By expanding the geographical scope of the history of violence and war, this volume challenges both Western and state-centric narratives of the decline of violence and its relationship to modernity. It highlights instead similarities across early modernity in terms of representations, legitimations, applications of, and motivations for violence. It seeks to integrate methodologies of the study of violence into the history of war, thereby extending the historical significance of both fields of research. Thirteen case studies outline the myriad ways in which large-scale violence was understood and used by states and non-state actors throughout the early modern period across Africa, Asia, the Americas, the Atlantic, and Europe, demonstrating that it was far more complex than would be suggested by simple narratives of conquest and resistance. Moreover, key features of imperial violence apply equally to large-scale violence within societies. As the authors argue, violence was a continuum, ranging from small-scale, local actions to full-blown war. The latter was privileged legally and increasingly associated with states during early modernity, but its legitimacy was frequently contested and many of its violent forms, such as raiding and destruction of buildings and crops, could be found in activities not officially classed as war.
In 1875, the entrance of women to the medical profession was discussed in the Belgian parliament. Along with discussions within medical societies, this public debate is an important source to study gendered views about women’s involvement in medicine. About three-quarters of a century before women’s suffrage was fully granted in Belgium, it was evident that women were not allowed at the negotiating table. Such public discussions thus pose a methodological challenge for historians who study the intersections of gender and medicine and aim to give women a voice. Due to a scarcity of personal documents and publications by female healthcare professionals and feminists, it remains a challenge to work with a corpus of sources in which men’s voices dominate.
The parliamentary debate of 1875 took place in the aftermath of international developments in favour of women’s access to medical studies; the American Elizabeth Blackwell being the first woman who, in 1849, obtained a medical degree. In the margin of a debate on a bill that was to regulate the awarding of academic degrees, the liberal deputy Eudore Pirmez suggested to offer women access to at least some branches of the medical profession. Pirmez’s plea consisted of different types of arguments. He started by referring to the natural capacities of women to fully devote themselves to the care for others, a degree of dedication that men rarely attained. The availability of women physicians would also lower the barriers for women to consult a doctor when confronted with intimate medical issues, as concerns with indecency would no longer be at play, Pirmez argued. At the end of his plea he referred to the American situation, where more than three hundred women doctors proved to be talented and successful practitioners. ‘Physicians will agree with me,’ he continued, ‘that there are no anatomical or physiological differences between American and Belgian men and women, and hence no reasons to continue to organise the medical field in a different way.’1
Parliamentary opinions on Pirmez’s proposal were divided and it was decided to ask the four Belgian universities and the Royal Academy of Medicine for advice. Responses were mainly negative.2 The most elaborate arguments against women’s entrance in the profession came from the Academy. In a lengthy discussion in which in fact all participants agreed, Pirmez’s three main arguments were reversed. Women’s nature was indeed inclined to care for others, but it was precisely her nature that made her physically, intellectually and emotionally unfit for both the studies and the hard profession of medicine. Women’s bodies and minds were mainly, and naturally so, determined and preoccupied by the heavy demands of menstruation, reproduction and lactation. Their nervous system was much more delicate than that of men, as the exclusive occurrence of hysteria among women made clear. In order to become a physician, masculine qualities were needed. The rare woman who by accident succeeded in becoming a doctor, could no longer be considered a woman – she would be ‘a virago’, a ‘monstrous being’.
Academy members also countered Pirmez’s argument that women doctors would lower the barrier for female patients to consult a physician. Wasn’t it telling, they stated, that while lower-class women relied on female midwives to deliver their babies, more distinguished women, who could not be suspected of having less modesty, all preferred male doctors? Problems of indecency would arise when female students were being exposed to male bodies in the anatomical theatre. And who wanted female students to have to study sperm and syphilis together with male students? Pirmez’s reference to the situation abroad was equally turned down. The so-called emancipation of women had indeed advocates in Germany, England, France, Russia and the United States, but should not be seen as a model, on the contrary. Belgium had so far been spared of such aberrations. It was no coincidence that the few women who had applied for an authorisation to exercise the medical profession in Belgium were ‘fanatics’ from abroad.3
The debate of 1875 not only offers an excellent insight in prevailing male opinions on the issue, but it also constitutes a good introduction in the many ways in which gender, health and medicine have been intertwined over the past two centuries. In a first, very explicit way, the discussion dealt with the social division of medical labour. Power relations within the medical field have indeed been structured along class and gender lines, and the definition of both the internal and the external boundaries of the medical profession has often been informed by cultural representations of men’s and women’s roles and their so-called nature. In the case of the 1875 debate, physicians’ elaborate argumentations on the physical and mental inferiority of women point to a second pattern: medical knowledge, medical practices and medically informed discourses have always been gendered. Specific cultural representations of men and women have indeed informed medical knowledge. While nineteenth-century physicians constructed hysteria as a typically female disease associated with women’s supposedly natural emotionality, men’s mental problems were related to ‘manly behaviour’ such as violent experiences or sexual excessive activity. Inversely, an apparent gender neutrality could result in inequalities when research, for instance, tended to concentrate on diseases that occur more in men than in women, or when medication was tested exclusively on men. These often invisible but structural historical inequalities have been laid bare by feminist scholars such as Londa Schiebinger and Ilana Löwy; they remain a topical issue within contemporary health research and theory.4 The explicitly feminist engagement of many scholars points to a third issue, which was also apparent in the 1875 debate, where fear of female emancipation was so obvious. Since the nineteenth century, feminists indeed have included questions of reproduction and health in their social activism. While medicine has often functioned as an instrument of male power over women’s bodies, it has also functioned as a space where both women and men could gain more control over their bodies, and the ways in which biological sex and gender relate to each other.
These three interrelated themes – the social division of medical labour, the gendered character of medical knowledge and practice, and feminist activism to claim and redefine the body – will structure this chapter. On each of these themes, an extensive body of literature has appeared since at least the 1970s – and in fact earlier. Substantive studies on, for instance, the history of female physicians did appear as early as 1900.5 Globally, this historiography has moved from a focus on the underestimated role of women in the field of healthcare to more structural analyses of the gendered nature of knowledge, scientific cultures and medical practices. While path-breaking studies such as Ludmilla Jordanova’s Sexual Visions (1989) and Alison Bashford’s Purity and Pollution (1998) demonstrated the interrelatedness of these questions, new and exciting research on more ‘classical’ topics such as women surgeons in the nineteenth century continues to be done.6 Here as elsewhere in the field of medical history, scholars based in the United Kingdom and the United States have played an important role in the development of the field.7 Their studies, which often privilege English-speaking regions, depict historical evolutions which also occurred in Belgium, albeit at a different pace and with different accents, given the long-standing dominance of Catholicism, the slow pace of women’s political emancipation and the major role of ideological pillars in the organisation and financing of healthcare. On the contrary, within Belgian historiography there hardly exists a tradition of historical research on intersections of gender and medicine in which these recent historiographical insights and perspectives are incorporated. Whereas female medical practitioners mainly figure in histories of medical professionalisation and medicalisation, the doctoral dissertation of Tommy De Ganck on nineteenth-century gynaecology in Brussels is one of the sole examples of historical scholarship on medicine’s role in the production of gendered cultural representations.8 Feminists’ activism to legalise birth control and abortion in Belgium – the third and last theme of this chapter – has received most historical attention, yet their medically informed views remain largely unexplored.
The division of medical labour
In the Southern Netherlands – the region that would become Belgium in 1830 – childbirth was women’s work. Officially recognised midwives mainly operated in cities, while unlicensed birth attendants assisted at deliveries in villages. In Belgium, as elsewhere, the medicalisation and professionalisation of midwifery coincided. International historiography has traced how physicians in Europe and the United States increasingly gained control of traditional female birthing practices in the nineteenth century.9 Early-modern attempts of doctors and surgeons to control (il)legal birth deliveries having been unsuccessful, it was under Dutch rule (1815–30) that medical supervision on the medical practice of childbirth was installed in the Southern Netherlands (see Chapter 5, pp. 177–9). The legal framework of 1818 established the education and practice of midwifery for the nineteenth century. The royal decree of 1823 further determined the organisation of two years of training. Female students mainly had to follow practical courses at an important maternity ward in their province.10 Similarly to French laws but unlike in the United States and Britain, Dutch legislation recognised midwifery as a distinct field of medical practice.11 The second part of the nineteenth century witnessed further calls for the improvement of midwifery training. In 1884 these attempts resulted in a royal decree that established stricter admission requirements and a broadening of the curriculum. At a time when the number of official midwives had increased in such a way as to – at least theoretically – replace non-official birth attendants, the sterner requirements for student midwives now slowed down a further growth in an age in which the number of doctors continued to rise.12
The professionalisation of midwifery was intertwined with the development of gendered hierarchies limiting the competences of female birth attendants vis-à-vis their male counterparts. The Dutch law of 1818 differentiated between three groups of obstetric practitioners: the doctor of obstetrics, the male midwife and the midwife. Unlike male practitioners, midwives had to confine their practice to ‘normal births’ that did not require specialised instruments. When confronted with difficult deliveries, they had to call a doctor or a male midwife.13 Taking such restrictions for midwives into account, historian Karel Velle has argued that the declining social role of midwives almost points at a process of ‘deprofessionalisation’.14 Throughout the nineteenth century the majority of doctors in the Academy of Medicine and in the provincial medical commissions, which supervised medical practice and advised the government on matters of public health, continued to defend such a gendered division of labour. The medical debate in the Belgian Academy in the 1870s on a proposition introduced by the physicians Hyacinthe Kuborn and Louis Mascart is exemplary in this respect. The proposition put forward the authorisation for midwives to use forceps when confronted with an emergency situation and an absence of doctors. Both physicians mainly argued that such an extension of midwives’ competences was necessary since midwives often stood alone in the countryside. It would, moreover, be an effective means to combat illegal birthing practices that mainly took place outside the cities. Most doctors disagreed, among other things arguing that midwives were ignorant and disposed of weak intellectual capabilities. Finally, in 1879, the proposition was rejected by the majority of academy members and midwives’ access to the forceps was formally prohibited.15 In 1908, a law that replaced the law of 1818 confirmed the supposedly limited competences of midwives.16 Recurring arguments about women’s ‘ignorance’ and medical debates about midwives’ insecure financial position make clear that social inequality was constructed on the intersection of gender and class hierarchies. Recently, however, historians have argued that studies privileging these medical sources have exaggerated the precarious social status of midwifery. Research into the social background of female birth attendants in Belgium has shown that while midwives operated within local communities of poor people, they themselves often originated from and married within the social environment of skilled laborers.17 Moreover, the fees midwives charged for a delivery were not necessarily different from what a doctor received for a delivery and were equivalent to what a day labourer earned in two to four working days.18
While male doctors solidified their dominance over the nineteenth-century domain of childbirth, nursing was an almost exclusively female domain consisting mainly of women religious (see Chapter 2, pp. 69–71). The first training programmes emerged in the context of tense ideological debate in the 1880s on the nursing competences of women religious. Early initiatives for lay nurses in the liberal settings of Liège and Brussels were followed by Catholic training programmes after 1900. Historians and feminists have often explained this gendered division of labour by underlining the hierarchy between caring and curing. Caring tasks of nursing were traditionally associated with ‘female’ maternal qualities, while the responsibility of curing patients belonged to the male-dominated field of medicine.19 In Belgium, as elsewhere, representations of the profession of nursing were indeed peppered with gendered notions of maternal care, altruistic dedication and female compassion.20 Recently, however, historians also challenged these gendered notions of care by paying more attention to the practices and discourses of male nurses who were most clearly visible in psychiatric hospitals.21 The Belgian mental institutions of the Brothers of Charity, for instance, were almost all-male spaces, both in terms of patients and nurses. A first exploration of the Brothers of Charity’s journal for nurses has shown that existing gender ideals informed the construction of a professional identity. ‘Male’ characteristics such as discipline and physical strength were associated with the care for mentally ill patients. At the same time, however, male nurses were also described as ‘mothers’ who cared for their children: the – equally male – patients.22 Outside psychiatric settings, male nurses were present as well. About 30 per cent of the first generations of qualified nurses were men.23 The gendered discourse on these nurses awaits research.
In the twentieth century, the position of Belgian independent midwives who assisted at home deliveries was increasingly threatened by the rapid professionalisation of nursing, on the one hand, and the medicalisation of giving birth in hospitals, on the other. The first process was accelerated by the development of midwifery as a specialisation within the nursing training programme as of 1951.24 The medicalisation of birth comprised the isolation of birthing women in hospital delivery rooms, the introduction of new medical technologies and the increasing use of anaesthesia during deliveries.25 In most countries – the Netherlands being a notable exception – the medicalisation of childbirth implied an increasing employment of midwives in hospital settings, where they were put in a subordinate position to physicians.26 A Belgian law of 1944 promoted deliveries in maternity clinics by offering mothers a compensation for all costs within the first ten days of a hospitalised stay, while home deliveries by midwives were not covered. Shortly afterwards, independent midwives were allowed to assist at deliveries in maternity departments. As a result, midwives preferred a paid employment in hospitals above poorly paid self-employment. From 2,513 independent midwives in 1900, there remained around 80 in 2000.27 The profession of midwifery remains a remarkably stable ‘feminine’ domain. In contrast to the domains of medicine and nursing, very few men practise midwifery at present. In France, for instance, there has been an increase of male students since the profession was opened to men in 1982, yet the actual number of male practitioners remains limited. In Belgium, male midwives also form a minority. In 2017, about 1 per cent of the qualified Belgian midwives were men.28
Testimonies of midwives themselves complicate the dominant narrative of medicalisation. In contrast to France, where historians have been able to integrate the professional experiences of midwives into their work,29 Belgium disposes of only a couple of oral and written testimonies of female birth attendants and their family members in the nineteenth and twentieth century.30 The few available testimonies display a more balanced view of being an independent midwife in the countryside before, during and after the Second World War. Their socially vulnerable position – low wages, hard work and stressful situations – was definitely an important facet of their lives. Yet, the testimonies also show expressions of commitment and a high internal motivation. Midwives took pride in the many roles they fulfilled and for which they were recognised and appreciated in their community. Those who worked among large poor families, for instance, did additional tasks as social workers by providing them with material help and advice. Midwives in rural territories hardly ever called upon doctors, except when medical intervention was necessary.31 Moreover, recent research based on witness statements of unqualified midwives in the context of court cases on infanticide and the illegal practice of medicine suggests that in urban contexts collaborations between doctors and (unqualified) midwives sometimes occurred until the beginning of the twentieth century.32
Since the 1990s, the existing power hierarchies between physicians and midwives have been challenged. In 1994, a European law determined that midwives were qualified to assist deliveries autonomously and decide whether it was necessary to call a doctor. At the same time Belgian midwives adopted new roles in counselling future parents. They opened the first birth centres, providing for prenatal consultations, workshops, specific courses and information sessions. There, they offered their services by giving parents information and care before, during and after home deliveries.33 For the setting up of these birth centres midwives looked for inspiration abroad – the Netherlands, Scandinavia, Britain and the United States – where home deliveries were more common.34
In contrast with the professions of midwifery and nursing, the field of medicine was for a long time closed to women. From an international perspective, Belgian medical education opened up quite late. Medical schools in Switzerland and France admitted women early on in the 1860s. The first woman to receive a French medical degree was the British Elizabeth Garrett, who had been unsuccessful in her attempts to enter a British medical school.35 In Belgium too, Isala van Diest had been denied access in Leuven in 1873. She went to Bern, where she took her degree in 1877 (Figure 1.1). Garrett and Van Diest fit in a broader pattern of the first generations of female students who studied abroad.
Around the same time, an initiative offering a minimal medical education to women was launched by the Brussels doctor Constant Crommelinck. In 1875 he opened a ‘free school of medicine’ that offered female students a two-year elementary training in ‘natural medicine’ consisting of weekly conferences.36 This initiative was, however, short-lived and remained marginal vis-à-vis mainstream medicine. In 1880, the right of women to enter academic studies would be recognised, although Van Diest had to wait until 1884 to be allowed to exercise her profession in Belgium and it would take another six years, until 1890, before the access of women to the medical profession was regulated. In 1887 the first female student, Clémence Everart, started at the Free University of Brussels. Soon other students followed in Brussels, Liège and Ghent, while the Catholic University of Leuven would only welcome female students from 1920 onwards.
Yet, it was too early for a real influx of women into medical studies, as there were hardly any secondary schools that provided girls the required qualifications to enter university. On the eve of the First World War, 27 Belgian women physicians had received medical qualifications out of a total of more than 4,400 Belgian physicians.37 This was a small number, also in comparison with the number of foreign female students who studied in Belgium. In the twentieth century, the number of female students enrolled in medicine increased gradually, with an acceleration in the 1960s. After 1970 male enrolment started to decline, which resulted in a majority of female medical students as of 1990.38
Little is known about the experiences of the first women physicians in Belgium. The few interviews that historian Denise Keymolen conducted with physicians in the 1970s indicate that the first female students were approached as equals by fellow male students.39 It took longer for women to become accepted as medical practitioners. Prejudices about women’s ‘limited capabilities’ among doctors and patients hindered the efforts of the very first female doctors to run an independent medical practice. In an interview published in the Brussels liberal newspaper La Réforme, Isala van Diest testified to her difficulties with setting up her own practice. She started working in a refuge for prostitutes, which probably damaged her reputation among bourgeois families. Her later private practice mainly attracted British and American female patients who were more used to women doctors.40 A sociological study of the professional life of graduates of the Catholic University of Leuven in the first half of the twentieth century confirms that most of the sick in a hospital or sanatorium preferred a man above a woman when first encountering their doctor.41 There were, however, exceptions. At the end of the nineteenth century, doctor Marie Derscheid not only attracted numerous patients, but she also participated in (male) scientific sociability and was a member of the editorial board of the Journal Médical de Bruxelles.42 Yet, her success was probably partly made possible thanks to her marriage with the notable physician and Brussels professor in medicine, Albert Delcour. More generally, family networks have been important for many ‘first’ women doctors. It was probably no coincidence that Belgium’s first female doctor, Isala van Diest, was the daughter of a doctor.43
In 1921, Derscheid would become the first president of the Belgian Federation of University Women (Fédération Belge Des Femmes Universitaires).44 The Belgian Federation was one of the many women’s organisations in Europe that arose following the birth in 1919 of the International Federation of University Women (IFUW), a British–American initiative aimed at the formation of a female educated elite and the promotion of ideals of peace and progress. In those early years, doctors formed the largest professional group within the Belgian Federation. As of 1922 they participated in conferences of the Medical Women’s International Association (1919), where critical reflections were made on the need for international cooperation and female empowerment within each country. Members combined their efforts to achieve equality of women physicians within the medical profession with broader claims for women’s professional rights.45
Despite these efforts, women doctors continued to struggle with career opportunities throughout the twentieth century. The difficult entrance of female researchers to medical faculties is a case in point. At Ghent University, as of 1900, women were allowed to specialise after their general medical training, yet their efforts to continue an academic career remained fruitless. Unspoken gendered divisions in academia discouraged women to aspire to a position in high academic ranks.46 Yvonne Desirant, for instance, who in the interwar period succeeded in becoming first assistant (‘chef de travaux’) at Ghent University, later testified that she had never hoped for a career as a professor. There were, however, differences between universities: while in Ghent the medical faculty appointed a female professor, Irène van der Bracht, in 1925, this would take another forty years in Leuven. Yet Van der Bracht had no medical training and she was appointed to teach educational gymnastics to female students. Early academic recognition of women doctors occurred at the margins of the medical profession.47
By contrast, the Belgian colony of Congo seems to have offered new employment opportunities for both men and women (see Chapter 3, pp. 106–20). The demand of medical care rose as the establishment of a series of colonial hospitals in Congo was envisioned. Organisations such as the Union of Belgian Colonial Women (L’Union Des Femmes Coloniales) (1923–40) and later on the Union of Women of the Belgian Congo and Ruanda-Urundi (L’Union des Femmes du Congo Belge et du Ruanda-Urundi) promoted colonial employment for women.48 However, as articles in the journal of this latter organisation indicate, women were expected to practise ‘essentially feminine’ medical professions such as midwifery and nursing.49 The case of sister Marie Guido – known by the local population as ‘the mother doctor’ – is a counterexample showing that religious congregations could empower female religious doctors. Marie Guido obtained her medical degree in the 1940s and worked in the Congolese locality of Musienene, where she performed medical operations such as caesarean sections and amputations.50
Women’s entrance into the medical profession was not only a slow process, it was also marked by disciplinary hierarchies. Women gained access most easily to disciplines such as paediatrics and gynaecology, which were considered to be ‘natural’ fields of specialisation for women in and beyond Belgium, while ‘masculine disciplines’ such as surgery, urology and orthopaedics remained highly closed to them. In a recent interview, Ilse Kerremans recalled the patronising words of fellow male colleagues when she started a specialisation in surgery in the 1970s.51 Up until today the medical profession is marked by gendered divisions of labour and prestige. Telling in this respect is the underrepresentation of women in the numbers of professors at Belgian medical faculties.52
The gendering of medical knowledge and medical practices
From the 1990s onwards scholars have shown the role of modern biomedicine in the production of ideas about men’s and women’s ‘nature’. Thomas Laqueur’s famous (and heavily debated) study Making Sex (1990), for instance, has highlighted the naturalisation of sexual difference since the end of the eighteenth century.53 Enlightenment brought about the dominant view of the so-called two-sex model, which accentuated fundamental sexual difference. Corporeal and physiological observations of female genitals increasingly served as evidence of the ‘natural’ roles of women as housewives and mothers. As Ornella Moscucci and others have shown, the nineteenth-century discipline of gynaecology provided a scientific basis for these cultural ideas about maternity and femininity.54 Contrary to existing medical disciplines that took the male body as a model for men and women, gynaecology was designed to study woman’s distinctive physical and mental characteristics through a focus on her reproductive functions. It became the ‘science of woman’. A similar discipline devoted to men’s sexual organs – andrology – arose only during the second half of the twentieth century.
Contrary to international trends, the Belgian gynaecological profession developed rather late. From the 1860s on, gynaecology acquired a status in most large cities as an autonomous specialty based on the first successes of modern surgery. In this context practitioners favoured an interventionist surgical approach to alleviate disorders in women.55 In Belgium, gynaecology emerged twenty years later with the establishment of a scientific gynaecological society (1889) and the organisation of the first clinical courses at the state universities of Liège and Ghent.56 In the 1890s, private hospitals were set up, and in collaboration with the universities specialised services in public hospitals were established. At this time the study of women’s diseases was not necessarily identified with the older branch of obstetrics. Belgian universities provided students with a general medical training in medicine, surgery and obstetrics, after which doctors could specialise in women’s pathologies through professional and scientific activities. In line with the international trend, gynaecological services in the public hospitals existed separately from the older obstetric services. While midwives and obstetricians in maternity wards took care of women’s deliveries, gynaecologists concentrated on diseases centred in the sexual system of women and problems following childbirth or medical abortion. To treat ‘women’s diseases’ they employed both methods preserving women’s fertility, such as the use of pessaries and curettage, and radical surgical therapies such as ovariotomy and hysterectomy, the surgical removal of the ovaries and the uterus. In Brussels, the focus of these early gynaecologists on abdominal surgery is exemplified by the placement of the first gynaecological service in an operating room.57
At the time of the institutionalisation of gynaecology, biological sex differences increasingly marked discourses in medicine and society. Belgian physicians started to accentuate women’s social mission as mothers by relating this mission to their ‘nature’. In this way doctors also came up with an answer to existing medical and political anxieties regarding the so-called degeneration of the Belgian nation. In the second half of the nineteenth century, degeneration was considered to be a process of degradation from a physical, psychological and moral point of view. According to degeneration theories, degenerated persons could contaminate healthy citizens through social interaction and sexual intercourse. Belgian and other physicians became fascinated by heredity and accentuated women’s reproductive ‘essence’ as a vital instrument to safeguard the survival and health of future generations.58 Unlike in France, population decline was not yet at stake before 1900, but it soon afterwards became an element of medical concern. Within the same context, Belgian physicians and politicians would start to actively intervene in the domain of infant care after the First World War.59 Gendered medicalised discourses equally marked reformatory politics. In response to the growing social protest of workers in the 1880s, ideals of home-centred maternity as a weapon against social disorder and immorality were promoted by political elites. Belgium’s first social legislation bore traces of this medicalised and gendered perspective. As of 1889, girls younger than twenty-one were forbidden to work in the mines and female workers who had given birth were obliged to stay at home for four weeks, without any financial compensation.60
Medically informed ideals of women’s important social roles as mothers were often countered by reality. The clientele of Brussels gynaecologists in public hospitals mainly consisted of poor women suffering from the physical effects of numerous successive pregnancies. These labouring women had neither the time nor the money to undergo a long gynaecological treatment. The research of Tommy De Ganck on gynaecology in the Brussels hospitals, where prostitutes and other working women were provided with free care, has shown that social inequalities determined doctor’s choice for radical treatments. To cure women who were incapable of working because of pelvic pain, physicians easily turned to the surgical removal of their ovaries and uterus, rather than investing in time-consuming and costly treatments that were offered to bourgeois women in private clinics. As this example shows, class differences often intersected with gender hierarchies, reinforcing each other.61
The case of ovariotomy is interesting from a different perspective as well, as it testifies to the role of medicine in producing ‘female’ pathologies and mental disorders.62 For the first time successfully performed in 1809 in the United States, the operation initially aimed at extirpating ovarian tumours. Starting in the 1870s, however, Anglo-Saxon surgeons also executed ovariotomies to amputate healthy ovaries of women who experienced mental problems.63 In Belgium and elsewhere in Europe it was also common to explain the causes of mental illness by referring to a woman’s defective reproductive physiology – among other things menstruation problems or specific injuries to the genitals. ‘Hysteria’, an umbrella term that was continuously redefined throughout history, was sexualised as a ‘female’ disease. It was linked with all sorts of deviant behaviour.64 Doctors therefore believed women could be cured by using localised genital therapies, of which ovariotomy was a radical example. Contrary to physicians in the United States and Britain, however, most Belgian gynaecologists were sceptical about ovariotomy as a treatment for non-gynaecological complaints. The research of Tommy De Ganck has shown that there is little evidence of actual operations for the purpose of curing hysteria in Belgium. By the time that ovariotomy became a regular operation in Belgium – the first known successful surgical removal of a cyst took place in 1870 – gynaecological explanations for hysteria had lost ground in international medical circles.65
Belgian and other doctors had instead adopted the neurological explanation of hysteria by the French doctor Jean-Martin Charcot in the 1880s. Years of clinical observations had convinced Charcot that both men and women could experience hysteria. His first descriptions of hysteria in adult men were highly controversial in the medical world. Notwithstanding this inclusion of men, Charcot’s published case studies do reveal the gendered nature of his diagnoses. Women were not only diagnosed much more frequently with hysteria than men, but his etiological theory differed for men and women. The neurologist mostly applied the hysteria diagnosis to males who had undergone traumatic physical accidents at work. Hysteria among women, on the other hand, was the result of an overpowering emotional experience in domestic settings. Moreover, erotic antics of several female hysterics clearly reveal a sexual component.66 Like French physicians, Belgian doctors diagnosed hysteria with men who had undergone physical trauma such as soldiers, a topic that appeared in the medical press in 1888. While Belgian military neurologists did not often refer to the traumatic effects of war in their own work, they did refer to foreign studies on the devastating psychological effect of traumatic war experiences. During the First World War, this type of psychological disorder would become known as ‘shell shock’ (see Chapter 8, pp. 298–300).67 In contrast, hysteria, depression and melancholy in women was related to their ‘emotional’ nature.68 Sexualised representations of female hysterics would remain visible in popular museum exhibitions, such as the travelling Spitzner Museum, where wax figures represented hysterical women.69
For both men and women, a healthy sex life within marriage was seen as the main solution to cope with mental problems. It follows that physicians were concerned about sexual behaviour that departed from this ideal, such as sexual abstinence, promiscuity and masturbation. While abstinence was associated with frigid upper-class women, physicians pathologised excessive sexual activity and masturbation among men. In Great Britain those men were regularly diagnosed with spermatorrhea.70 The disease, with an excessive loss of sperm as the main symptom, was understood to elicit, among other things, anxiety, nervousness and impotence. It is unclear to what extent spermatorrhea determined medical practice in Belgium, yet research has shown that masturbation and sexual excess were seen as causes for mental illness in men.71
Excessive sexual behaviour was also seen as a major cause of the spread of venereal diseases. Prostitutes in particular were held accountable for this, even though they were increasingly perceived not only as seductresses, but also as victims. In Belgian debates on the problems of prostitution in the army – an all-male space – inebriety was seen as part of the problem.72 Physicians argued that alcohol made soldiers more susceptible to both careless sexual behaviour and infections.73 As elsewhere, Belgian regulations on alcohol and prostitution were supposed to prevent the outbreak of diseases. In Brussels, the first Belgian city to regulate prostitution in 1844, registered prostitutes were subjected to medical examination twice a week. In case of sickness, they were isolated in hospitals until they recovered. In other Belgian cities similar medical procedures were introduced. In 1948 – after more than fifty years of political protest – the system of forced medical supervision was abolished.74
The gynaecological examinations also point at an issue that was at the heart of the discipline of gynaecology in Belgium and abroad. Physicians were concerned about the chastity of ‘respectable’ women. While prostitutes were not considered to be modest, visual examinations of the private parts of middle-class women were seen as offensive to women’s sexual pudency. Especially the reintroduction of the speculum in medical practice from 1820 onwards aroused international moral concerns over the exposure of respectable women’s bodies to visual inspection (Figure 1.2). Until the end of the century, gynaecologists preferred other tactile procedures above ocular examinations.75 Concerns about modesty also influenced the management of hospital spaces, where sexual segregation was to protect female dignity. In the 1900s in the public hospitals of Brussels, for instance, gynaecological consultations were held at specific times as to prevent the presence of male patients. Private rooms for surgery and curtains were installed for the same purpose.76
In the interwar years, the medical protection of maternity took on a new dimension. In this period, stagnating infant and maternal mortality rates were seen as a problem for the survival of the nation by physicians and politicians alike. Belgian physicians for the first time linked the survival of children with the health of women during the whole process of pregnancy. Prenatal consultations for future mothers were therefore installed in hospitals and maternity departments.77 As in Great Britain, this political climate of scrutinising and pathologising pregnancy seems to have facilitated the unification of gynaecology and obstetrics in hospitals and universities. The law of 1957 officially reunited and recognised gynaecology and obstetrics as one specialty along with other specialties in Belgium. Little is known, however, about the specific reasons for the rapprochement between the two disciplines.78 The twentieth-century history of Belgian medical specialisation is a promising avenue of future research. With the exception of a recent study of the Leuven academic hospitals, it has mainly been researched from a legal perspective.79
In the same context of pro-natalist policies, Belgian gynaecologists made an important contribution to a moralising sexualised discourse regarding birth planning. Different from other countries, Belgian gynaecologists, such as the Leuven professor Rufin Schockaert, undertook a leading role in promoting a Catholic vision on sexuality. According to this vision, reproduction was the sole purpose of marriage, implying the condemnation of birth control and contraception (see Chapter 2, pp. 82–4). The scant Belgian literature on this subject has revealed the dominance of Catholic approaches in twentieth-century medicine,80 and medico-ethical debates on infertility.81 Neo-Malthusianism – the movement that originated in Great Britain in the 1870s and aimed at expanding knowledge on and the dissemination of contraceptives – had limited success in Belgium. Historians have explained this by referring to the condemnation of the movement by Belgian church representatives, legal opposition by Catholics and socialists and the mobilisation of Catholic doctors and midwives against abortion and birth control.82 Small organised neo-Malthusian movements emerged after 1900. These organisations consisted of a limited number of liberals and a stronger representation of socialist members, including some prominent socialist doctors such as Fernand Mascaux.83
Feminism and bodily self-determination
Birth control and related questions were also explicit concerns of the first and in particular the second wave of organised feminism in Belgium, and of women’s activism throughout the twentieth century. Actors involved in political debates about women’s rights had to fight against stereotypical, often medically legitimised views about women’s moral and physical weaknesses and their incapacity to assume various social roles. An exemplary legal dispute in this respect is the so-called Popelin Affair of 1888. In that year Marie Popelin claimed the right to practise as a lawyer in court. Having obtained a doctoral degree in law she was refused to take the oath as an attorney. She decided to challenge this decision legally. In its refusal of Popelin’s request, the court of appeal used a language that was interspersed with sexualised visions of women. The battles and hard work of the bar were considered incompatible with women’s nature and their social mission in the household. Several historians have argued that this decision was partly motivated by the then dominant association between masculinity and the public sphere. To open up the public profession of a lawyer to women was inconceivable. The medical profession by contrast could be linked with ‘feminine qualities’ of care and with advantages for the modesty of female patients.84 Notwithstanding this difference, at the time of the Popelin Affair the legal position of women physicians was still uncertain and a matter of dispute in medical and political circles.
The Popelin Affair was the starting point for feminists to organise themselves politically in order to press for legal reforms. Starting from 1892 with the Belgian League for the Rights of Women (Ligue Belge du Droit des Femmes), this and other politically ‘neutral’ associations were founded, alongside socialist and Catholic women’s organisations. Neo-Malthusianism was marginal within first-wave feminism in and beyond Belgium. The socialist feminist Emilie Claeys was one of the only Belgian pioneers who defended the use of contraceptives in the early 1890s. She associated voluntary motherhood with women’s emancipation. In the socialist journal De Vrouw she published under a pseudonym, whereas the same journal featured some publications on family planning by the Dutch female doctor Aletta Jacobs. These feminist ideas on reproductive self-determination were very contentious, as they radically separated sexuality from reproduction. Many Western European feminists chose to remain silent on the matter and focused instead on themes such as equal political rights, women’s education and work.85
That does not mean that contraception and abortion were non-existent at that time. Contraceptive methods such as coitus interruptus, sexual abstinence and – since the 1860s – condoms were often used. Abortion, however, remained the most accessible method of birth control. Social and liberal newspapers featured weekly advertisements for self-made abortionists and abortive products. At first, many practitioners were unqualified midwives. At the end of the century, abortion also became the working terrain of doctors. To compete with these physicians, unqualified midwives started to present themselves as experts by adding medically related titles to their names such as ‘former intern of hospitals’. Abortionists were rarely convicted for their practices. Despite the penal law of 1867 that criminalised abortion, illegal abortionists were not actively pursued.86 Convictions were also rare in countries such as Britain where criminal law on abortion was among the severest in Europe.87
Until the interwar period, Belgian feminists wrote little on the subject of birth control. In their pleas in favour of women’s rights, they often reappropriated traditional and biologically based images of gendered differences. For instance, Isabelle Gatti de Gamond, one of the leading Belgian feminists, provided argumentation in favour of specific public roles – teaching, nursing and curing – that were harmonious with women’s ‘natural’ domestic capacities.88 In line with the political and moral discourse of the time, the aforementioned working-class feminist Claeys promoted birth control by pointing at the well-being of the children and the benefits for a harmonious relationship between wife and husband. Nevertheless, her plea for birth control in the socialist journal De Vrouw was so controversial in the 1890s that she risked a legal sentence. After having been accused of maintaining an extramarital relationship, her marginalisation within the socialist and feminist movement came as no surprise.89 Although more research needs to be done on the topic, it seems that the first generations of female doctors – including those united in the Belgian Federation of University Women – did not publicly engage in favour of women’s reproductive rights. The achievement of professional recognition in the male-dominated medical field was probably felt as a more pressing issue.
During the interwar years, it was lone voices who discussed women’s reproductive and sexual rights. Referring to contemporary and older sexologists such as Mary Stopes and Henry Havelock Ellis, a handful of self-made sexologists, among whom Marc Lanval and Geert Grub, pleaded for the legalisation of abortion and the female right to sexual pleasure. They advocated female sexual liberation by opposing a bourgeois anti-physical masculinity. According to them, the sexual taboo had caused men to hide their sexuality in the nineteenth century. By contrast, the ‘new man’ was responsible for the sexual satisfaction of his wife. For women this implied that they had equal rights to sexual pleasure. At the same time, however, the discourse of Lanval and Grub was marked by nineteenth-century biological and social hierarchies between men and women.90
Nevertheless, the ideas of the sexologists on abortion and sexuality were very controversial in the 1920s and 1930s. Fear of population decline led the post-war Belgian governments to pursue pro-natalist policies. In 1923, a law banned the selling, disseminating and advertising of contraceptives and abortion. Maternity-oriented policies connected with the long-standing efforts of the Catholic Church and Catholic doctors to counter the use of contraceptives. For instance, in 1931, the Society of Saint-Luc, an association of Catholic doctors, organised a conference where Catholic doctors along with jurists, philosophers and religious leaders discussed the causes and solutions of the falling birth rate. At the conference, doctors underlined women’s role in procreation by pointing at the manifold harmful effects of birth planning. The Leuven physician Schockaert argued that birth control made women sick, which eventually prevented their sexual organs from functioning normally.91
Women’s movements between 1918 and 1960 were partly encapsulated within maternity-oriented discourses. Especially Catholic feminists but also feminists within socialist women’s organisations advocated socio-economic measures that complied with women’s role as housewives.92 From the 1930s onwards, some socialist women such as Vogelina Dille-Lobe and Isabelle Blum took up the theme of ‘conscious maternity’ and tentatively argued in favour of birth planning. Twenty years later, Dille-Lobe developed into a more ardent advocate of the liberalisation of contraceptives. Gradually, feminist publications placed women’s reproductive rights at the heart of the issue of birth control.93 Socialist women and especially the Socialist’s Women Federation (SVV) would also play an important role in sex education. In the 1960s the Belgian Society for Sex Education (Belgische Vereniging voor Seksuele Vorming) (BSSE, 1955) and its French-speaking counterpart La Famille Heureuse (1962) founded consultation bureaus in diverse Belgian cities that provided information on birth control and distributed contraceptives.94
Yet, in the 1950s and 1960s the influence of the Catholic Church on sexual morality remained extensive (see Chapter 2, pp. 84–5). The most read literature on sex education was Catholic and progressive voices remained exceptional, as the limited numbers of members of the BSSE show.95 According to Catholic doctrine, calendar-based methods (which had been improved in the 1930s) were the only accepted form of contraception. Not surprisingly, the contraceptive pill had little success when it was introduced to the Belgian market in 1961. In the beginning, mainly doctors linked to the BSSE and La Famille Heureuse prescribed the pill.96 Yet, recent research on the Leuven hospitals shows that the contraceptive pill also became an accepted reality among Catholic doctors. In the Leuven hospitals gynaecologists were quite open to women’s concern of unwanted pregnancies.97 Moreover, the devout Catholic gynaecologist Ferdinand Peeters made an important contribution to the development of Anovlar – the successful pill produced by the company Schering AG – out of concern for health problems in women and social strains related to family growth.98 These shifts have to be understood in relation to more lenient Catholic positions regarding contraception during the papacy of the progressive pope John XXIII (1958–63) and the second Vatican Council (1962–65). In that climate of openness, progressive efforts, such as the medically informed sexology under impulse of the Belgian archbishop Leo Jozef Suenens, were welcomed. Suenens pleaded in favour of a revision of the Catholic doctrine regarding birth control. Pope Paul VI, however, made an end to hopes of reform with Humanae Vitae (1968) which reaffirmed the earlier ban on contraception of Casti Connubii (1930).99
In the 1970s the theme of abortion was taken up by a coalition of new mediagenic feminist movements such as Dolle Mina and Marie Mineur, older movements of socialist women and free-thinking doctors linked to centres of family planning. Their pleas for the legalisation of abortion resulted in a first bill for law reform in 1971, which went largely unnoticed in parliament. The arrest of ‘abortion doctor’ Willy Peers in 1973 served as a catalyst for mobilising both supporters and opponents of abortion (Figure 1.3). Women indeed looked for ‘underground’ solutions, such as a secret abortion by doctors like Peers in Belgium or ‘abortion tourism’ in Great Britain and later also the Netherlands.100 Abortion practices at the academic hospital of Brussels are well documented. At the Catholic academic Leuven hospitals, doctors also performed abortions, for example in the case of severe genetic defects. An institutional policy of secrecy, however, made sure that no publicity was given to such practices.101
In the first parliamentary discussions on abortion in 1971 and 1973, the traditional parties were completely polarised on the issue. The socialist party was clearly in favour of the liberalisation of abortion, while the Catholic party took the opposite side. As a sort of compromise, in 1973 the government lifted the legal ban on selling and advertising contraceptives. In the following years, the political debate was repeatedly revitalised. Continuing protest of pressure groups, qualitative improvements to the practice of abortion and the rise of actual abortions reinforced the position of proponents of abortion. In the 1980s times had clearly changed. Abortion was more openly discussed in newspapers, on the radio and on television. In medicine there was increasing attention for the patient’s right to make informed decisions, an argument that was also present in the political debate on abortion. In politics the advocates of abortion grew in numbers, while the Catholic party became ever more isolated. In 1990 abortion was partially depenalised (until twelve weeks of pregnancy), a measure that was taken quite late compared with several other European countries. In 2018 a further step was undertaken to decriminalise abortion. Previously considered as a criminal offence outside of the legal restrictions of 1990, the clauses on abortion were taken out of the penal code and converted into a specific law on abortion. Up till now the legalisation of abortion remains contested by ‘pro-life’ groups.102
In the last decades a shift in gender identities has occurred. The increasing visibility and achievements of transgender activism and the important role of medicine in answering health concerns of transsexual, transgender and gender non-conforming people invite us to think beyond the persistent gender binary. The historical analysis presented in this chapter shows that notions of femininity and masculinity have in fact never been stable categories. On the intersection of medicine and gender, medical practitioners and feminists have renegotiated gender hierarchies, while medicine as a body of expert knowledge has often participated in the historical construction of gender difference. And it continues to do so, for instance by developing medical aesthetic treatments that reinforce the normativity of Western feminine beauty ideals.
Within Belgian historiography, the field of gender and medicine awaits further research. In traditional sources such as meeting reports of parliament or medical societies the voice of women is mostly absent. Historians’ dependence on these sources has for a long time hindered more complex stories of interaction and competition between male and female medical practitioners. In the domain of childbirth, recent research has for instance shown that largely unexplored sources such as witness statements can lead to cases where physicians and (illegal) birth attendants collaborated during deliveries. Together with the few available testimonies on professional experiences, these sources provide us with tools to look at actual practices and bypass top-down narratives of medicalisation and professionalisation. In the same vein, legal sources can illuminate the role of medical knowledge by laywomen. In cases of rape and sexual assault of minors, for instance, recent research has shown that the physical examination by mothers of their children’s body was considered as reliable evidence by coroners.103
The history of sexuality might also be a promising avenue to broaden such histories of medicine and gender by adding a health perspective. Patient registers, in which physicians took regular notes on the health of patients with mental or other problems, can for instance inform historical knowledge about medical ideas on a healthy sex life. Although patient registers first and foremost reflect the doctor’s voice, they also reveal much about patients’ sexual experiences and expectations. The promising results of histories from below, however, do not alter the fact that female voices remain difficult to trace for the nineteenth and the early twentieth century. When it comes to medically informed ideas about gender, feminists and historians have started to uncover the constructions of gender difference in relation to other social hierarchies such as class and ethnicity. In Belgium, as elsewhere, medicine played an important role in the production of gendered diseases and in the promotion of ‘natural’ social roles of women of different classes and ethnicities. In particular, the role of ethnicity in the gendered history of medicine awaits research, not only in relation to Belgium’s colonial past, but also with regard to the more recent multi-ethnic composition of the population.