader remit
of women’s health, therefore, the first international definition of repro-
ductive health is a key point of departure. Debated and delivered at the
1994 International Conference on Population and Development (ICPD),
it outlined the clinical subset as ‘…a state of physical, emotional, mental
and social well-being and not merely the absence of disease, dysfunction
or infirmity’ as underpinned by a ‘constellation of methods, techniques
and services’ (UNFPA, 1994, para. 7.2). Importantly, the recognition
of three baseline human rights followed. First, the right of all couples
and individuals to decide freely and responsibly the number, spacing and
timing of their children, and to have the information to do so was stated.
Second, the right to attain the highest standard of sexual and reproduc-
tive health supported this assertion. Third, the right to make decisions
concerning reproduction free of discrimination, coercion and violence
was lastly detailed (UNFPA, 1994, para. 7.3). In summation, it estab-

lished the right of men and women to be informed, and have safe access,
to: family planning, the regulation of fertility (by methods not against
the law) and healthcare services relating to safe pregnancy, childbirth and
infant health. This wording represented the success of women’s health
activists in the proliferation of a public health discourse around repro-
duction (Cottingham et al., 2019) and secured its acceptance within
population and development strategies (Marshall, 1996) that continues
to influence the parameters of domestic policy programmes to this day.
The harmonious ‘Cairo consensus’ (AbouZahr, 1999) did not extend
to all aspects under debate, however, and the media heavily focused on
the issue of abortion and the Roman Catholic Church remaining staunch
on its historical position. In fact, efforts to align with Islamic concerns
over ‘sexual excesses’ were evidenced by the Vatican (Fincher, 1994) in a
clear attempt to reassert conservative cultural forces. This unease was simi-
larly felt across discussions on sexual health, and its incorporation into the
programme was far less equivocal that the definition of reproduction, with
‘virulent objections’ from some governments (Cottingham et al. 199). As
a result, it was merely tacked on to reproductive health with the purpose
of ‘enhancement of life and personal relations, and not merely coun-
seling and care related to reproduction and sexually transmitted diseases’
(UN, 1995, para. 7.2). Fuelled by the HIV/AIDS pandemic (Johnson
et al., 2005), however, a more robust appreciation of sexual health instead
came later in 2006 that urged for its legitimate role in public health
discourse and human development (Coleman, 2011). Following a tech-
nical consultation in Geneva in 2002, the WHO stipulated ‘…a state of
physical, emotional, mental and social well-being in relation to sexuality;
it is not merely the absence of disease, dysfunction or infirmity’ that
include a ‘positive and respectful approach to sexuality and sexual rela-
tionships’ (WHO, 2006). Taking as its lead the human rights reflected in
the ICPD’s approach, sexual rights were listed to include, amongst others,
the highest attainable standards of sexual health, sexuality education and
to decide whether or not to have children.
Sexual and reproductive health combined therefore embodies a range
of issues in global policy efforts that extend further than traditional
accounts of family planning and maternal health, to additionally include
practices such as female genital mutilation, gender-based violence and
child marriage (e.g. USAID). Added to this evolving clinical area are
the healthcare needs of the reconstituted population falling within
14 S. COOPER
women’s health discussed above. Certainly, the legitimatisation of a

medical frame for gender identity (Lee, 2008), alongside other thera-
peutic needs such as drug addiction (e.g. Conrad, 1975; Smart, 1984),
suicide (e.g. MacDonald, 1989) and even compulsive buying (Lee &
Mysyk, 2004), brought clinical oversight onto a once socially infused
field. This, sometimes harmful, medicalisation has in turn been challenged
and complimented by the stretching and shifting of sex-based capabilities
in the advent of technology. The ability of biotechnology to engender
the process of clinical control, for example, has indeed been noted as a
key trend of the contemporary healthcare in the literature (e.g. Conrad,
2005), with some now delving into a new phase of biomedicalisation
(e.g. Coveney et al., 2011). This can be most keenly observed in the
area of reproduction in which child bearing later in life, for a larger
pool of patients, is safer and more viable than ever before. Discoveries
and research around intrauterine insemination (IUI) and IVF have simi-
larly extended the biological limits of creating new life, and the once
strict genetic categorisation of sex capabilities has been dispelled in light
of a range of interventions for gender identity disorders from hormone
replacement to reassignment surgery now a steadfast possibility.
With these adaptions in mind, therefore, and for the purposes of
this UK-centric study, focus within the broad auspices of sexual and
reproductive health—namely the case studies of adolescent sexual health,
abortion and assisted reproductive technologies (ART)—is urged by
coupling public resource requirements with the evolving clinical need.
First, although often conservatively viewed in terms of teenage pregnancy
prevention, sexual health risk factors for secondary school-aged chil-
dren are more significantly associated with sexually transmitted infections
(STIs). In 2019, for example, there were 468,342 diagnoses in England,
marking a 5% annual increase (Mitchell et al., 2020) and requiring signif-
icant public financing; back in 2011, it was estimated that treatment in
this field treatment cost the NHS £620 million (NHE, 2013). Within
this observation, sexual minority youths are at a particular health disad-
vantage (Fish, 2020), more likely as they are to engage in behaviours
such as condomless sex (Paul Poteat et al., 2019). Second, the number of
abortions in 2019 were also notable, indicated by the 207,384 patients
seeking treatment (DHSC, 2020), with growing scholarly recognition of
the difficulties in access for transgender, non-binary and gender expan-
sive people (e.g. Moseson et al., 2021). Third, the Office for National
Statistics (ONS) also submitted declining fertility rates at this time across
the UK (ONS, 2019) further supported by a groundbreaking US study

of 120,000 men outlining the increase in fertility problems from 12.4%
in 2004 to 21.3% in 2017 (IVI, 2019). Back in 2013, it was estimated
that £68 million was being spent annually on in vitro fertilisation (IVF)
treatment in the UK (NICE, 2013). Biomedical advances have impor-
tantly strengthened the inclusion of the LGBTQI+ community in assisted
reproduction and increased the possibilities of family formation, but this
inevitably places further financial strain on the system.
This first research question will consequently deliberate the legisla-
tive and regulatory development of treatment in these three areas and
will consider parity of access across patients. The geographical parameters
of this study will oscillate between the UK, and its separate jurisdic-
tions; although the English experience is at the forefront of this book’s
objectives, the accompanying policy narrative is unavoidably shaped by
devolution across Scotland, Wales and Northern Ireland, and due regard
is afforded to this.
How Have These Decisions Been Shaped in the Healthcare Community?

A significant consequence of the positive interdependent relationship
between medicine and society, including the progressive delineation of sex
from gender, attrition of the pyscho-pathologisation of trans people and
rhetoric of healing around intersex, outlined previously in the chapter,
is that the ensuing regulation is now faced with increasing interaction
with a diverse collection of voices. To capture the significance of these
exchanges in explanations of policy decisions, the ‘currency’ (Thatcher,
1998) of network analysis techniques in public policy as an organising
concept (e.g. Marsh & Smith, 2000), appreciating that policymaking
in subsystems is delegated to bureaucrats who in turn seek informa-
tion and advice from affected groups (e.g. Atkinson et al., 1992; Tyler
and Dinan, 2001), is first recognised. Posited as an ‘intuitively compre-
hensible metaphor’ (Adam and Kriesi, 2007), the fundamental logic of
the approach insists that self-organising, stable relationships and coordi-
nation of mutual interests, can ensue from regular communication and
frequent exchange of information between actors. Henry (2011) elabo-
rates that acknowledgement of the drivers establishing a network is largely
divided across competing understandings; the Advocacy Coalition Frame-
work (ACF) highlights shared ideology across actors, in sharp contrast
to Resource Dependency Theory’s insistence that perceived influence is
16 S. COOPER
at the heart of formation. This latter favour is of immediate interest

here within the field of healthcare, so easily identified as dominated by
professional power and knowledge. Located within a broader critique
of the approach in terms of its ability to provide analytical ‘models’
(Dowding, 1995), however, the need to move the theoretical framework
beyond a somewhat static conceptualisation of a professionalised network
is unpacked in Chapter 2 and comprises the analytical pathway of the
succeeding case studies of adolescent sexual health, abortion and ART in
Chapters 3, 4 and 5. Acknowledging the utility of a structural approach to
healthcare, therefore, but emphasising adaptations conceptually derived
from a substantial body of dialectical policy networks literature (e.g.
Marsh and Smith, 2000), a fruitful theoretical framework is established.
What Has Been the Impact of COVID-19 on Gendered Healthcare?

Presenting first in Wuhan in China at the end of 2019, SARS-CoV-2
or COVID-19, was declared a global health emergency on 30 January
2020. Since that time, the direct health consequence has been enor-
mous; as of March 2022, there have been 440,807,756 confirmed cases
with 5,978,096 deaths, and the numbers continue to rise (WHO, 2022).
Although developing countries with dense communities and restricted
diagnostic capacities were, and still are, at particular risk (Velevan &
Meyer, 2020) the significant reaches of the virus have been felt across
all developed states, and in all parts of society. Although the intense
research and development race to develop a vaccine (e.g. Khuroo
et al., 2020) has pushed back against this tide of healthcare risk, with
10,704,043,684 doses administered to date (WHO, 2022), the ongoing
healthcare disruption will nevertheless be experienced indefinitely and
with a disproportionate impact for certain populations.
Specifically of concern for this study, the unprecedented demand on
clinical services has forced many treatments into the shadows, and the
resource strain placed on the NHS in the UK has inevitably resulted in
delays in cancer diagnoses (Gathani et al., 2021), rescheduled surgeries
(Phillips et al., 2020) and reduced cardiology service provision (Fersia
et al., 2020). This is further complicated by organisational challenges,
including moral injury-related mental health difficulties for front line staff
(Williamson et al., 2020), including a significant impact on the well-being
of general practitioners (GPs) (Jefferson et al., 2022), and a concerning
burden on ethnic minority healthcare workers (Smith et al., 2020).
Efforts to gather knowledge as to how people’s experience of the

pandemic has been shaped by their health and pre-existing inequalities
have therefore begun (e.g. Garrido-Cumbrera et al., 2021), with inequity
in the labour market (Reichelt et al., 2021), homelessness (Lima et al.,
2020) and digital access all cited as creating COVID-related vulnera-
bility (Beaunoyer et al., 2020). Furthermore, the intersections of race
(Gauthier et al., 2021) sexuality and disability (Hough, 2020) and migra-
tion (Mukumbang et al., 2020), are all posited as facing greater potential
impact. This growing body of literature has been joined by an investi-
gation of the virus’s impact on the ‘gender health paradox’—that men
have lower life expectancies, yet women experience higher levels of illness
in their later years—with rising incidences of GBV, reduced services and
mental health all submitted as of greater effect on women during this time
(Bambra et al., 2021). Similar observations can be levied at sexual and
reproductive health, with school and specialist clinic closures widespread
and the inevitability of a gendered effect.
The financial and operational demand on healthcare in the UK, and the
implications for service delivery and patient access across the case studies
of adolescent sexual health, abortion and ART, thereby allow for contem-
porary and future consideration of the empirical impact of COVID-19 on
gendered healthcare. This acute context of resource reformulation and
pandemic vulnerability is of further conceptual interest, however, when
consideration is afforded to the manner in which the exogenous shock of
such a crisis has disrupted relationships within the health policy network.
Revisiting the driving deficiencies in the current literature of dynamic
account of decision-making in the sector, the final ambition of the project
is to question COVID-19’s ability to incite structural network adaption
in the long term.
Structure of the Book

As this opening chapter has discussed, a person’s sexual and reproductive
health places an inevitable biological demand on any clinical system that
comes with a substantial price tag. These fiduciary concerns have long
surpassed a one-dimensional child-bearing function, however, and devel-
opments in gender, sexuality and sex create a rich politics of diverging
demands and conundrums. How UK policymaking interacts with these
advances is of central concern to the book. To tackle this puzzle, Chap-
ters 3–5 will traverse, in turn, adolescent sexual health, ToP and ART.
18 S. COOPER
The evolving requirements of a publicly funded healthcare system sector,

as derived from a broader scientific categorisation and ideological appreci-
ation of ‘women’s health’ in this clinical subset, are clearly palpable from
the discussion engaged above. Within each chapter, therefore, a series of
analytical steps will be undertaken. To begin, an outline of the current
conditions of access, including a historical contextualisation of this posi-
tion, to the aspect of sexual and reproductive health in question will be
submitted. Next, in efforts to acquire a deeper understanding of the core
relationships in the field, critical decisions of the health policy network
in the respective domain will be traced. This will cover the design of the
school-based HPV immunisation programme, conflict over the statutory
interpretation of the 1967 Abortion Act and the regional commissioning
of IVF, respectively. The activity of structural interests, and the demon-
stration and shaping of power within the network, will form the analytical
drive of this subsection. Finally, the current context of healthcare crisis,
and the impact of COVID-19 on service provision and community inter-
actions, is deliberated in the penultimate subsection before a conclusion.
These stages address the research questions presented above to appreciate
how the UK health policy network responds to the progressive parameters
of ‘women’s health’. This in turn allows for a consideration of the future
of gender-related healthcare post-pandemic, including possible shifts in
power, in the concluding Chapter 6.
Prior to embarking upon this rich analysis, however, an entry point
to understanding the structural balance of healthcare decision-making,
and a conceptual framework to map network interactions, first demands
rigorous exploration. The next chapter undertakes this task alongside an
outline of the book’s qualitative methodology.
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CHAPTER 2
Understanding Outcomes
The prevailing esteem for medicine in society, with its inherent highly
technical knowledge and specialism, creates a privileged position for the
profession. As a result, cultural attitudes long appeared to preserve the
pervasive dominance of hegemony and paternalism in clinical decision-
making. Indeed, hierarchical beliefs concerning medical knowledge
encouraged reverence to doctors, particularly when the emotive issues
central to discussion largely amount to matters of life and death. With
rising patient autonomy, however, the type of deference paid is trans-
forming, with a uni-directional form no longer fully encapsulating the
reality of activity in the field (Devaney & Holm, 2018). Furthermore, as
our attention to political processes grows, our expanded understanding
of the multifaceted nature of public healthcare design and delivery ushers
in acknowledgement of pivotal voices beyond the traditional doctor–
patient relationship, and appreciates a wider healthcare environment beset
with complex trade-offs over resources. The electoral battleground of
the National Health Service (NHS) is testament to this, with perennial
fears of ‘winter is coming’ occupying debate long before the current
pandemic. Coupled with the diverse demands of the broadened parame-
ters of women’s health outlined in Chapter 1, therefore, society is now
more deeply engaged with expressing their rights within this system.
© The Author(s), under exclusive license to Springer Nature 29

Switzerland AG 2022
S. Cooper, Analysing Gender in Healthcare,
Palgrave Studies in Public Health Policy Research,
https://doi.org/10.1007/978-3-031-08728-8_2
30 S. COOPER
Outcry at the NHS’ ‘stay at home’ social media advertisement during

England’s second wave of COVID-19 is just one example of this growing
trend of speaking out. The binary depiction of women completing home
schooling and chores, with a man relaxing on the sofa, faced such backlash
that the government was quickly forced to remove it (Oppenheim, 2021).
In the same time period, even the then Health Minister Nadine Dorries
was urging women to stand up to general practitioners (GPs) if they
were unhappy with their therapeutic management (Philpotts, 2021). This
is not the first time concerning trends with the organisation have been
highlighted, with the use of homophobic language previously posited
as ‘commonplace’ (Ford, 2015) and deficiencies in treatments for trans
patients also fervently discussed (Gani, 2016).
The question of whether these observations move beyond popular
media fodder to have a discernable impact on provision of care is of
significance. To date, however, the study of gendered healthcare has yet
to rigorously explore the respective weight of a range of competing and
complementary influences on policy outcomes for an expanded class of
patients. Instead, efforts have largely focused on the social patterning
of clinical need through a binary lens, and such absence fundamen-
tally urges the research design housed in this chapter. Building upon
the principal empirical objectives of this project to capture the nature
of current provisions for sexual and reproductive healthcare in the UK
across adolescent sexual health, abortion and assisted reproductive tech-
nologies (ART), therefore, the conceptual ambitions drill down below
these surface level attributes to gain a richer understanding of how
these decisions have been shaped. A seminal understanding of this is
derived from Alford’s (1975) typology of structural interests as divisible
across professional dominance, challenging corporate rationalisers, and
the repressed community population. Despite a proliferation of medial
specialisms increasing elite knowledge and expanding the complexity
of medicine, however, notable moments of British Medical Association
(BMA) dissatisfaction with the NHS, and purposeful moves towards clin-
ical leadership, indicate successful monopoly challenge from government
bureaucrats overseeing the pragmatic use of resources in the UK. With
the addition of the Conservative-led initiative of patients’ rights in the
1990s, and strengthening the position of patients’ views through Labour
measures in 2000, an additional developing societal trend and feature of
the narrative surrounding publicly funded healthcare is patient choice.
As a result, the space for interaction across doctors, bureaucrats and
2 UNDERSTANDING OUTCOMES 31
the wider community is, at least on the surface, vast, thereby calling
into question this default thinking of uncontested clinical hegemony and
casting doubt on the isolated utility of static, structural conceptualisations
of healthcare design that emphasise rule-based exchanges. A combined
study which supplements observations of rational transactions, therefore,
with more nuanced sociological understanding of temporal preference
shaping within the network, is consequently championed. The carefully
crafted qualitative methodology required for this task is initiated here,
with positional bargaining accompanied with the mechanisms of framing
and priming, and alliance building. This fruitful analytical pathway in turn
allows for discussion in later chapters of how the shifting COVID-19
context has further altered network dynamics.
The chapter houses three substantive segments that explain the
research design of the book and allows the process to move from a
fluid view of gender as the unit of analysis identified in the introduc-
tory chapter, to contributing to knowledge on how decisions on sexual
and reproductive healthcare are made in the policy network. To begin,
the state of knowledge and existing study of women in the sector,
and an emerging, albeit limited, intersectional approach, is discussed.
Second, a structural categorisation of the series of actors integral to
the formulation of health policy is outlined as the first building block
for understanding the division of power in the network. For this task,
Alford’s (1975) aforementioned classic theory of interests is engaged,
and its efficacy, and need for extension, in this contemporary venture
is established. During this brief, indication of evolving responsibilities
and relationships across a large site for potential exchange drives the
need for further study of interest intermediation and preference shaping
at the micro-level. The third subsection therefore couples rational and
sociological insights from the policy networks literature to outline the
analytical pathway of the project, and the study of outcome shaping.
Three potential mechanisms of power—bargaining, framing and priming,
and alliance building—are established at this juncture, to be traced across
a body of diagnostic evidence in the succeeding case studies of sexual and
reproductive healthcare in Chapters 3, 4 and 5. A conclusion follows.
32 S. COOPER
Beyond Binary Service Delivery

Demographic differences in health outcomes are increasingly stark when
viewed in terms of the expanded class of gender, sex and sexuality
discussed in the context of women’s health in Chapter 1. On the surface,
for example, the Global Gender Gap Index 2021 indicates a positive
progression, with 96% of the ‘Health and Survival’ disparity having been
closed, and 56 countries reaching full equality. Importantly, the report
notes a deficiency in its data pertaining to the problem of ‘missing
women’, in which prenatal and postnatal sex selective practices, and
neglect-related mortality, create a skewed sex ratio at birth (Crotti et al.,
2021). In addition to this expressed limitation, however, the qualitative
and binary methodology adopted in the report obscures the inequitable
reality of access for a more diverse class including sex and gender minority
patients, in which choice is often constrained by the intervening impact
of social, political and legislative variables. This observation is also true of
the development of literature in the field in which calls for intersectional
research are rife. Although a strand of feminist medicine underlining the
Women’s Health Movement (WHM) has certainly grown since the 1970s,
its focus on service provision has been a key criticism over the last decade.
Despite quality attempts to rectify this chasm in the field of gender and
healthcare, greater work that continues to press an expanded under-
standing of healthcare decisions, past a static duality of the life conditions
of men and women, is required.
The emergence of second-wave feminism in the 1970s served to prolif-
erate a host of research into women’s healthcare that not only identified
discriminatory practice in the US, but served to transform understand-
ings of women’s biological and psychological state (Munch, 2006). The
ensuing work of the WHM was largely divided across two concerns.
First, efforts were driven towards highlighting constraints on reproduc-
tive rights, bodily autonomy and a need for women to take ‘health into
their own hands’ (Morgen, 2002), and specific attention was garnered for
the legalisation of abortion (Norsigian, 2019). One substantial product
of this activity was the publication of ‘Our Bodies, Ourselves’ (BWHBC,
1971). Second, lengths were taken to understand the lack of women in
the profession (Walsh, 1977) and expose sexism and adrocentrism (Tuana,
2006) for service recipients, with the pressing need for healthcare for
women, by women. As a result, some success in increasing representation
of female clinicians was witnessed (Riska, 2010), but with clear subor-
dination in aspects such as nursing (e.g. Aranda, 2016) and midwifery
(Davison, 2020) remaining. In a similar vein, successful progression
towards women’s clinics were made (Ruzek, 1978) but with the draw-
back that many of the accounts of patients became contingent on their
additional roles. Family-orientated approaches to the practice of medicine
dominated (Candib, 1995), for example, and with inadequate holistic
alternatives to the power dynamics within mainstream clinical encoun-
ters suggested as remedy (Scott, 1998). The movement in the UK was
further constrained by the alternative political and economic context of
the NHS; strategies to improve services in a feminist manner threatened
the promotion of private measures for middle class clientele, and therefore
greater concern was directed at ensuring the national scheme accepted
the real needs of women (Doyal, 1983). Attention for global improve-
ment in the field (Plechner, 2000) and calls to action for women’s health
research have therefore increased over the decades since the WHM’s inau-
gural activities (Auerbach & Figert, 1995). The growing body of work,
however, has concerned service delivery, and has significantly overlooked
racial and ethnic disparities (Kumanyika et al., 2001) and housed a clear
binary preoccupation.
Indeed, extensive understanding of the causal interplay of contributing
factors to healthcare inequality has historically been a key deficiency to the
literature. Efforts to chart this subset of clinical care have instead largely
coalesced around improving the equitable reality of service delivery at the
point of consumption. This has included broad areas such as reproductive
rights (e.g. Cooper, 2016), maternal healthcare (e.g. Gitobu et al., 2018;
Villar et al., 2001) and female cancer (e.g. Wyatt & Friedman, 1996).
Granted, such studies have not been reserved solely for the state level, and
quality work has been undertaken to extend this body of work to appre-
ciate the global situation (e.g. Becker, 2015) including mortality rates
(Patton et al., 2009), and even extended to the care of sex workers (e.g.
Scambler and Paoli, 2008). Further still, regional demands ranging from
affluent nations, such as the aforementioned women’s health movement
in the US (Morgen, 2002), to developing states in areas such as Ghana
(Frank et al., 2016), and incorporating specific considerations around
autonomy and reproductive behaviour (Jejeebhoy, 1995), and violence
against women (Heise et al., 1994) to name just a few, all feature in the
scholarly landscape. More recently, this has additionally reacted to the
34 S. COOPER
COVID-19 pandemic, with studies of maternity care in particular mush-

rooming (e.g. Heath et al., 2020, Khalil et al., 2020, Larki et al., 2020).
Yet often overlooked in these multi-level observations of provision are
the interactions and influences of competing actors within the health-
care community that can shape these policy outcomes. Indeed, running
in parallel to the popularity of equitable arrangements is a stream of
research into healthcare more generally that tends to favour economic
analysis in the delineation of power over outcomes (e.g. Drummond et al.,
2015; Lehoux et al., 2017), focusing heavily on the siloed planning and
financing of healthcare (e.g. Abel-Smith, 1994; Blank et al., 2017). As a
result, a deep understanding of the interplay and conflict of medical, polit-
ical and societal factors is lacking, and this is especially the case in regard
to minorities within the clinical subset of sex and reproductive health.
This is not to refute any form of causal study, however, and the ‘per-
tinence’ (Perrig-Chiello & Hutchison, 2010) of gender mainstreaming
in the study of health policy has emerged throughout the 1990s (e.g.
Ravindran & Kelkar-Khambete, 2008). The acknowledgement of social
patterning of clinical need and illness, and inequitable access and practice,
for example, was at the heart of a substantial collective effort in 2012
(Kulhman & Annadale, 2012). Alongside quality insights of the time
into gender-sensitive indicators for healthcare (Lin & L’Orange, 2012),
the intersection of age (Burau et al., 2012; Roy & Chaudhuri, 2012),
and maternal healthcare (Patel, 2012; Sandall et al., 2012), however,
two key areas for development can be identified. First, the approach’s
implicit deference to patriarchal systems of oppression crowds out further
consideration of strategic decision-making within healthcare; of course,
the subordination of women is indispensable in the analysis, but the
comparative provision of gendered services indicates competing powers
and pressures that are not convincingly accounted for. This critique leads
onto the second observation of a binary approach, and limited view of
sexuality, that is again entrenched throughout. Granted, the healthcare
needs of gay and lesbian patients is championed, and increased visibility
of ‘non-heterosexual’ experience is supported through consideration of
the interaction between gender and sexuality by Edwards (2012), with
the lack of uniformed experience in the LGBTQI+ population a crucial
offering of the chapter. Not only does this endeavour stand alone in
a volume otherwise conservative in its approach, however, but it again
focuses heavily on service delivery. As a potential remedy to the ‘crit-
ical mass’ of gender mainstreaming opponents that perceived a growing
disconnect between the approach and contemporary feminist theory

(Tolhurst et al., 2012), the desire to move beyond the limits of ‘add
women and stir’ research was the crucial rationale for Gideon (2016) and
colleagues with their study of the multi determinants of health and well-
being a couple of years later. Whilst their theoretical engagement with the
organisational and institutional structure of design and delivery is a task
similarly echoed in this book, the axes of inequality, and engendering the
social determinants of health, again largely overlooked a broader reformu-
lation of women’s health discussed in Chapter 1. Granted, Part VIII of the
book is focused on sexuality and rights, but the majority of the chapters
once again refer repeatedly to men and women in the context of repro-
duction, with only one chapter dedicated to LGBT (Gideon, 2016). In
such a section, the incorporation of sexual rights into international devel-
opment, and specifically US AID-funded sexual health interventions for
sexual minorities in Ghana, was shown to be inhibited by a discourse of
Western imposition (Eveslage, 2016) and encouraged important cultural
awareness of intersections.
Importantly, the audibility of concerns around this largely homoge-
nous approach to both inequity and service user experience in healthcare
research is growing, and the inability of healthcare design to successfully
transfer between dramatically different systems has led to a call to action
to develop studies to analyse anecdotal differences (Crocker, 2021).
Despite intersectional frameworks for studying countries (Hankivsky,
2011), men (Griffith, 2012), and multi-level models to account for
‘nesting’ within social strata (Evans, 2019), however, rich qualitative
understanding of varying user experience is still limited at this point.
Adding to current efforts to study gender and sexual minority popu-
lations (e.g. Rothblum, 2020), therefore, including the invisibility of
low-income African-American women (Okoro et al., 2021) and identity
and British Muslim gay men (Semlyen et al., 2018), the book’s analysis of
gender must resist cisgendered and heteronormative blinkers. Lacombe-
Duncan (2016) pushes this agenda further still to draw in consideration
of intersecting systems of oppression; moving beyond an exclusive view
of transphobia when accounting for disparity of access to HIV-related
healthcare for transgender women, acknowledgement of cisnormativity,
substance use and sex work stigma is additionally posited in this work. It
is with these scholarly and empirical ques to explore beyond binary service
delivery, and the absence of meaningful focus on the governmental and
36 S. COOPER
societal linkages constructing policy responses to developing understand-

ings and capabilities of gender, sexuality and sex, that a network approach
to policy analysis in the clinical subset of sex and reproduction is therefore
constructed in the following two subsections.
Structural Adaptations
The politics of sex and reproduction is an expansive regulatory space
within which a host of clinical techniques are discussed, but considerations
extend far beyond healthcare delivery to engulf complex societal move-
ments and react to neighbouring and encroaching legislative debates.
The self-interested actions, and structural interactions between govern-
mental, non-governmental and interest groups, that are exchanged and
create policy outcomes in this arena, however, can promisingly be studied
through a synthesised policy networks approach that emphasises the trans-
formative potential of intermediation. First, the foundations of the book’s
research design are built on an understanding of the origins of the UK’s
healthcare subsystem, and the identification of power and influence spread
across structural interests within the community. For this entry point,
this section champions a return to Alford’s (1975) classic delineation of
healthcare partners as comprising professional monopoly, challenged by
corporate rationalisers, and overlooking the repressed community popu-
lation, but critiques the static tone, and strict adherence to rational rules,
of this approach with a number of British-centric developments. These
include a contemporary update to the category of challenging interests,
derived from mounting professional BMA discontent with the NHS, to
acknowledge the evolution of NHS clinical leadership, particularly across
primary healthcare. In addition, the maturing of the typically repressed
character of the community population, through a rise in patient infor-
mation and choice, is explored. Conceptually suggesting greater fluidity
in the reach and influence of these categories as derived from sociolog-
ical changes, that is similarly afforded credit in the surrounding literature,
therefore, matters of sex and reproduction specifically are identified as
a site of high variable exchange between these doctors, corporate ratio-
nalisers and patients, urging the second stage of the integrated research
approach and the temporal study of micro-level preference shaping.
The intermediation that ensues between these actors, and an analytical
pathway for the book’s case studies, will be built upon in section ‘Shaping
Outcomes’. with a detailed outline of the policy network approach and
the importance of mechanisms of power. Of course, the developments

outlined in this chapter adopt an England-centric tone, but the caveat
must be added that the diverging post-devolution policy styles of Scot-
land, Wales and Northern Ireland provide an additional dimension to
these relationships.
As the state of technology and medial provision has innovated and
matured, and alongside the developed questioning of an engaged popu-
lation, the web of decisions concerning the nature, level and regulation of
clinical care has steadily grown in popular inquiry. Correspondingly, the
respective influence of varying interests in healthcare began as an impor-
tant thread of scholarly engagement in the 1970s, and has been applied
sporadically in the intervening years since. In particular, the endeavours
of American political sociologist Robert Alford’s (1975) study concerning
the alleged health care crisis in the US offers the important concep-
tual foundations of this book. He elaborates his view of ‘crises’ as the
product of a political capital game engaged by interest groups, utilising
the situation as a ‘weapon’ in an attempt to redirect resources (Alford,
1975, xii). The hypothesis continues, however, that the situation will in
fact largely remain the same, even after the ‘crisis’ has dissipated from
the public view, as the strategic organisation of power within health care
policy provides barriers to significant reform. As contrasted to a pluralist
understanding of groups organised to represent its interests (a classic and
easily recognisable ‘interest group’), therefore, Alford conversely submits
that this power is divided across an alternative collection of interests
that are served by the way they fit into the logic and principles of an
organisation. These, he states, are ‘structural interests’ and follow a three-
fold typology of ‘dominant, challenging and repressed’ (Alford, 1975).
Although clearly dated and entrenched in US-driven considerations, this
is surprisingly not a significant limitation of Alford’s theory in this project,
despite its contemporary obscurity in healthcare studies. Rather, if subject
to a UK-focused update here, and later combined with an apprecia-
tion of dialectical network interaction in the section ‘Shaping Outcomes’,
the approach presents a key point of departure for study beyond binary
service delivery.
Drawing heavily on the aforementioned structural account of US
healthcare in the 1970s, Wistow (1992) contended that the health service
was most readily explained in terms of a professionalised network, char-
acterised by the interests of a specific class of actor, and a degree of
vertical interdependence, strongly insulated from other influences. Three
38 S. COOPER
core values inherent in such ‘professionalised networks’ are identified:

that principal importance is afforded to political and managerial influ-
ences, that the values embedded within the network have a determining
impact on outcomes, and that the needs of service recipients are filtered
through professional values. In summation of these clauses, therefore,
professionals ‘monopolise’ the field, and there is little opportunity for
external actors to enter the community at any level, or indeed occupy a
seat at the metaphorical policymaking table. An important caveat is added
in this work, however, to provide consideration of the political decentral-
isation to regional levels evidenced through the 1980s and beyond; the
semi-autonomous role of local health authorities created a new level to
the health policy community, and a diversion in the flow of command
to create a new horizontal, regional level. Wistow (1992) nevertheless
contends that the expression of professional interests remains the prin-
cipal determinant of policy outcomes even at the local level. Although
this sentiment will be treated with scepticism below, asserted as it was
prior to Labour’s promotion of clinical governance, the tools provided by
this structural approach are undeniable.
Indeed, the grouping of interests into larger umbrella terms, and the
flexibility this allows for analysing diverging and more contemporary
healthcare schemes, is a virtue extolled in a thread of domestic and inter-
national literature (e.g. Ham, 2009). As noted by the aforementioned
Wistow’s (1992) for example, set against a backdrop of Thatcherism and
New Public Management (NPM), the structural approach ‘prompts spec-
ulation’ (p. 54) of their changing balance over time. Although ultimately
highlighting the privileged position of the medical profession, Alford’s
approach has spurred considerations of attrition to clinical autonomy in
the decades since (or what Wistow refers to as the ‘balance sheet’ [Wistow,
1992, 74]). North and Peckham (2001), for example, push this appli-
cation outside of a hospital setting, to use the categorisation to study
primary care organisation in the community. The theory allowed them to
sound a warning note of emerging tensions arising from the dual role of
GPs as professional monopolisers and corporate rationalisers back at the
start of the millennium; a prediction that is perhaps most readily observed
with the contemporary strain on ‘in-person’ appointments with family
doctors. The current Health Secretary Sajid Javid’s push to ‘name and
shame’ surgeries not delivering enough face-to-face meetings has been
met with various cries of bureaucratic drowning on the part of the GPs
(Campbell, 2021). Back in the 2000s, these tensions were again envisaged
Another random document with
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“Nevada! You shall not be so bold,” she cried in Pahute. “Take
away your hand from the white man.”
The girl turned her head and answered sharply in the same
tongue and afterwards smiled across at Rawley, meeting his eyes
with perfect frankness.
“Yes, my name is Nevada. I’ll save you the trouble of asking,” she
said calmly. “El Dorado Nevada Macalister, if you want it all at once.
Luckily, no one ever attempts to call me all of it. My parents were
loyal, romantic, and had an ear for euphony.”
“Were?” The small impertinence slipped out in spite of Rawley; but
fortunately she did not seem to mind.
“Yes. My father was caught in a cave-in in the Quartette Mine
when I was a baby. Mother died when I was six. I have a beautiful,
impractical name—and not much else—to remember them by. I’ve
lived with Grandfather and Grandmother; except, of course, what
time I have been in school.” She gave him another quick look behind
Johnny Buffalo’s back. “And your autobiography?”
“Mine is more simple and not so interesting. Name, George
Rawlins King. Place of birth, a suburb of St. Louis. Occupation,
mining engineer. Present avocation, prospecting during my vacation.
My idea of play, you see, is to get out here in the heat and snakes
and work at my trade—for myself.”
“And Johnny Buffalo?”
“Oh, he just came along. Hadn’t seen this country since he was a
kid and wanted to get back, I suppose, on his old stamping ground.
He lived with Grandfather. But Grandfather died a few weeks ago,
and Johnny and I have sort of thrown in together. Now, I suppose our
prospecting trip is all off—for the present, anyway.”
“This country has been gone over with a microscope, almost,”
said Nevada. “I suppose there is mineral in these hills yet, but it must
be pretty well hidden. The country used to swarm with prospectors,
but they seem to have got disgusted and quit. The war in Europe, of
course, has created a market—” She stopped and laughed with
chagrin. “Of course a lady desert rat like me can give a mining
engineer valuable information concerning markets and economic
conditions in general!”
“I’m always glad to talk shop,” Rawley declared tactfully.
But Nevada fell silent and would not talk at all during the
remainder of the journey.
CHAPTER EIGHT
“HIM THAT IS—MINE ENEMY”
Their progress was necessarily slow, and Nevada’s “mile or so”
seemed longer. Johnny Buffalo remained no more than half-
conscious and breathed painfully. Nevada invented a makeshift
sunshade for him, breaking off and trimming a drooping greasewood
branch and borrowing the squaw’s apron to spread over it. This
Rawley held awkwardly with one hand while he steadied the swaying
figure with the other, and so they came at last abruptly to the river he
had left at sunrise.
The trail dipped down steeply to a small basin that overlooked the
river possibly a hundred feet below. The canyon walls rose bold and
black beyond,—sheer crags of rock with here and there a brush-filled
crevice. Around the barren rim of the basin two or three crude
shacks were set within easy calling distance of one another, and
three or four swarthy, unkempt children accompanied by nondescript
dogs rushed forth to greet the newcomers.
The old squaw waddled forward and drove the dogs from the
heels of the burro called Pickles, which lashed out and sent one cur
yelping to the nearest shack. The children halted abruptly and stared
at the two strangers open-mouthed, retreating slowly backward,
unwilling to lose sight of them for an instant.
Rawley stole a glance at Nevada, just turning his eyes under his
heavy-lashed lids. A furtive look directed at his face was intercepted,
and the red suffused her cheeks. Then her head lifted proudly.
“My uncle’s children are not accustomed to seeing people,” she
explained evenly. “Strangers seldom come here, and the children
have never been away from home. Please forgive their bad
manners.”
“Kids are honest in their manners,” Rawley replied, “and that’s
more than grown-ups can say. I reckon these youngsters wonder
what the deuce has been taking place. I’d want an eyeful, myself, if I
were in their places.”
Nevada did not answer but led the way past the shacks, which did
not look particularly inviting, to a rock-faced building with screened
porch that faced the river, its back pushed deep into the hill behind it.
Rawley gave her a grateful glance. He did not need to be told that
this was the quietest, coolest place in the basin.
“We’ll make him as comfortable as we can, and I’ll send for Uncle
Peter,” she said, as they stopped before the door. She called to the
oldest of the children, a boy, and spoke to him rapidly in Indian. It
seemed to Rawley that she was purposely emphasizing her bizarre
relationship.
A younger squaw—or so she looked to be—came from a shack, a
fat, solemn-eyed baby riding her hip. Her hair was wound somehow
on top of her head and held there insecurely with hairpins half falling
out and cheap, glisteny side combs. A second glance convinced
Rawley that she had white man’s blood in her veins, but her
predominant traits were Indian, he judged; except that she lacked
the Indian aloofness.
“Mr. King, this is my Aunt Gladys—Mrs. Cramer,” Nevada
announced distinctly. “Aunt Gladys, Queo shot Mr. King’s partner,
who had discovered him lying in wait for Grandmother and me and
was trying to protect us. Mr. King ran down to the trail to warn us,
while his partner crept up behind Queo. He fired, after Queo had
shot at us, but he thinks he missed altogether. At any rate Queo shot
him. So Grandmother and I brought him on home. He saved our
lives, and we must try to save his.”
Aunt Gladys ducked her unkempt head, grinned awkwardly at
Rawley, who lifted his hat to her—and thereby embarrassed her the
more—and hitched the baby into a new position on her hip.
“Whadda yuh think ol’ Jess’ll say?” she asked, in an undertone.
“My, ain’t it awful, the way that Queo is acting up? Is there anything I
can do? It won’t take but a few minutes to start a fire and heat
water.”
They had eased Johnny Buffalo from the burro’s back to the broad
doorstep, which was shaded by the wide eaves of the porch. Now
they were preparing to carry him in, feet first so that Nevada could
lead the way. She turned her head and nodded approval of the
suggestion. So Aunt Gladys, after lingering to watch the wounded
man’s removal, departed to her own shack, shooing her progeny
before her.
Rawley had never had much experience with wounds, but he went
to work as carefully as possible, getting the old man to bed and
ready for ministrations more expert than his. In a few minutes
Nevada came with a basin of water that smelled of antiseptic. Very
matter-of-factly she helped him wash the wound.
“I think that is as much as we can do until Uncle Peter comes,”
she said when they had finished. “He’s the one who always looks
after hurts in the family.” She left the room and did not return again.
With nothing to do but sit beside the bed, Rawley found himself
dwelling rather intently upon the strangeness of the situation. From
the name spoken by Nevada, he knew that he must be in the camp
of the enemy. At least, Jess Cramer was the name of Grandfather’s
rival who figured unfortunately in that Fourth of July fight away back
in ’66, and there was furthermore the warning of the code, “Take
heed now ... on the hillside ... which is upon the bank of the
river ... in the wilderness ... ye shall find ... him that ... is mine
enemy.” Rawley had certainly not expected that the enemy would be
Jess Cramer, but it might be so.
He was repeating to himself that other warning, “He that keepeth
his mouth keepeth his life,” when Nevada’s voice outside brought his
attention back to the immediate exigencies of the case. He had
already told her his name—she had repeated it to that flat-faced,
hopelessly uninteresting “Aunt Gladys.” Nevada had taken particular
pains, he remembered, to tell her aunt all about the mishap and to
stress the service which he and Johnny Buffalo had rendered her
and her grandmother. Was it because she wished to have some one
beside herself who was well-disposed toward them? Partly that, he
guessed, and partly because the easiest way to forestall curiosity is
to give a full explanation at once. In Nevada’s rapid-fire account of
the shooting, Rawley fancied that he had unconsciously been given
a key to the situation and to the disposition of Aunt Gladys. He
grinned while he filled his pipe and waited.
Presently the deep, masculine voice he had heard outside talking
with Nevada ceased, and a firm, measured tread was heard on the
porch. A big man paused for a few seconds in the doorway and then
came forward; a man as tall as Rawley, as broad of shoulder, as
narrow hipped. He was dressed much as Rawley was dressed,
except that his shirt was of cheaper, darker material and the
breeches were earth-stained and old, as were his boots. He carried
his head well up and looked down at Rawley calmly, appraisingly,
with neither dislike nor favor in his face. He was smooth-shaven, and
his jaw was square, his lips firm and somewhat bitter. Rawley rose
and bowed and stood back from the bed.
“My niece has told me all about the shooting,” he said, moving
toward the bed. “I’m not a doctor, but I’ve had some experience with
wounds. In this country we have to learn to take care of ourselves. Is
your partner unconscious?”
“Dopey, I’d say. I can rouse him, but it seemed best to let him be
as quiet as possible. He had over an hour in the heat, and the
joggling on the burro didn’t do him any good, I imagine.” Rawley
hoped Uncle Peter would not think he was staring like an idiot, but
he could not rid himself of the feeling that somewhere, some time, he
had seen this man before.
Uncle Peter bent and examined the wound. When he moved
Johnny Buffalo a bit, the Indian opened his eyes and stared hard into
his face.
“My sergeant! I did not think to—”
“Out of his head,” Rawley muttered uneasily. “It’s the first
symptom of it he’s shown.”
Johnny Buffalo muttered again, pressed his lips together and
closed his eyes. After that he did not speak, or give any sign that he
heard, though Uncle Peter was talking all the while he dressed the
wound.
“It’s going to take some time,” he said. “The bullet broke his
shoulder blade, but if the lung is touched at all it was barely grazed.
Nevada spoke of my taking him down the river to Needles, but it
can’t be done. The engine in the launch is useless until I can get a
new connecting rod and another part or two.” He stared down at
Johnny Buffalo, frowning.
“Well, from all accounts the two of you saved the women’s lives
to-day,” he said, after a minute of studying over the situation. “Queo
was after the grub, probably—and he’s no particular love for any of
us. He undoubtedly knew who was coming down the trail—he may
have watched them go up, just about daybreak. Common gratitude
gives the orders, in this case. You can stay here until this man is well
enough to ride, or until I can take you to Needles.”
A little more of harshness and his tone would have been grudging.
Rawley flushed at the implied reluctance of the offered hospitality.
“It’s mighty good of you, but we don’t want to impose on any one,”
he said stiffly. “If he can stay for a day or two, I can get out to
Needles and bring up a boat of some kind. It’s the only thing I can
think of—but I can make it in a couple of days.”
The other turned and regarded him much as Nevada had first
done, with a mixture of defiance and pride. His jaw squared, the lines
beside his mouth grew more bitter.
“We may be breeds—but we aren’t brutes,” he said harshly. “You’ll
stay where you are and take care of your partner. The burden of
nursing him can’t fall on the women.” He stopped and seemed
debating something within himself. “We’ve no reason to open our
arms to outsiders,” he added finally. “If folks let us alone, we let them
alone—and glad to do it. Father’s touchy about having strangers in
camp. But all rules must be broken once, they say.”
“I think you’re over-sensitive,” Rawley told him bluntly. “You’re self-
conscious over something no one else would think of twice. It’s—”
“Oh, I know. You needn’t say it. Sounds pretty, but it isn’t worth a
damn when you try to put it in practice. Well, let it drop. I’ll send over
some medicine to keep his fever down, and the rest is pretty much
up to nature and the care you give him. It’s cool here—that’s a great
deal.”
“We’ll be turning out your niece, though, I’m afraid. I can’t do that.”
For the first time Rawley was keenly conscious of the incongruity of
his surroundings. Here in a settlement of Indians (he could scarcely
put it more mildly, with the dogs and the frowsy papooses and the
two squaws for evidence) one little oasis of civilized furnishings
spoke eloquently of the white blood warring against the red. The
room was furnished cheaply, it is true, and much of the furniture was
homemade; but for all its simplicity there was not one false note
anywhere, not one tawdry adornment. It was like the girl herself,—
simple, clean-cut, dignified.
“My niece won’t mind. I shall give her my own dugout, which is as
comfortable as this. I can find plenty of room to stretch out. Hard
work makes a soft bed.” He smiled briefly. Again Rawley was struck
with a sense of familiarity, of having known Uncle Peter somewhere
before.
But before he could put the question the man was gone, and
Johnny Buffalo was looking at him gravely. But he did not speak, and
presently his eyes closed. After that, the medicine was handed in by
a bashful, beady-eyed boy who showed white teeth and scudded
away, kicking up hot dust with his bare feet as he ran.
After all, what did it matter? A chance meeting in some near-by
town and afterwards forgetfulness. Uncle Peter evidently did not
remember him, so the meeting must have been brief and
unimportant.
CHAPTER NINE
“A PLEASANT TRIP TO YOU!”
Rawley chanced to look out of the window. He muttered
something then and strode to the screened door.
“Hey! You aren’t going back up that trail, surely?” He went out
hurriedly and took long steps after Nevada.
The girl turned and looked at him over her shoulder, flinging back
a heavy braid of coppery auburn hair. She had Pickles by his lead
rope and was plainly heading into the trail to Nelson.
“Why, yes. There’s a load of grub beside the trail where Deacon
upset. I’m going after it.”
Rawley rushed back, seized his hat, sent an anxious glance
toward the bed and then ran. He overtook Nevada just at the edge of
the basin and stopped her by the simple method of stopping the
burro with a strong hand.
“You go back and sit beside Johnny,” he commanded. “I’ll get that
grub, myself. And if you’ve got a rifle, I’d like to borrow it.”
“That’s utter nonsense—your going,” Nevada exclaimed. “I meant
to take one of the boys—I just sent him in to wash his face, first.”
Rawley laughed. “Do you think a clean face on a kid will have any
effect on Queo? You’ll both stay at home, please. I’m going.”
“If you’re determined, I can’t very well stop you,” she said coldly.
“But I certainly am going. I always do these things. There’s no
possible reason—”
Rawley looked over at the nearest shack, where Aunt Gladys
stood watching them, the baby still on her hip. “Mrs. Cramer, I am
going up after the grub we left by the trail. Will you see that Johnny
Buffalo is looked after? And will you call Miss Macalister’s
grandmother, or whoever has any authority over her?” His voice was
stern, but the twinkle in his eyes belied the tone.
Aunt Gladys giggled and hitched the baby up from its sagging
position. “There ain’t nobody but Peter can do nothing with Nevada,”
she informed him. “Her gran’paw, maybe—but he don’t pay no
attention half the time. You better stay home, Nevada. Queo might
shoot you.”
“How perfectly idiotic! Do you suppose he would refrain from
shooting Mr. King, but kill me instead?”
“Well, you can’t tell what he might do,” Aunt Gladys observed
sagely. “He’s crazy in the head.”
Rawley laid his fingers on Nevada’s hand, where she held Pickles
by the bridle. He looked straight into her eyes, bright with anger. His
own eyes pleaded with her.
“Miss Macalister, please don’t be obstinate. To let you go back up
that trail is unthinkable. I am going, and some one must be with my
partner. I can make the trip well under two hours; there is heavy stuff
in that ditch which needs a man’s shoulder under it, getting it back
into the trail. Please stay with Johnny Buffalo, won’t you?”
Nevada hesitated, staring back into his eyes. Her hand slid
reluctantly from the bridle. Her lip curled at one corner, though her
cheeks flushed contradictorily.
“Masculine superiority asserts itself,” she drawled. “Since I can’t
prevent your going, I think, after all, I shall prefer to stay at home. A
pleasant trip to you, Mr. King!”
“Thanks for those kind words,” Rawley cried, his voice as mocking
as hers. “Come on, Pickles, old son!”
A boy of ten, with his face clean to the point of his jaws, came
running from the shack with a rifle sagging his right shoulder. Rawley
waited until he came up, then took the rifle, spun the boy half around
and gave him a gentle push.
“Thanks, sonny. Ladies and children not allowed on this trip,
however. You stay and protect the women and babies, son. Got to
leave a man in camp, you know. Wounded to look after.”
The boy whirled back, valor overcoming his tongue-tied
bashfulness. “Aw, he wouldn’t come here! Gran’paw’d kill ’im.
Gran’paw purt’ near did, one time. I c’n shoot, mister. I c’n hit a rabbit
in the eye from here to that big rock over there.”
“Yes—well—this isn’t going to be a rabbit hunt. You stay here,
sonny.”
“Aw, you’re as bad as Uncle Peter!” the boy muttered resentfully,
kicking small rocks with his bare toes. “I guess you’ll wish I’d come
along, if Queo gets after you!”
Rawley only laughed and swung up the trail, leading the burro
behind him, since he was not at all acquainted with the beast and
had no desire to follow it vainly to Nelson, for lack of the proper
knowledge to halt it beside the scene of Deacon’s downfall.
As he went, Rawley scanned the near-by ridges and the brush
along the trail. There was slight chance, according to his belief, that
the outlaw Indian would venture down this far, especially since he
could not be sure he had failed to kill Johnny Buffalo. On the other
hand, he must have been rather desperate to lie in wait for two
women coming home with supplies. Rawley wondered why he had
remained up on the ridge; why he had not waited by the trail and
robbed them of such things as he needed. Then he remembered
Nevada’s very evident ability to whip wildcats, if necessary—
certainly to meet any emergency calmly—and shook his head. The
old squaw, too, would probably do some clawing if the occasion
demanded, and she knew just who and why she was fighting. On the
whole, Rawley decided that Queo had merely borne out Johnny
Buffalo’s statement that he was a coward and had taken no chances.
And from the boy’s remark about his grandfather nearly killing Queo,
he thought the outlaw had not wanted his identity discovered.
As for his own risk, Rawley did not give it a second thought. Queo
had been well scared, finding two men on the job where he had
expected to deal only with women. He had been headed toward the
river when Rawley last saw him. It was more than probable that he
would continue in that direction.
But it is never safe to guess what an Indian will do,—much less an
Indian outlaw who must become a beast of prey if he would live and
keep his freedom. Rawley remembered Johnny Buffalo’s pack and
tied Pickles to a bush directly under the spot where the shooting had
taken place, while he climbed the ridge to retrieve his belongings. He
brought canteen and pack down to the trail and hung them on the
packsaddle, feeling absolutely secure. The ridge was hot and
deserted, even the birds and rabbits having taken cover from the
heat.
He went on around the little bend and anchored the burro again
while he carried up a sack of potatoes, bacon, flour and a package
wrapped in damp canvas, which he guessed to be butter. The tribe
of Cramer had what they wanted to eat, at least, he reflected. Also,
the load would have made a nice grubstake for the outlaw. Two such
burro loads would have supplied Queo for months, adding what
game he would undoubtedly kill.
Rawley had just finished packing the burro and had looped up the
tie rope to send Pickles down the home trail, when some warning (a
sound, perhaps, or a flicker of movement) caused him to look quickly
behind him. He glimpsed a dark, heavy face behind a leveled gun
barrel, broken teeth showing in an evil grin. Rawley threw himself to
one side just as the gun belched full at him. Something jerked his left
arm viciously, and a numb warmth stole into that side.
He dropped forward, his right hand flinging back to his holstered
automatic and drawing up convulsively with the gun in his hand.
“Thanks for packing the stuff!” chortled Queo, and the two fired
simultaneously.
Both scored hits. The leering, black face sobered and slid slowly
out of sight behind the rock. Rawley’s head dropped so that his face
lay in the blistering dust of the trail. Through his hat crown a small,
singed hole showed in front, a ragged tear opposite at the back.
Pickles, scored on the leg with the second shot from Queo’s gun,
kicked savagely with both feet and went careening down the trail
toward home, his pack wabbling violently as he galloped.
It was the sight of him trotting down the trail alone that halted
Nevada midway between her rock dugout and the shack where
Gladys was setting steaming dishes on the table for the three men
who were “washing up” at the bench under the crude porch. Nevada
gave a little cry and ran to meet Pickles, and the first thing she
noticed was the fresh, red furrow on his leg, from which the blood
was still dripping. Turning to call, she saw Peter coming close behind
her, wiping his face and neck as he walked.
“Oh, Uncle Peter—he’s been shot!” she cried tremulously. “It must
be Queo again.”
Peter’s eyes turned to the trail, visible for some distance up the
side hill. There was no one in sight, and without a word he turned
back to his own house, dug into the hill near Nevada’s, and presently
returned, passing the girl with long strides. He carried his rifle and
struck into the hill trail bareheaded. Nevada looked after him, her
eyes wide and dark.
An hour later, Peter returned, walking steadily down the trail with
Rawley on his back. Without a word he passed the staring group at
the shack and carried his burden into the room where Johnny Buffalo
lay in uneasy slumber. A step sounded behind him, and he spoke
without turning.
“Have Jess and Gladys bring that spring cot out of my cabin,
Nevada. They’ll be more contented in the same room. He got Queo
—I found him behind a rock not fifty feet from this chap. Now Queo’s
cousin will take up the feud and get this fellow—if he pulls out of this
scrape.”
“Is he badly hurt?” Nevada was holding her voice steady from
sheer will power.
“Arm smashed and a scalp wound. All depends on the care he
gets. Well—” Peter straightened and wiped his forehead, looking
thoughtfully at Rawley, half lying in a big chair, his long legs spread
limply, his face white and streaked with blood, “—we owe him good
care, I guess. He must have killed Queo after he’d been shot in the
arm. And he’s saved this outfit some trouble. I didn’t tell you—but
Queo was laying for a chance at us. Well—run and get that cot
here.”
Nevada pushed back her craning family and sent them running
here and there on errands. Her grandfather and Jess, the husband
of Gladys, looked at her inquiringly from the porch of the shack.
Rawley might have thought it strange that they remained mere
bystanders during the excitement. But Nevada did not seem to
notice their indifference.
“Queo shot him twice—but he killed Queo,” she told them. “Uncle
Jess, you’re to get his spring cot, Uncle Peter says, and fix a bed in
there.” Her eyes went challengingly to her grandfather. “Uncle Peter
says we owe them the best care we can give,” she stated clearly.
“He says they have saved some lives in this family.”
The tall, bearded old patriarch looked at her frowningly. He
glanced toward the rock cabin, grunted something unintelligible to
the girl, and went in to his interrupted dinner.
CHAPTER TEN
A FAMILY TREE
It seemed as fantastic as a troubled dream. To be lying there
helpless, to look across and see Johnny Buffalo staring grimly up at
the ceiling, his face set stoically to hide the pain that burned beneath
the white bandage, held no semblance of reality. Was it that morning
only, that they had left the car and started out to walk to the “great
and high mountain”? Perhaps several days had passed in oblivion.
He did not know. To Rawley the shock of drifting back from
unconsciousness to these surroundings had been as great as the
shock of incredulous slipping down and down into blackness. He
moved his head a half-inch. The pain brought his eyebrows together,
but he made no sound. Johnny Buffalo must not be worried.
“All right again, are you?” Peter moved into Rawley’s range of
vision. “You had a close squeak. The thickness of your skull between
you and death—that was all. The bullet skinned along on the outside
instead of the inside.”
“I’ll be all right then,” Rawley muttered thickly. “Don’t mean to be a
nuisance. Soon as this grogginess lets up—”
“You’ll be less trouble where you are,” Peter interrupted him
bluntly. “I’ve done all I can for you now, so I’ll go back to my work.
The Injun’s making out all right, too. Head clear as a bell, near as I
can judge. I’ll see you this evening, and if there’s anything you want,
either of you, just pound that toy drum beside you. That will bring
one of the women.”
Rawley looked up at him, though the movement of his eyeballs
was excruciatingly painful. Again that sense of familiarity came to
tantalize him. What was it? Peter’s great, square shoulders, his
eyes? He made another effort to look more closely and failed
altogether. His vision blurred; things went black again. Perhaps he
slept, after that. When he opened his eyes again a cool wind was
blowing; the intolerable glare outside the window had softened.
He was conscious of a definite feeling of satisfaction when
Nevada appeared with a tray of food such as fever patients may
have; tea, toast, a bit of fruit—mostly juice. Behind her waddled her
grandmother; Rawley could not yet believe in the reality of the
relationship between this high-bred white girl and the old squaw. In
the back of his mind he thought there must be some joke; or at least,
he told himself, looking at the two closely, Nevada must be one of
the tribe by adoption. He had heard of such things.
And there was her Uncle Peter, who was a white man in looks, in
personality, everything. Yet Uncle Peter had flared proudly, “We may
be breeds—but we aren’t brutes.” He could only have meant himself
and Nevada. He looked at her, his eyes going again to the squaw
with her gray bangs, the red kerchief, her squat shapelessness.
Her fear of him seemed to have evaporated upon reflection. Her
curiosity concerning him had not, evidently. She set down the tray
and stared at him with a frank fixity that reminded Rawley of the
solemn regard of the sloe-eyed baby riding astride Aunt Gladys’
slatternly hip.
“You feed Johnny Buffalo, Grandmother,” Nevada directed. “He
used to live in this country when he was a boy. You can’t tell—you
might be old acquaintances.” She smiled, patted the old woman on a
cushiony shoulder and approached Rawley, who was suddenly
resigned to his helplessness.
“Grandmother rather holds herself above full-blood Indians,” she
whispered. “She’s only half Indian, herself. I don’t want her to snub
your partner; he looks so lonely, somehow. What is it?”
“He’s grieving over my grandfather’s death,” Rawley told her, his
own voice dropped to an undertone that would not carry. “Until I
proposed this trip he didn’t want to live. He’s better, out here.”
“I do hope—”
A shrill ejaculation from the squaw brought Nevada’s head
around. “What is it, Grandmother?”
The old woman started a singsong Indian explanation, and
Nevada smiled. “She says they do know each other. She remembers
him when he was a boy and was lost. So that’s fine. He can hear
about all his old playmates and his family.” She turned her back on
them as if the duties of hostess sat more lightly on her shoulders,
since one of the patients could visit with her grandmother.
“I’m wondering what happened, up the trail.”
Nevada thoughtfully cooled the tea with the spoon and looked at
him speculatively. “Uncle Peter can tell you better than I can—since I
was not permitted to go along. Besides, the less talking you do now,
I believe, the less danger there is of complications. Neither wound is
so bad of itself, Uncle Peter says. It’s having your head hurt, along
with the broken bone in the arm. Unless you are very quiet for a day
or two, there may be fever; and fevered blood makes slow healing.
That’s Uncle Peter’s theory, and it must be correct. He has books
and studies all the time—when he isn’t working. Then, of course,
there’s the danger of infection from the outside; but he has been very
careful in the dressings. Johnny Buffalo,” she added after a minute,
“is worse off than you are. His shoulder blade is badly smashed. And
then he’s so much older.”
She was talking, he knew, to prevent him from doing so. And
since his head felt like a nest of crickets, all performing at once, he
was content to let her have her way. Across the room he could hear
the intermittent murmur of the two Indians, the voice of the
grandmother droning musically, with sliding, minor inflections as she
recounted, no doubt, the history of the old man’s family and friends.
He watched Nevada pour and sweeten a second cup of tea and
did a swift mental calculation in genealogy. Jess Cramer, he knew,
was a white man. The husband of Gladys, bearing the name of
Grandfather King’s enemy, must be a son of the old man and of this
half-breed squaw. Very well, then, old Jess Cramer’s children would
be one quarter Indian—Peter, Jess and Nevada’s mother (granting
that Nevada was a blood relative). Nevada’s father must have been
white,—a Scotchman, by the name, and by Nevada’s clear skin and
coppery hair. Well, then, Nevada was—A knife thrust of pain stabbed
through his brain, and he could not think. Nevada set down the cup
hastily and laid cool fingers on his temple. He lifted his right hand
and held her fingers there. The throbbing agony lessened, grew
fainter and fainter. After all, what did it matter—the blood in those
fingers? They were cool and sweet and soothing—
He thought Nevada had lifted her hand and was gently removing
the bandage from his head. But it was Uncle Peter, and Nevada was
not there, and it was dark outside. In another room a clock began to
strike the hour. He counted nine. It was strange; he could not
remember going to sleep with her fingers pressed against the pulse
beat in his temple. Yet he must have slept for hours. He closed his
eyes and then opened them again, staring up with a child-like candor
into the man’s bent face.
“I know. You look like Grandfather,” he said thickly. And when
Peter’s eyes met his, “It’s your eyes. Grandfather had eyes exactly
like yours. And there’s something about the mouth—a bitterness.
Gameness, too. Grandfather had his legs off at the knees, for fifty
years. Called himself a hunk of meat in a wheel chair. God, it must
be awful—a thing like that, when the rest of you is big and strong—
but you’re not crippled that way. Oh, Johnny! Are you awake?” He
heard a grunt. “I’ve got it—what you meant at first, about seeing your
sergeant. Uncle Peter looks like—”
A hand went over his mouth quite unexpectedly and effectually.
He looked up into the eyes like Grandfather King’s and found them
very terrible.
“Fool! Never whisper it. Am I not the son of Jess Cramer? It had
better be so! Better not see that I am like his enemy—and rival.” He
leaned close, his eyes boring into the eyes so like his own. “One
word to any one that would slur my mother, and—” he pressed his
lips together, his meaning told by his eyes. “She came to me to-day,
chattering her fear. Old Jess Cramer lives with other thoughts, and
his eyes are dim at close range. Never come close to him, boy.
Never recall the past to him. It would mean—God knows what it
would mean. My mother’s life, maybe. And then his own, for I’d kill
him, of course, if he touched her.”
Rawley blinked, trying to make sense of the riddle. Then his good
hand went out and rested on Peter’s arm, that was trembling under
the thin shirt sleeve.
“Uncle Peter!” His lips barely moved to form the words, and
afterward they smiled. “The blood of the Kings! I’m glad—”
“Are you?” Peter bent over him fiercely. “Proud of a man who went
away and left my mother—”
“He had to go,” Rawley defended hastily. “He meant to come back
in a month’s time. But he was shot through the legs, and in hospital
for months, and then sent home a cripple. After that he lost his legs
altogether. How could he come back? Johnny can tell you.”
Peter pulled himself together and redressed the long, angry gash
on Rawley’s head. Johnny Buffalo, having slowly squirmed his body
to a position that gave him a view of Rawley’s cot, watched them
unblinkingly, his wise old eyes gravely inscrutable. When he had
finished, Peter strode to the door and stood there looking out.
Rawley had a queer feeling that he was looking for eavesdroppers.
“What you say will make my mother happier,” he told Rawley,
coming back and speaking in his usual calm tone of immutable
reserve. “She seemed very bitter to-day when she talked with me.
She has always thought your grandfather went away knowing he
would never come back. And she has proud, Spanish blood in her
veins—”
“Anita, by ——!” Rawley’s jaw dropped in sheer, crestfallen
amazement.
“Did he tell you?” Peter eyed him queerly.
“It’s the diary. The beautiful, half-Spanish girl, all fire and life—he
described her like that. And—”
“Well, they change as they grow old.” Peter’s lips twitched in a
grin. “The beautiful Spanish señoritas get fat and ugly, and the Indian
women are more so. Your grandfather’s fiery Spanish girl had
nothing to pull her up the hill. Monotony, hardships—one can’t
wonder if the recidivous influences surrounding her all these years
pulled her down to the dead level of her mother’s people. Take this
Indian here—” he tilted his head toward Johnny Buffalo—“he was
taken out of it when he was a kid. Now, aside from certain traits of
dignity and repression, I imagine he’s more white than Indian.”
Rawley nodded. “Lived right with Grandfather all his life and has
studied and read everything he could get his hands on. He’s better
educated than lots of college men; aren’t you, Johnny?”
“Yes. I think very much, of many things which Indians do not know.
I do not talk very much. And that is wisdom also.”
“Mother had nothing from books. When her youth went and she
began to take on weight, she dropped her pretty ways and became
like the squaws. I remember, and it used to hurt my pride to see her
slip into their ways. I was—white.” His mouth shut grimly.
Rawley lay looking into his face, trying to realize the full
significance of this amazing truth. His grandfather’s son, and Anita’s.
His own uncle. With Indian blood, but his uncle nevertheless. If
Grandfather King had known—
“He’d have been proud,” he said aloud, “to have a son like you.
He always wanted—and my father was a weakling, physically, I
mean. He died when I was just a kid. Grandfather called him a
damned milksop, because he wanted to work in a bank. Johnny can
tell you a lot about Grandfather—your—father.” He lowered his
voice, mindful of Peter’s warning. And then, “Does Nev—does your
niece know about it?”
“She does not. The fewer who know it, the better for all
concerned. There will be four of us, as it is. There mustn’t be five.
Why make the lives of two old people bitter? Old Jess—I’ve a
brother, Young Jess—thinks I am his son. He needs me, and
Nevada needs me. We’ve hung together, in spite of the mixed breed
you see us. Jess is Injun in looks and ways. Nevada’s mother was all
white. Jess married a mission half-breed girl, and their kids are Injun
to the bone. Belle, Nevada’s mother, married a Scotchman—good
blood, I always thought, from his looks and actions. Nevada’s—
Nevada.”
He said it proudly, and Rawley felt his blood tingle with something
of the same pride.
From the other bed Johnny Buffalo spoke suddenly. “Anita, your
mother, is my cousin. The daughter of my aunt. My blood is mingled
with the blood of my sergeant’s son. My heart is now alive again and
life is good. My sergeant has gone where he can walk on two feet,
and I am left to care for his son and his grandson. I now see that
God is very wise.”
“He is?” Peter pulled down his heavy, black brows and the corners
of his lips. “I’ve spent a good deal of time wondering about that.
There’s Nevada—and one-eighth Indian. Is that—”

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Analysing Gender in Healthcare: The

Politics of Sex and Reproduction Sarah

Sex and Gender Bias in Technology and Artificial

The Psychology of Sex and Gender – Ebook PDF Version

Rabbinic tales of destruction: sex, gender, and

Man-Made Women: The Sexual Politics of Sex Dolls and

Sex Matters: Essays in Gender-Critical Philosophy Holly

Architecture and the Politics of Gender in Early Modern

Early Modern Women's Complaint: Gender, Form, and

The Politics of Marriage in Medieval India : Gender and

Palgrave Studies in Public Health Policy Research

Cover image: © Mohamed Osama/Alamy Stock Photo

1 The Politics of Sex and Reproduction 1

5 Assisted Reproductive Technologies 169

The Politics of Sex and Reproduction

Addressing the clinical needs of the population is a principle concern for

© The Author(s), under exclusive license to Springer Nature 1

as a concern for restricted resource settings, and the cost of medicine

the social determinants of health and gender-based disparities has only

of the debate beyond economic issues, to be, as she stated, a matter

Inclusivity in ‘Women’s Health’

endorsed by the medical profession. The latter is clinically defined as an

cultivated. Arriving at this point of understanding, however, has been a

cannot be externally manipulated (Safer, 2019). Despite these develop-

2008), and open discussion concerning the full implications of surgery on

the dynamic societal understandings and acceptance of gender and sexu-

Analysing Gender in Healthcare

How is Sexual and Reproductive Healthcare Provided in the UK?

was lastly detailed (UNFPA, 1994, para. 7.3). In summation, it estab-

women’s health discussed above. Certainly, the legitimatisation of a

the UK (ONS, 2019) further supported by a groundbreaking US study

How Have These Decisions Been Shaped in the Healthcare Community?

at the heart of formation. This latter favour is of immediate interest

What Has Been the Impact of COVID-19 on Gendered Healthcare?

Efforts to gather knowledge as to how people’s experience of the

Structure of the Book

The evolving requirements of a publicly funded healthcare system sector,

directions. In Proceedings of the 2021 CHI Conference on Human Factors

with rheumatic and musculoskeletal diseases in Europe: results from the

Lee, C. (1998). Women’s health: Psychological and social perspectives. Sage.

ONS. (2021). Healthcare expenditure, UK health accounts provisional estimates:

© The Author(s), under exclusive license to Springer Nature 29

Outcry at the NHS’ ‘stay at home’ social media advertisement during

Beyond Binary Service Delivery

COVID-19 pandemic, with studies of maternity care in particular mush-

disconnect between the approach and contemporary feminist theory

societal linkages constructing policy responses to developing understand-

the importance of mechanisms of power. Of course, the developments

core values inherent in such ‘professionalised networks’ are identified:

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