In response to the rapidly growing base of knowledge about women's health, several general textbooks have been published. These texts address important questions that have been raised in women's health. In this paper, we discuss three of these questions: 1) How do we define "women's health" when only reproductive and gynecologic issues are unique to women? 2) What do women want? Women receive more health services than men-why is there an outcry about health care for women? 3) Why focus on women's health? Men die at a younger age than women, and women's advantage in longevity has remained the same for decades.

How Do We Define Women's Health?

The definition of "women's health" has engendered a powerful and evolving debate. All of the texts discussed in this article (Table 1) struggle with how to define this issue. Some of the earlier texts rely on traditional criteria that were developed in the 1980s; that is, they discuss health problems that manifest or respond differently in women than in men or occur more commonly or exclusively in women. As a result, these texts [2-4] emphasize reproductive issues, including general gynecology, gynecologic surgery, conception, and pregnancy.

In contrast, Leppert and Howard, in Primary Care for Women, use World Health Organization criteria to define women's health as complete physical, mental, and social well-being [6]. They discuss the far-reaching implications of this definition, including the importance of social and economic resources, multiple disciplines, and the diminished value that the world places on women's lives. The book states that "Women's health is related to far more than health during childbirth and means more than the absence of gynecologic disease. Women's health encompasses the total well-being of each individual woman" [6].

One issue in defining women's health concerns the "women" part of the definition. Most earlier texts do not address health care for diverse populations of women. This omission is important because health status and mortality rates vary markedly by ethnicity and socioeconomic status. In addition, the number of women who live in poverty or are single parents and the number of elderly women who live alone and have few economic resources have increased dramatically. Perhaps as evidence of the evolving sophistication of the field of women's health, only the most recent texts have devoted substantial effort to exploring the importance of economic and cultural factors to the health status of women. These issues are best developed in Textbook of Women's Health [7], which discusses not only specific ethnic groups but also the health needs of women with disabilities, homeless women, and lesbians.

The definition of women's health is also reflected in how the editors of these texts create themes or organize chapters. For example, in Textbook of Women's Health [7], the traditional discipline-based approach to medicine is criticized. The book presents an alternative framework that organizes knowledge by life phases (for example, adolescence, the young adult years, perimenopause, menopause, and advancing age). However, applying this life-phase framework to discussions of major system-related health problems can be difficult because diseases that occur at specific ages may be rooted in causes that developed years before.

Another definitional issue emerges when the content of individual chapters is examined. Some chapter authors provide general health information that may be based on studies of men, and others go to great lengths to provide sex-specific information. For example, in one text, a discussion of the differential diagnosis of genital lesions includes "pearly penile papules" [6]. In contrast, in Primary Care of Women (edited by Carlson and colleagues [3]), a chapter on gastrointestinal disorders discusses the effect of the menstrual cycle and hormonal influences on gastrointestinal function and the association of sexual abuse with chronic abdominal pain.

What Do Women Want?

Women receive more health services than men, but national surveys have documented that women are less satisfied with their health care [8]. Thus, another fundamental issue in women's health is the quality and delivery of health services for women. Although many of the concerns raised by women affect all persons, women have been most vocal in criticizing certain issues, such as fragmentation of care, overspecialization, medicalization of natural processes, and issues of gender in physician-patient communication.

As Textbook of Women's Health [7] states,

"Women are referred back and forth among gynecologists, internists, family practitioners, and various other specialties. A woman seldom receives thorough, comprehensive health care. Men are not referred to a urologist for a genital examination, whereas a woman must go to another specialist for a routine pelvic exam."

Fragmented care is a primary reason for creating women's health texts, and all of the texts synthesize knowledge from multiple disciplines to improve the integration of women's health care. None of the texts advocates a separate specialty for women, but all emphasize that integrated, multidisciplinary approaches should be developed.

Another important theme in women's health is overspecialization. Most of the texts argue that the rapid proliferation of scientific knowledge and technology has caused many physicians to narrow their focus and subspecialize, losing sight of the comprehensive health needs of women by concentrating on a particular disease process. Women's health texts emphasize holistic care, wellness, and preventive approaches. A very useful chapter in Primary Care for Women [6] summarizes the age- and risk-appropriate screening and immunization guidelines that are recommended by national organizations.

A second issue related to overspecialization is the questioning of the emphasis on biomedical approaches to health care. As Primary Care of Women states, "The complexities of a woman's biologic, emotional, and social functioning cannot easily be reduced to the organ-system approach of traditional medical education and practice" [3]. Anne Kasper notes that as we work from the vantage point of women, we will learn that health and illness are as much the result of social, cultural, political, and economic influences as they are of DNA and microorganisms [7]. Thus, all the texts argue for an inclusive approach to women's health that recognizes the importance of emotional and social circumstances.

Finally, women frequently report that physicians "talk down" to them and do not take their concerns seriously [9, 10]. Despite the widespread perception of the importance of physician-patient communication to women, only Textbook of Women's Health [7] addresses the issue extensively. Several chapters summarize our knowledge of patient satisfaction, physician behavior, and cultural and societal influences on communication. The philosophical basis for the section is a model of shared decision making and partnership in health.

Why Women's Health Books?

Several reasons why women's health textbooks are needed emerge from the texts. Women face a higher prevalence of disability and chronic illnesses than men; thus, our approach to health care must shift from the acute management of life-threatening disorders to a deeper understanding of and a better ability to cope with chronic, disabling conditions. We are in the midst of an information explosion, and women's health texts must codify this information so that new knowledge can be incorporated into the training of health professionals and the everyday health care of women. Because past clinical research studied mostly men, tremendous gaps remain in our knowledge. By documenting what is and is not known about women's health, these texts help focus on these gaps and define directions for future research and education efforts. The emergence of these texts also represents the natural evolution of a new field. New issues are often identified through editorials or discussion, are investigated in individual studies, and, finally, are consolidated into textbooks. What is apparent from examining women's health textbooks over time is the way in which they help to define the clinical field and the body of knowledge on which it is built.

Conclusion

Top Conclusion Author & Article Info References

Although women's health textbooks emphasize several common messages and may seem similar at first glance, they differ substantially. How can internists select among them? The first three texts, published in 1995 [2-4], are the most useful for learning more about office-based gynecology and medical management of pregnancy. Primary Care of Women (edited by Lemcke and colleagues [5]) provides a concise synthesis of sex-specific information and is definitely worth a quick read, although its coverage of medical problems is too superficial to serve as a comprehensive reference. In contrast, Primary Care for Women [6] is comprehensive and could serve as a general primary care text because most chapters provide general, rather than sex-specific, information. Textbook of Women's Health [7] is the best choice for a comprehensive clinical text that would be useful to both primary care providers and specialists.

These recently published textbooks reflect a rapid evolution in our understanding of and approach to caring for women. This evolution is evident not only in the explosion of knowledge but also in the shifts in paradigms that are advocated. The earliest textbooks focused primarily on integrated, multidisciplinary care and emphasized prevention. Subsequent textbooks built on those precepts and expanded the focus to incorporate cultural, social, and economic issues. These later textbooks raise fundamental questions about models of scientific inquiry and health care that are not specific to women's health, such as, What constitutes and contributes to health and illness? As Anne Kasper states in Textbook of Women's Health, "we need research that addresses how classism, racism, sexism, heterosexism, disability, prejudice, violence, and poverty precede, contribute to, and haunt the health and illness of all women" [7]. Perhaps the most important contribution these textbooks will make, aside from synthesizing newly emerging information on women's health, is the insistence that our definition of health and our delivery of health care must be continually examined in the context of the lives of our patients.

Dr. Battistini: University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104.

Ms. Ryan: 2209 Mt. Vernon Street, #3, Philadelphia, PA 19130.