The making of the ‘useless and pathological’ uterus in Taiwan, 1960s to 1990s

In the process of the promotion of cancer prevention and under the shadow of cancer risk, the notion of yilao yongyi was gradually applied to hysterectomy as it had been applied to tubal ligation. According to Xiang-Da Wu (1938–2018) and his colleagues, prominent ob/gyns at Taipei Veterans’ Hospital, prophylactic hysterectomy became popular in the mid-1970s. The first large-scale cancer prevention campaign began at this time, led by the Cancer Society of the Republic of China and the public health expert, Pesus Bise Chou (Bi-Se Zhou). Cervical cancer figured prominently in the gendered cancer prevention discourses and measures, 104 and it was also a model cancer for the idea of early detection and early treatment; the campaign popularised the idea that, if it was caught early, it could be 100% cured. 105 The campaign’s main tasks were to educate women and to make individual ob/gyn practitioners the campaign’s partners. Like the family planning campaign, it identified rural women, perceived to have no knowledge of prevention, as their main target. Public health experts and physicians alike saw rural women’s ignorance as an obstacle. 106 The campaign sought to educate women via films, lectures, cancer survivors’ experience-sharing and small-group meetings at local farmers’ associations. Women were told to accept Pap smears and seek regular follow-up surveillance of their body; the message was to be constantly on guard and undergo gynaecological examination regularly. 107 I will return to the problem of gynaecological examinations later. To convince women to take preventive action, such as accepting an unpleasant Pap smear, the prevention campaign employed scare tactics and emphasized the deadly consequences of undetected and untreated disease. 108 For example, the film, Shengsi zhijian (Between Life and Death), purportedly the first of its kind, was meant to ‘flash a warning light’ at the intersection of life and death ‘under the horrible shadow of cancer’. 109 The film featured well-known actors, such as Chang Feng and Mei Fang, and, in a time when not much entertainment was available, the showing of such films was often considered the highlight of a cancer prevention event, attracting many from afar, especially those living in the remote rural areas. The campaign reported that, after watching the film, women sought free Pap smears at their local ob/gyn clinics and husbands brought their wives to the ob/gyns. As a result, clinics were busier than before. 110 The spread of fear was double-edged. 111 Women were motivated to action by fear; some would rather ‘overreact’ than accept ambiguous results, which would mean living with the risk. The campaign created two main groups of women – cooperative patients and non-participants (who refused to accept a Pap smear and follow-up exams). Those who were willing to cooperate ‘erroneously took the attitude that they were not far from death, which greatly troubled their minds’. 112 If a test indicated something suspicious, a woman was encouraged to do further tests. As research has pointed out, women’s experience of cervical screening may have reinforced a sense of risk, particularly for those who received suspicious results. 113 The leader of the campaign reported a case of ‘overreaction’ – a woman who would rather undergo hysterectomy than live with the risk: ‘[There was] a patient whose Pap smear result was class III, but the tissue biopsy indicated merely cervix erosion. She was worried and went to three different hospitals to get tissue biopsies. The results were all the same – no cancer. Normally, she should have felt happy…. She complained, ‘I’d rather have cancer and cut off my uterus so I can have quick relief’. 114 Ambiguous test results prompted many women to accept hysterectomy as a preventive measure after being encouraged by their doctor to err on the side of caution. In the late 1970s, Ms Huang’s mother had a Pap smear with ambiguous results. It read, ‘X is suspected’. Her mother was so terrified that she became bedridden for weeks. As she greatly feared surgery, she did not have the courage to do more than worry, but several of her friends who had received similar reports ‘bravely’ accepted hysterectomy. 115 ‘[There was] a patient whose Pap smear result was class III, but the tissue biopsy indicated merely cervix erosion. She was worried and went to three different hospitals to get tissue biopsies. The results were all the same – no cancer. Normally, she should have felt happy…. She complained, ‘I’d rather have cancer and cut off my uterus so I can have quick relief’. 114 The campaign also recruited individual ob/gyns into their network of prevention; when the campaign conducted the first two cervical cancer mass screenings (between 1974 and 1978 and between 1979 and 1984), 661 and 569 ob/gyn clinics were involved, respectively. 116 By 1977, the campaign had carried out over 60 000 Pap smears. 117 In addition to sending those who were diagnosed with cervical cancer to ob/gyns who would provide the treatment of hysterectomy, the campaign invited ob/gyns to hold funded free clinics and offered updated cancer knowledge from the United States, such as educational films sent by the American Cancer Society. Ob/gyns and their practice, along with popular literature (mostly written by ob/gyns such as the aforementioned Xiandai Funu Baojian ), became part of the infrastructure for the cultivation of risk awareness. In an article meant to encourage women to receive regular exams, Tao-Sun Wang, MD, who also participated in Pap smear screening in the early 1970s, wrote about hysterectomy as one of the treatments for cervical cancer: ‘The uterus, except for menstruation and nurturing the fetus, is not very important. If a woman has had enough children and has reached middle age, the uterus is not very useful for her. Hysterectomy would not damage her femininity’. 118 In trying to convince women to accept hysterectomy, Dr Wang repeated the notion of wuyong and argued against the popular notion that a woman without a uterus was not a true woman. ‘The uterus, except for menstruation and nurturing the fetus, is not very important. If a woman has had enough children and has reached middle age, the uterus is not very useful for her. Hysterectomy would not damage her femininity’. 118 As part of their persuasive tactics, physicians might also bring up the additional benefit of insurance compensation to their women patients. For women of reproductive age having no uterus (therefore infertile) was officially compensated as a form of canfei (handicap, disability), according to several major government insurance programmes, including Labor Insurance (1950–1995), Government Employees’ Benefits and Insurance (1958–1995), and Farmer’s Health Insurance (1987–1995). Therefore, women under 45, who underwent hysterectomy, were qualified to receive handicap (later disability) compensation, regardless of whether or not they had received prophylactic hysterectomy because they had fulfilled their maternal duty. An additional aspect potentially enforcing the notion of the useless and pathological uterus was women’s concern of modesty. Pap smears or regular check-ups were the two main weapons against cancer. However, both were resisted because the ways in which they were carried out made women uncomfortable. Women’s concern for modesty in ob/gyn exams has a long history, noted by Western-trained ob/gyns struggling to establish their practice in the colonial period. 119 This problem continued after the Second World War and into the post-war period. Reports about the embarrassing ob/gyn visit were common. Family planning workers reported conservative women’s refusal to let men doctors install the Loop. Sometimes they asked the nurse to talk to the patient behind a curtain while the doctor worked silently also behind the curtain, obscuring the identity of the Loop installer. 120 Women asked about clinics that had women physicians installing the Loop, and the names of such clinics were listed in the popular magazine, Fengnian. In addition, the exam space itself contributed to women’s resistance. In 1977, a group of physicians acknowledged that exam rooms were inadequately set up – the space was poorly regulated, people other than doctors and nurses were allowed to walk in and out of the room freely and women frequently felt embarrassed. 121 Hysterectomy became a way to avoid this kind of risk surveillance; violation of modesty or privacy was obviated by the hysterectomy as yilao yongyi, ending the need for routine gynaecological examinations. When Ms Miao Young was being discharged from the hospital after her hysterectomy (due to myoma), she was given a business card by her gynaecologist, who commented: ‘You have biye (graduated) from here [ob/gyn department]’, implying that she was done with ob/gyn clinics and could pass the business card to other women who might want to ‘graduate’ from the ob/gyn department. Ms Young’s story suggests that having a uterus meant a woman would never be free from uncomfortable ob/gyn visits. Similarly, Mrs Hong explained, ‘[after hysterectomy] one will not have to take off one’s pants and expose oneself to others’. Ms Xu mentioned that many of her friends in the Buddhist community, especially the nuns, did not think it was respectable to expose themselves to an ob/gyn regularly, and therefore they underwent hysterectomy. In addition to the cancer prevention campaign, another important place to observe how medical knowledge portrayed women’s body as a site of cancer risk was a popular health literature for women, a genre that emerged in the late 1960s and early 1970s and included health manuals and newspaper columns. Popular health manuals tended to pathologise the female body, and, in this light, cervical cancer and its early symptoms were featured in most of the health manuals. 122 In the 1950s, the discourse of cancer risk had already penetrated the existing genres: both popular health literature and traditional Chinese medicine. Ob/gyns had been warning women in the news media that baidai (‘whites strips’, whites, leucorrhoea) were a sign of uterine cancer. 123 The popular literature of traditional Chinese medicine manufacturers also appropriated Western medical knowledge on cancer and emphasized the importance of menstrual regulation, offering remedies for menstrual problems and whites. 124 However, at this point, neither advocated hysterectomy as a form of prevention. The 1970s saw a marked increase in the number of news reports, magazine articles and health manuals for women on cervical cancer, which, together with the cancer prevention campaign, contributed to the cultivation of risk. 125 Specifically, women were told to watch out for two warning signs of cervical cancer, bu zhengchang chuxie (abnormal, irregular bleeding) as well as whites, in addition to conditions, such as myoma and cervical erosion, which were also linked to cancer. Abnormal bleeding was a frequent key term in the popular writing, and women were educated to seek doctor’s help upon observing it; signs of bleeding now pointed to the problem of the uterus. Sumama (b. 1933) visited the ob/gyn clinic in her neighbourhood for ‘abnormal’ bleeding around 1980. Without doing any exams, the doctor simply told her that something bad was growing inside her uterus and a hysterectomy should be done. She decided to get a second opinion, however, and it turned out that the bleeding was a sign of menopause. 126 Another salient example of how a symptom was seen differently once the risk discourse spread was myoma, which has been the number one indication for hysterectomy since the 1970s. 127 The Chinese term for myoma, jiliu, is a term that can be easily confused with cancer, zhongliu, as they share the word liu (tumour). During the 1960s, ob/gyns’ recommendations regarding myoma were conditioned by women’s marital status and age. In 1967, an article, ‘Why conduct hysterectomy’, published in the popular health magazine, Dazhong Yixue , listed four conditions that would require hysterectomy: tumour (both malignant and benign), infection (especially, uterine dysfunction and haemorrhage) and uterine prolapse due to endometriosis or tubo-ovarian abscesses. Compared to the case of malignant tumours, in which the removal of the uterus, ovaries and fallopian tubes should be carried out hao-wu-bao-liu (without reservation, or leaving nothing), in the case of benign tumours, the author writes that it depends on the patient’s age; ‘If the patient is over 40, has many children, and has had severe anemia’, she should have a total hysterectomy. If the patient is young, has not given birth yet, and the uterus is still healthy, she might consider partial hysterectomy to keep her married (sex) life unaffected. 128 In other words, risk was evaluated differently depending on a woman’s marital status, reproductive status and age. However, health experts gradually began to write about the potential for myoma to become something malignant. Obstetrician/gynaecologists in their practice expressed the same concern. Women often heard and worried that ‘something bad might be growing inside the uterus’. 129 For example, Mrs Lin (b. 1953), a dressmaker, had tubal ligation in the early 1970s. Almost 20 years later, in 1991, Mrs Lin went to her local ob/gyn for an ultrasound check-up, as many of her customers had recently been diagnosed with cancer. The doctor suggested that the tubes be removed, but he asked permission from her family to do a hysterectomy during operation because he thought the uterus was not something to keep. 130 Other uterine diseases also contributed to the problematizing of the uterus. For instance, the case of endometriosis, a disease whose numbers increased dramatically after the introduction of laparoscopy technology. Impossible to cure but rarely fatal, it acquired the nickname of ‘benign cancer’, an oxymoron that still indicated cause for concern. Again, the treatment options were highly dependent on the woman’s marital and reproductive status. If she was young and not married, the doctor would recommend marriage, under the assumption that she should have children as soon as possible. If she was married without children, the doctor would treat her (assumed) infertility. If she was married with enough children, a hysterectomy would be recommended. 131 Some physicians went so far as to advocate the notion that having no symptom for cervical cancer was in itself a symptom. Citing a Japanese authority, Dr Zhang wrote, ‘We should accept Kushima’s suggestion that gynecology textbooks should list no symptom as one of the first, early symptoms of cervical cancer to increase women’s awareness. Since early cervical cancer is not symptomatic, regular examinations are a necessary prevention measure’. 132 Dr Zhang was not alone in this view; the ‘no symptom as the symptom’ can also be found in the popular literature. 133 ‘We should accept Kushima’s suggestion that gynecology textbooks should list no symptom as one of the first, early symptoms of cervical cancer to increase women’s awareness. Since early cervical cancer is not symptomatic, regular examinations are a necessary prevention measure’. 132 Almost every woman interviewed in this study had heard from her doctor that after giving birth the uterus was ‘useless’, and if you leave it alone, it might develop into something evil. 134 Their physicians’ common refrain was along the lines of: ‘You do not know what might be growing inside [the uterus]’, which were the specific, ominous words of Ms Zheng’s doctor. The uterus’s interior was a dark mystery, a source of fear stoked by their physicians’ statements. Other interviewees reported hearing or using a related expression: ‘The uterus is not something you want to keep’ (Lin, Xu, Mrs Wang, Ms Miao Young’s doctors and Ms Miao Young). Hysterectomy was considered a logical step in response to cancer fears. Not surprisingly, some women demanded hysterectomies from their physicians out of fear. For example, Ms Miao (b. 1952), who worked at a textile factory, after giving birth to three children, feared getting pregnant again. She had had two abortions by the age of 30. If it was fear of unwanted pregnancy alone, a tubal ligation would have sufficed. But she was also troubled by the volume of her leucorrhoea, which made her worry about cervical cancer. In 1982, she demanded the local gynaecologist remove her uterus, but the doctor was hesitant to do the surgery, saying ‘you are too young’. She nevertheless persisted and eventually convinced him to do it. She had heard from her fellow women workers that having too much whites was a sign of cancer. While she did not see working in a factory as a hardship, she certainly did not want to have any more children or get cancer. Dr Yi-Hung Zhan (Yi-Hong Zhan) writes about a 23-year-old woman who similarly requested hysterectomy to avoid ‘houhuan’ (future troubles), and another 39-year-old woman who, troubled by leucorrhoea and fearing that it might be cancer, also made the request. He cautioned that, even though the surgery was relatively safe, there were potential side-effects, such as infection and damage to the bladder and urethra. 135 More often than not, newspaper advice columns promoted the risk posed by the uterus and of not having a hysterectomy, and the sources of information were often from the US and, to a lesser degree, Japan, both of which carried some degree of imperial/social authority. The following, attributed to the American Cancer Society and appearing in translation, is just one example, in which every organ in a woman’s reproductive system was depicted as potentially lethal. ‘If a woman has had total hysterectomy (including uterus and cervix), of course, she will be free from the danger, but if the hysterectomy is not total, she will still have the risk of cervical cancer. Likewise, if the ovaries are not removed, they might become the prime source of disaster’. 136 Another example, also a translation into Chinese from an American source: ‘According to Dr Lu Ka Si, a woman over 40 when facing hysterectomy should also remove her ovaries to prevent uterine and ovarian cancers…Therefore, Dr Lu Ka Si recommends that all women older than 40 should remove their ovaries’. 137 It is in this context of heightened sense of cancer risk that the notion of a pathological uterus emerged. 138 The pathologisation of the uterus was a critical element in the transformation of hysterectomy from a treatment to a prophylaxis. It is difficult to get an exact picture of the extent to which the practice of hysterectomy increased, since comprehensive data for medical procedures were not available before the implementation of National Health Insurance in 1995. However, we may extrapolate from statistics of particular groups of the population, mainly those who were enrolled in Government Employees’ Insurance (since 1958), since it paid cash benefits for loss of fertility. 139 According to Statistical Data for Government Employees’ Insurance (GEI), the number of claims for ‘loss of fertility function’ for women steadily increased from 3 in 1960 to 514 in 1990, the cumulative number being 6,233. 140 Moreover, since the mid-1960s, removal of the uterus was at the top of the list for ‘disability’ cases, and by 1990 it had reached 71.8% (514 cases) of all cases in the Loss of Fertility category. 141 In contrast, the number for men under the same category remained constant over the years, the cumulative number reaching a mere 65 ( Figure 1 ). 142 Since its implementation in 1950, Labour Insurance has also provided cash benefits if one becomes canfei (handicapped, disabled), including loss of fertility. 143 There are, however, no data specifically on the loss of fertility in the category of ‘Disability Benefit’. Even though the population of public employees was relatively small, its status as a stable middle-class group can be said to make it representative of a large portion of the rapidly economically developing society’s population. Figure 1 Source: Central Trust of China [Taiwan], Statistical Data for Government Employees’ Insurance Republic of China, (1991): 226–227. ‘If a woman has had total hysterectomy (including uterus and cervix), of course, she will be free from the danger, but if the hysterectomy is not total, she will still have the risk of cervical cancer. Likewise, if the ovaries are not removed, they might become the prime source of disaster’. 136 ‘According to Dr Lu Ka Si, a woman over 40 when facing hysterectomy should also remove her ovaries to prevent uterine and ovarian cancers…Therefore, Dr Lu Ka Si recommends that all women older than 40 should remove their ovaries’. 137 Source: Central Trust of China [Taiwan], Statistical Data for Government Employees’ Insurance Republic of China, (1991): 226–227. Although dissenting voices within Taiwan’s ob/gyn profession were rare, public controversies over hysterectomy and other surgeries resulted in broader critiques of the medical profession. A few popular essays, appearing in translation, warned women not to accept hysterectomy too easily. For example, a translated essay from the American women’s magazine McCall’s, written by a Dr William A. Kolem, 144 suggested that seeing the uterus as a dispensable organ and cutting it without much consideration was an extremely arbitrary decision. One of the few ob/gyns who voiced a moderately different opinion in Taiwan was the prominent ob/gyn, Xiang-Da Wu, who was also one of the translators of the feminist classic, Our Bodies Ourselves. Wu was weary of his fellow ob/gyns, who were acting like the surgeons who had made cutting open the stomach a ‘trend’; hysterectomy had become ‘known by all ages’, he lamented. He listed 10 indications for hysterectomy, and he particularly focused on myoma, as it was the most common indication for hysterectomies. He explained, one might consider hysterectomy only if the myoma was growing on the muscle of the uterus and extended into the inside of the uterus, as big as a 12-week foetus, causing aches, and bleeding after menopause. 145 In professional writings, Wu’s position against unnecessary hysterectomy was more explicit. In a co-authored article on hysterectomy, noting its popularity, Wu and his colleagues concluded that ‘it is not reasonable to do hysterectomy in order to sterilise, prevent cancer, or avoid symptoms of menopause’. 146 The fact that hysterectomy, along with other surgeries, had become so common no doubt also raised suspicions over surgical abuse. A 1977 newspaper article about unnecessary surgeries indicated that stomach, thyroid and uterus were the most frequently removed organs. 147 An ob/gyn, Dr Zu-Miao Zhao, went so far as to publish two books entitled Choulou de Yisheng  (The Ugly Doctors), which exposed numerous forms of medical misconduct. 148 Bo Yang (1920–2008), a well-known writer and cultural critic, sarcastically suggested that a Kangzai Weiyuanhui (Resisting Butchery Council) be established in order to curb such a trend. 149 Yet, the notion of the veteran uterus as useless and pathological persisted up to the end of the twentieth century. Nuquan Hui’s (Taiwan Association for the Promotion of Women’s Rights) Women’s Health Support Service Phone Line reported receiving 1 021 phone calls in the period between October 1998 and July 1999, and they found that nearly 90% of the women who went to the doctor because of myoma had been encouraged to have hysterectomy. The reasons given by the doctors were: ‘You are not going to have any more children anyway’, ‘It will save you a lot of trouble in the future’, and, ‘It’s cancer prevention’. Some of the doctors even recommended the removal of the ovaries altogether as a prevention measure. 150

As a justification for preventive measures to combat unwanted situations, the notion of yilao yongyi (one effort, once and for all) was first attached to appendectomy, tubal ligation, and, eventually, to hysterectomy in a historical process of making the uterus useless and pathological. Even though limiting births and dreading cancer were not new for post-colonial Taiwan, the response had its roots in surgical prowess that dated back to the Japanese colonial period and flourished in the American-dominated family planning and cancer prevention. The three forces formed a powerful push towards a more rational technological control of reproduction and disease. Yilao yongyi was a history of various competing yet connecting birth control methods, as in the case of Lippes Loop and tubal ligation. Even though the Loop was heavily promoted by the United States, the later, a surgery that was already mature locally, came to be the yilao yongyi method. Women would be rid of any further work after tubal ligation. Yet, tubal ligation was not the right method if one also wanted to be yilao yongyi with cervical cancer; hysterectomy served the dual purposes of birth control and cancer prevention. The uterus, an organ that can breed lives and grow cancer, became the target to be removed. Hysterectomy was carried out as a prophylactic strike for women who were thought in need of birth control and cancer prevention. The discourse of wuyong ‘useless and pathological’ uterus and various associated practices were a form of bio-power at work, and it involved women, surgeons, public health nurses and the state. However, in a society where women took on the sole burden of birth control, the different actors did not share the stakes equally. If women wanted to retire from maternal social duty and they could find no satisfactory birth control method, the idea that they might be better off without a uterus was appealing. One wonders what would have happened if women had not had to take on the main burden of birth control, the project of family planning had devoted more attention to male methods, and the medical professions had been less surgery-oriented. Would the uterus still have been at the centre of family planning or cancer risk discourse? Without the cultivation of a rational reproductive mindset, as seen in the notion of technocratic ‘planning’, the uterus as useless would have been incomprehensible. Moreover, without the cultivation of a visceral sense of cancer risk, many women would not have gone to local ob/gyn clinics and the uterus would not have become a prime suspect of cancer (as opposed to being an interconnected part of the body). All of the behaviours and conditions of the uterus, including bleeding, excreting, eroding and developing myoma, were made into components of the pathologisation of the uterus. In the cancer prevention discourse, early detection and treatment necessitated regular surveillance of their bodies, and women’s aversion to gynaecological exams, combined with the fear of cancer, further rendered the uterus a problem. In Taiwan, the history of reproductive technologies and the history of cervical cancer crossed at the nexus of hysterectomy, a practice that went from being a treatment for cervical cancer and obstetrical emergencies to a birth control method and routine prophylactic measure. The timing of action was moved to a very early point in life – that is, when the woman had had ‘enough’ children – as early detection came to be deemed inadequate in the face of heightened risk perceptions or unacceptable surveillance measures. 151 The uterus itself was the risk, giving but also taking life. In short, women were advised to be on guard for their life as soon as they had brought ‘enough’ lives into the world, and to seek convenience by seemingly rational, techno-scientific means. Thus, the history of the uterus being wuyong is also the history of how yilao yongyi became desirable and hysterectomy became a reasonable solution. Yilao yongyi (one effort, once and for all) gradually adhered to hysterectomy as a convenient and rational response to having a supposedly useless and pathological organ, authorised by biomedical authority, popular health discourses and women’s testimonials. This paper not only adds to the current literature of bio-politics in East Asian context, but by bringing the history of the useless and pathological uterus into the story, it also answers Warwick Anderson’s call to pay more attention to the ‘more intimate and private parts of public health’. 152 The uterus was a woman’s private body part, but it was also at the nexus of colonial surgical legacy, American dominance and local medical culture. Scholars have questioned the common assumption that biomedicine has been an unproblematic force for women’s liberation. 153 Indeed, the construction of the useless and pathological uterus was armed with the rhetoric of progress and liberation; medicine’s progress was meant to bring liberation for women from unwanted pregnancies and cancer. Nevertheless, the history of wuyong is a case of the bio-politics of population and disease control that shaped anatomo-politics by singling out the uterus as an organ that could be removed to manage risk. The isolated uterus is very different from the view from Chinese medicine, in which the uterus is intimately connected with other internal organs (and the removal would disconnect the flow of the qi ). It is striking that the ways in which Taiwanese obstetrician/gynaecologists portrayed the uterus were very similar to their American and Japanese counterparts’ depictions of a useless, dangerous and troublesome organ. No substantive research is yet available on how such a notion or practice has travelled globally. However, from the fact that ob/gyns in the second half of the twentieth century in Taiwan actively promoted the ‘useless and pathological uterus’ in ways socio-culturally significant in Taiwan while engaging in international medical networks, 154 we can glimpse how medical practice and knowledge circulated globally and, at the same time, developed local variations.