A Literary Analysis of Global Female Identify, Health, and Equity

Introduction

Globally, women’s health is a key indicator of a country’s social and economic strength.¹ Internationally, men experience higher rates of mortality and lower life expectancy, though women experience more poor health.² Biological determinants of health explain some variation, but social determinants of health also play a compelling role. Gender is considered a set of socially constructed characteristics that dictate what roles, behaviors, and attributes are appropriate for men and women. Gender is known to impact how health care is accessed, utilized, and supported. A World Health Organization (WHO) study of 228,882 individuals within 57 countries demonstrated that social determinants differentially impact the health of men and women with women having lower self-reported health across all age groups.³

Health equality and equity are key markers of a population’s ability to prevent and manage health problems. Whereas equality measures disparities in health, equity refers to the normative value associated with that disparity. Braveman and Gruskin defined health equity as the absence of systematic disparities in health between social groups who have different levels of underlying social advantage.⁴ Social advantage is determined by the distribution of power, wealth, or influence within a society and how these serve to empower or disempower social groups. These systematic factors are products of cultural norms, political movements, and historical memories that make health equity difficult to operationalize within traditional research measurements.

To date, measures of global gender health equity have relied on static measures rather than the dynamic determinants known to exist within socio-cultural systems. Shannon et al. measured the relationship between women’s health and average education, waged employment, and government participation in order to evaluate progress toward Millennium Development Goal Three in Southeast Asia.⁵ Such indicators only provide snapshots into the realities of females’ lives. In order to capture the socio-cultural processes and structures that shape women’s lives, a more contextual understanding should be sought.^6,7

By capturing the systemic and societal factors that create a social disadvantage for women, we can understand the conditions for violence against women to occur. Gender-based violence, defined as physical, economic, political, and social harm^{8 (p27)}, impacts the economic development, health care, and well-being of women gloablly.⁹ Without clearly describing and naming the contextual, intricate, and multitude of ways in which inequity and violence impact women’s health, we are unable to fully understand their impact of individual lives of women.

Novels are a useful source for uncovering historical and imagined social realities. Beyond mere entertainment, novels provide keen insight into the stories we create about ourselves, revealing our shared narratives and creating our cultures. They employ vivid, descriptive tales of our identities, values, and beliefs through the use of characters and plot lines. As stylized versions of reality, novels magnify cultural trends and provide a platform for social commentary and critique not possible through other literary mediums.

By using novels as data sources, we can re-discover our social and personal realities in ways that traditional research cannot capture. Whereas typical research aims to control variables and seek causal relationships between them, novels provide ethnographic texture and expressive possibilities to how and why females experience health inequities and violence. Not only are the characters’ personalities and plot events open for interpretation and analysis as in typical qualitative research, but so are the interactions between characters, contextual time periods and structures, and cultural norms and institutions.

In this paper, we conduct a narrative analysis to compare themes of gender and health equity across four acclaimed fiction novels. An interpretive analysis approach of these narratives uncovers the similar and dissimilar themes of female identity-making across the novels and how this influences the conditions for health promotion and treatment. Across time and culture, females’ experiences of living in someone else’s world and endeavoring to create a separate place reveal common themes of captivation and emancipation. We conclude that parallel gendered experiences of prescribed and proscribed feminine roles elicit women the world-over to assert their identities and empower themselves to manage their health.

This analysis’ integration and expansion of knowledge concerning global themes of health equity enhances nursing’s potential to recognize the personal impact of violence against women, support women’s decision making regarding their health, and question the structural barriers to women’s access to healthcare. By recognizing the co-occurring social context of women’s health along with the social isolation experienced by women, these narratives illustrate how women’s health requires societal commitment to female empowerment.

Purpose

The purpose of this analysis is to describe the narratives of women from four novels in order to uncover themes of feminine identity and health equity. Protagonists’ life histories provide intimate and intricate insight into the multi-faceted ways in which violence against women impacts women’s the daily lives. These narratives will be compared across protagonists, cultures, and political systems in order to add to nursing’s understanding of common themes of global women’s health.

Methodology

Narrative analysis uses the novel as a cultural and psychological artifact illustrating individuals’ stories for a public audience. This methodology was selected for its convenient and profound insight into a variety of time periods and cultures. Unlike traditional qualitative narrative analysis research, the novel follows how a protagonist relates to variety of other characters, cultural norms, quotidian life, historical events, and political institutions. Women’s life accounts can be studied within their socio-ecological context and compared across accounts. The literary anthropologist Poyatos notes that these literary narratives are taken as “tools…[which] constitute without doubt the richest source of documentation about human life styles and the most advanced form of one’s projection in time and space and of communicating with contemporary and future generations.”^{10 (p4)} In this way, novels are not merely a piece of art without a connection to reality, but a fusion of forms constituting “the ‘poetization’ of the functional description and the ‘functionalization’ of the poetic…a truly artistic form of realism.” ^{10 (p5-6)} If science is a form of creation and therefore art, then art may likewise be taken as a form of science.

Four novels were selected that represent a variety of ethnicities, time periods, ages, and social classes in which women have resided. Each contained a female protagonist whose life history was explained through the course of the novel. 1) The Handmaid’s Tale¹¹ by Margaret Atwood portrays a totalitarian, theocratic regime that overtakes the United States and relegates women into subordinate positions used solely to support the male hierarchy. 2) The House on Mango Street¹² by Sandra Cisneros follows the immigrant teenager Esperanza in 1950s Chicago as she experiences the transition from reliance and obliviousness into independence and strength. 3) Snow Flower and the Secret Fan¹³ by Lisa See follows the journey of Snow Flower, a poor girl who marries into Chinese aristocracy during the Taiping Revolution and her relationship with a less-fortunate friend. 4) Woman at Point Zero¹⁴ by Nawal El Saadawi is a novel based on conversation with an Egyptian woman on death row after a lifetime of continual abuse, subjugation and disrespect.

Selections were purposefully made based on the variety of narratives and cultures represented and the critical acclaim of each novel in order to ensure a variety of quality female narratives. Table 1 summarizes the four novel’s protagonists, ethnicities, time periods, and social statuses.

Table 1.

Description of Four Novels and Protagonists

Novel	Genre	Protagonist	Ethnicity	Time Period	Age	Social Status
1. The Handmaid’s Tale	Science fiction	Offred	Republic of Gilead (formerly United States)	Near future	Mid-30s	Gilead: Handmaid United States: Middle class, mother, divorced and remarried
2. The House on Mango Street	Novella	Esperanza	Mexican American	Mid 20th century	Teenager	Poor, working class immigrant in inner-city Chicago
3. Snow Flower and the Secret Fan	Novel	Lily	Chinese	19th Century	Lifespan: childhood through elderly	Rural, farming class
4. Woman at Point Zero	Creative non-fiction	Firdaus	Egyptian	Mid 20th century	Lifespan: childhood through execution	Poverty; prostitution

This analysis deliberately considers each novel through a feminist lens. Women’s narratives were read as packaged stories that report and embellish the realities as lived by women in the context of their social and political realities. Feminists recognize gender as a constructed phenomenon with origins in material realities with consequences in the physical and psychological domains. The authors of all four novels define and deconstruct these realities through the stories they illustrate. No author ostensibly writes from a critical feminist perspective and this analysis does not attempt a feminist literary critique of the novels, however the novels’ shared themes of emancipation of the feminine from underneath the masculine provide the data to be analyzed.

The co-authors read each novel separately and summarized the themes based on their personal interpretation. Then the co-authors compared their individual analyses and came to consensus on each novel’s shared themes of gender, health, and inequity. After each novel was read and themes agreed upon, these themes were sequentially compared to the themes of the other novels. This process is similar to a content analysis of qualitative interviews in which common themes across participant interviews are collectively described and summarized.

This paper reports the universal themes present in each of the four narratives, and incorporates differences where appropriate to highlight distinctions between narratives. While the emphasis of the analysis was to uncover the processes by which female protagonists addressed their specific injustices, consideration of how social determinants of health within and across novels is also described.

Analysis

Within each novel protagonists experienced a different sort of inequity and violence and therefore responded with varying forms of rebellion or submission. Each female had distinct profiles based on social determinants. We summarized the WHO’s list of social determinants of health¹⁵ in Table 2 along with how each protagonist rates for each variable. Offred, trapped in a patriarchal regime, uses subversion and rebellion as a means of self-assertion without ever having an opportunity to affirm her will or needs on those in control of the Republic of Gilead. Esperaza, perhaps the most emancipated of the protagonists, is a teenager by the end of the novella and dreams of owning her own peaceful, hospitable house away from the crime and victimization of women she currently sees. Snow Flower, herself escaping the illness and harshness of poverty through a fortuitous marriage, betrays those closest to her and in so doing exposes them to social isolation and the depravity and illness of poverty. Firdaus attempted desperately to escape the male-dominated Egyptian culture, but failed at both peaceful and violent attempts to assert her own agency.

Table 2.

Social Determinants of Health Related to the Four Novels’ Protagonists

	Protagonist and Novel
Social Determinant of Health	Offred The Handmaid’s Tale	Esperanza The House on Mango Street	Lily Snow Flower and the Secret Fan	Firdaus Woman at Point Zero
Social & Economic Environment
1. Low socio-economic status	Women owned by males	Described as poor, though not deprived	Becomes wealthy through marriage	Poor after running away from family; becomes a prostitute to make money
2. Relative deprivation	Women restrained to six social roles	Less wealthy as non-immigrant classmates at school	Transitions from position of poverty to power through marriage	Less wealthy than peers throughout life, save for employment as a prostitute
3. Social exclusion	Women not allowed to talk with each other	Social relationships limited to family members and friends	As child, socialized within family; as adult, socialized within in-law’s family and entourage	Few female or male friends; people she assumes are friends use her
Physical Environment
4. Restriction of movement	Not allowed out of house for risk of being caught and executed	Chaperoned by male siblings	Forced to stay within family compound; foot-binding ritual	Ran away from uncle to keep from being slave to men
5. Access to resources	Not allowed to own anything; provided limited, bare essentials by male leaders	Family is poor, but dreams of owning house	Females own very few items, but are gifted material items to show beauty and class	Extremely limited access to material goods; must have male family members, bosses, or clients to provide for her
6. Safe communities	No safety; constantly in danger from violence with man who owns her and anyone else who sees or hears her	Neighborhood in Chicago is friendly, but gang violence and family violence exists	Safe, save for Taipei Revolution forcing family to journey to safety	No safe place to go; always feels other peoples’ eyes staring at her; feels safest in prison
Individual Characteristics & Behaviors
7. Female gender	Yes	Yes	Yes	Yes
8. Age	Middle-aged	Pre-teen and teenager	Life narrative from childhood through adulthood	Life narrative from childhood through adulthood
9. Systemic support	No system present for recourse against inequities	Family is supportive; some school teachers and neighbors are supportive	Family support when needed, not always comforting but helpful	Abusive family members; female teacher provided limited support; female and male friendships all manipulative
10. Marital status	Separated from husband after political overhaul; having affair with male in house	Unmarried, thinking about starting to date boys but unsure they are worth it	Marries wealthy man due to physical beauty and deal-making with matchmaker	Never married; no dating with men
11. Employment status	Formerly employed, not after revolution	Works at photo store	Unemployed as adult, but caregiver to husband’s family and accountable for family, political responsibilities	Prostitute to make money until told it was disrespectful; then works in office where she is subject to sexual harassment
12. Self-reported health	Physically healthy; health is maintained by men in power so that she can bear children; tries to maintain health through natural ways	Physically healthy; noticing bodily changes of puberty Mentally health; imagines	Physically healthy; foot binding causes serious, though temporary pain Mentally stable, but realizes emotional coldness related to her friend, Snow Flower	Physically and mentally unhealthy; mother forces her to have female genital mutilation as a young girl; body is abused and is constant fear of being violated by others

The analysis across the four novels, by incorporating multiple female voices, is able to outline a collective feminine experiences, motivations, and characteristics without removing individual protagonists’ uniqueness. In this path to emancipation, females, accustomed to distrusting and silencing themselves, learn to find their voice and use it to empower themselves. Although not all females were able to achieve each step in this process, all novels traced this pathway as the ideal to be achieved in the absence of barriers.

All four novels illustrate similar trajectories of female protagonists moving from positions of disenfranchisement toward independence. First, women have the common experience of living in someone else’s world as second-class citizens. Their relationships with men, themselves, and other women reinforce the belief that women are weak and dependent on male dominance. This dialect of female confinement in male-dominated society creates the conditions for structural and direct violence against women. Secondly, female protagonists rebel against their inferior social position by creating a separate space in which they can live away from the direct gender subjugation. Finally, females claim their personal identities and independence through direct rejection of social norms and reclamation of their self-worth. The shared female empowerment trajectory reveals a shared pathway to reject the social and cultural conditions of violence against women and create the necessary conditions to improve female physical and psychological health globally.

A) Living in someone else’s world

The four female protagonists all describe environments in which females are outsiders. Social norms dictate that women’s roles are always in deference to male’s needs. Thus, the cultural contract in which the protagonists are expected to enroll provides them little freedom beyond that which is approved by their male counterparts. Lily in Snow Flower and the Secret Fan is taught the following idiom to becoming a proper woman: “When a girl, obey your father; when a wife, obey your husband; when a widow, obey your son.”^{13 (p24)} Esperanza in The House on Mango Street recognizes that “The boys and the girls live in separate worlds.”^{12 (p8)} These worlds, though separate, depict women as possessions of men with limited control or autonomy. Some women on Esperanza’s street are confined to their apartments, instructed by their husbands to avoid the lust of other men and danger in the street. By separating the women from the masculine dangers of the neighborhood (whether real or imagined), women were stripped of the social outlet by which they could find friendship and community.

Female separation is not always so directly visible. Systems of social regulations maintain female inferiority by either tacitly enforcing or outwardly legislating prohibitions on female rights to education, employment, or independence. Firdaus lives in the most restrictive environment, and even though she has access to grade school and jobs, her uncle prohibits her from advancing to higher levels of schooling in order to work at home and her employers sexually harass her.

Cultural norms create pervasive, lingering aggression against females by which females are subjected to psychological and physical abuse. Such subtle violence is what subjects Firdaus in Woman at Point Zero to the constant threat of eyes watching her on the street and objectifying her.^{14 (p43)} While each novel’s cultures have separate methods by which gender inequality is enforced and carried down across generations, all four cultures uphold male dominance over females. Violence, therefore, is a direct result of the purposeful separation of sexes which leads to division in females’ relationships both with men, themselves, and other women. Each of these relationships will be analyzed to demonstrate how the position of women as outsiders in society underlies the gender disparities and health concerns that result from violence against women.

Relationships with men

If the four women describe themselves as living in someone else’s world, then men are the rulers of the world. Within this dynamic, women’s relationships with men are defined by the cultural rules designed to maintain the social order of male dominance. These relationships demonstrate power imbalances, oppression, and sexual domination.

Male dominance is most clearly and disturbingly demonstrated within the 1970s Egyptian legal and social exploitation of women in Woman at Point Zero. Firdaus’ relationships with men are solely based on dominance and sexual exploitation. Every man in her life makes sexual demands of her, from her uncle, boyfriends, and employers. The only occupation that offers her a degree of comfort through the form of material goods is when she begins prostituting herself. Ironically, the more she objectifies herself by increasing her prices, the more she gains the attention from men and social status she wants. Slowly she realizes that her power is an illusion as her pimp always has ultimate control over her.

Esperanza, growing up in poverty with her Mexican immigrant family in 1950’s Chicago, witnesses other women trapped in their homes, dominated by their husbands. She realizes that males can be manipulated with lipstick and high heels, but that seduction produces a perverse relationship that will only lead to more objectification. Her only male relationship demonstrates her overpowering of this unequal relationship. After catching a neighborhood boy staring at her, she notes that, “I had to prove to me I wasn’t scared of nobody’s eyes, not even his. I had to look back hard, just once, like he was glass.”^{12 (p72)} Esperanza’s rejection of male attention mirrors her refusal to use males as a means to escape poverty.

Relationships with women

Given the marginalized status of women within each novel, the relationships protagonists have with other women reflect their mutual experiences of victimization. Only the women in The House on Mango Street, in which the least amount of outward male domination occurs, support each other through friendship and care. The more pervasive the power imbalance between men and women, the more likely women are to re-victimize each other through economic abuse (Firdaus’ madam who lures her into prostitution, Lily’s abandonment of Snow Flower after marrying into wealth, or Offred’s other classifications of women who are dressed and socialized to distance themselves from other women and inform on women disobeying the laws). After women found their own voice, however, and escaped their own victimization to a place of empowerment, they were typically able to begin reaching out to other women through social support and assistance.

Relationship with self

As the four protagonists’ relationships with men are strained by gender division and violence, their relationships with themselves also suffer from personal mistrust and alienation. Because females are tasked with maintaining the social order, and that order depends on male dominance, women doubt their own thoughts as impossible or disruptive. Lily’s 1800’s Chinese society has sophisticated traditions of female decorum, meant to train women to become upper-class women. Customs including foot-binding (frequently involving bone breaking, infection, and incapacitation), starvation, and silence may have served the dual purpose of preparing doll-like females to attract high-class arranged marriages, but also served to teach females to distrust their bodies and minds and become voiceless possessions. In an added layer of female alienation, these time-honored protocols for female socialization were brutally enforced by mothers and female relations, creating cycles of physical violence that united women in their pain and bred loathing of those same women.

Offred in the science fiction novel The Handmaid’s Tale is forced out of modern America into the male totalitarian Republic of Gilead. Assigned to the role of a concubine, Offred’s indoctrination and social isolation slowly wears on her ability to think independently. She witnesses her mind’s atrophy and descent into objectification, “I used to think of my body as an instrument…or an implement for the accomplishment of my will…. Now I’m a cloud, congealed around a central object, the shape of a pear, which is heard and more real than I am and glows red with its translucent power.”^{11 (p72)} Women’s health is controlled by Gilead’s government, and though routinely monitored for pregnancy and disease completely ignores non-reproductive aspects of women’s physical and psychological health.

Relationship with women

While living in a man’s world and feeling estranged from themselves, the female protagonists’ relationships with other women suffer. Women learn to live by the expectations the male-society demands of them mostly overseeing domestic concerns of childrearing and food preparation. These demands sometimes encourage females to collaborate to improve their status together and sometimes promote antagonism against each other.

Lily is considered blessed to be presented with a laotong (a formal, revered friendship traditional to Hunan culture) to provide her with female intimacy beyond the cold, distant relationships with their mother. Lily and Snow Flower write in a secret female language, trading messages. Yet as Lily marries one of the most powerful men of her county, she eventually abuses her laotong relationship by exposing the secrets Snow Flower shared with her, therefore ruining her reputation and cutting her off from the social support she needed to escape her abusive husband. Such aggression between females isolates Snow Flower, stripping her of the social support needed to escape her extreme financial poverty, physically abusive husband, and social ostracization.

The male leaders of the military dictatorship in the Republic of Gilead organize this system to prevent an uprising. Intricate social rules categorize females according to their ability to bear children and create inter-female competition to conceive. Strict rules whereby inter-female conversation is strictly proscribed and consequences of disobeying this are severe, women avoid each other out of fear of being exposed. Females are cut off from socializing by outlawing social contact, forcing women to wear bulky uniforms and blinding headdresses. By disconnecting women from each other, women must live and think by themselves. Offred’s thoughts degenerate into self-preservation planning and dreams of pre-Gilead life.

Violence against women by women is perhaps most clearly illustrated in Firdaus’ narrative. Firdaus attempts to cultivate female relationships but is continually betrayed. Her teacher refuses to support her and her sole female friend sells her into prostitution. From such constant rejection from the women she yearns to love and confide in, it does not seem so radical for her to enjoy the authority and financial boom she gets from managing her prostitution business.

B) Creating a separate space

The violence created by living in a man’s world spurs a desire to create a separate space in which females can freely live without the threat to their identity and health. This separate space acts as an individual hide-away, distant from the relationships that define and confine them. It is a place to explore their individuality and freedom of though and expression.

Several characters attempt to create a personal space without separating from the male dominance. These efforts, despite being deviant acts against the social norm, place women as the counter-image to the rules rather than creating new rules altogether. Rather than rejecting the system, these women reinforce the system insofar as their behavior is reactionary distancing from the role they used to play.

For example, Lily earns a separate space through a high-powered marriage but never questions the system that keeps her laotong in an abusive marriage. Lily finds her separate space after marrying a man of high social status. Marriage removes Lily from her previous conditions of poverty and the corresponding pressure to perform by her mother and female elders. She sits as the high-ranking female in her in-laws household and an influential local icon. The position of power allows her a separate space within which to act and assert authority. However, as earlier described, it also gives her the social clout she wields in rejecting Snow Flower.

Moreover, Offred finds small ways to repel against the male hegemony in Gilead and improve her overall health. To promote her own psychological strengths, she finds pleasure in swearing, seeing it as defiance against her male oppressors, “There is something powerful in the whispering of obscenities, about those in power. There’s something delightful about it, something naughty, secretive, forbidden, thrilling. It’s like a spell, of sorts. It deflates them, reduces them to the common denominator where they can be dealt.”^{11 (p222)} To promote her physical health, Offred steals butter to use as lotion for her dry, cracked skin. Though a minor gesture, the skin care ritual is a sensual experience for Offred. The luxury of personal grooming allows her to reaffirm her individuality and beauty, otherwise disallowed female sentiments.

Other female protagonists create separate spaces that directly confront their status as second class citizens. Firdaus recognizes that her mental and physical suffering are consequences of being confined by males both sexually and socially, and that her health depends on escaping the male power system. Even when she makes attempts at starting a career as a secretary, her plans are stifled by a male boss who uses her for sex. After this final denial for finding independence in a respectable manner, Firdaus refuses to partake in the role of subservient Egyptian female. Given the extreme violence present in Egypt’s social and political environment, any step away from male domination represents a rejection of social norms and immediate danger. Her fate is sealed when she is approached by a prince and refuses his solicitations. Her imprisonment and execution are her separation from society. It is also when she is most physically and emotionally healthy. While a prisoner, she is free from the demands of male domination, prompting her to proclaim herself to be the freest person is the world.^{14 (p110)}

Esperanza, even as the youngest protagonist, is determined to escape the fate of the women around her as she grows up. She stakes out a separate self based on self-empowerment: “But I have decided not to grow up tame like the others who lay their necks on the threshold waiting for the ball and chain;”^{12 (p 88)} “I have begun my own quiet war. Simple. Sure. I am one who leaves the table like a man, without putting back the chair or picking up the plate;”^{12 (p 89)} she will be beautiful and cruel; she will be powerful, and her power will be her own; “Her power is her own. She will not give it away.”^{12 (p 88-89)} She imagines for herself a house that she owns and rules. In the house, she can invite her family, friends, and social groups over under her terms. “A home in a heart”^{12 (p 64)} and she wants to share her heart with those she cares about. If Esperanza can realize this goal of escaping poverty and avoiding male domination, she will be a caretaker for others rather than depending on others.

C) Femaleness as reclaiming self

As the female protagonists attempt (even if at varying degrees of directness) to create separate spaces outside of the confines of male dominated societies they create platforms from which women can act in assertive, independent ways. This space allows them the capacity to gain or regain their own power from which they can act to decrease violence and oppression. Female agency developed as women carved their own quest toward a better future.

Firdaus’ awakening came when she realized that her being human was based on her need to love freely. Men stood in her way of this dream: “Men impose deception on women and punish them for being deceived, force them down to the lowest level and punish them for falling so low, bind them in marriage and then chastise them with menial service for life, or insults, or blows.”^{14 (p94)} To avoid this, Firdaus recognizes the hefty task ahead of her: “To find myself again, to recover the self I had lost. To become a human being who was not looked upon with scorn, or despised, but respected, and cherished and made to feel whole”.^{14 (p 93-94)} The only way Firdaus could accomplish her emancipation was through living on death row, free from her captors. She uses her agency to lock herself away from the eyes of men and dissatisfaction of women, preferring a future of death to a certain life of disconnection and pain.

Not all protagonists achieved the same momentous, deadly defiance as Firdaus’, but many found other ways of reclaiming their individual feminine identity within the context of their social order. Offred, for example, only has the separate space of her sexuality to reclaim her individuality. Within a society of tortuous female subjugation and segregation, she acts against society by engaging in passionate, physical romance with Nick and the Commander. Even if not used for sexual pleasure or expressions of love, these are acts of defiance and self-assertion against a society that condemns femininity and female choice. Likewise, Lily develops a form of feminine identity at the end of the novel as she becomes a caregiver to the dying Snow Flower. Within her sphere of domesticity, she provides comfort and benevolence after realizing she had been mistaken and wrongly ostracized the already despairing Snow Flower. She uses her newfound social status to offer recompense to her steadfastly devoted friend and so repair the friendship she destroyed. She has forgone the regimented obedience to males and begun to follow the advice of her mentor, Madame Lu: “obey, obey, obey, then do what you want.”^{13 (p 157)} While neither Offred nor Lily are willing or capable of rejecting the restraints of their societies, both find ways to express their personal, feminine identities either as acts of rebelliousness against society or as a reclamation of female friendships.

Discussion

We traced the movement of female protagonists from four international novels from living in a male-dominated world into a separate space, and finally toward a reclamation of self. Esperanza plans for her house not just as a means of escaping the dual insult of poverty and objectification, but also as a location where she can invite her friends and family to convene. In the narratives where women are physically or politically constrained in their liberation attempts, they can imagine the connections and networks they desire. Offred resists the brainwashing of male Gilead totalitarianism not for her own survival but in a desperate search for news of her daughter and for her pre-Gilead college friend, Moira. Even Firdaus, having survived female genital mutilation, her parents’ deaths, and life as a prostitute, she identifies her lowest point when she is told she is not respectable. Respectability meant she would be able to form relationships and be a member of society, a comfort that escaped her throughout her life and leads to her shunning the company of others once she is imprisoned.

The multiplicity of milieus in which women exist creates unique circumstances for women, yet the process of emancipation remains the same. Each protagonist experiences most of the WHO’s list of social determinants of health, each with a unique range of factors determined by the immediate time and space within which she lives. Her constellation of social determinants of health shapes how society treats her, and how in turn she must fight for her emancipation. For example, Firdaus’ male-dominated Egyptian culture was similar to Offred’s dystopian Republic of Gilead in their relative female inequities and violence toward women, yet both experienced different threats to their health and wellness. Of primary concern, however, is that both Firdaus and Offred (as well as the other protagonists) must overcome the same process to mitigate the inequities and violence imposed on them by their worlds before carving out their own space.

The narratives correspond with female development theory in which females mature in connection with other others. Compared to masculine narratives of development through separation of self from others, most of the female protagonists gain power by nurturing intimate relationships and social connection. Carol Gilligan asserts that “if aggression is tied, as women perceive, to the fracture of human connection, then the activities of care, as their fantasies suggest, are the activities that make the social world safe, by avoiding isolation and preventing aggression rather than by seeking rules to limit its extent.”^{16 (p43)} Furthermore, Chinn¹⁷ defines power as a “feminist ideal” in which what is valued is the capacity to be in harmony with others. Similarly, empowerment is “growth of personal strength, power, and ability to enact one’s own will and love for self in the context of love and respect for others.” ^17(p8) Therefore, the protagonists attempt to build connections with others as a way of bridging the separation of male-dominated societies and concurrently support their personal health.

Feminist theories including self-in-relation theory and ethic-of-care theory specify female’s need for connection during every stage of development, and so directly influence their choices and feelings about their health. Jean Baker Miller¹⁸ noted that female identity rested on female’s ability to become oneself (“authenticity”) and re-envision themselves and the world around them (“creativity”). She states that “when women begin to perceive forms of strength based on their own life experiences, rather than believing they should have the qualities they attribute to men, they often find new sources of strength.”^{18 (p36)} Miller goes on to spotlight the patient-advocate system as an exemplar of how women find strength through weakness. Female patients are able to confront fearful and disempowering experiences within the healthcare system by asking an advocate for help, admitting their weaknesses, and in so doing identify their needs.

The present analysis provides a fresh perspective by describing the different structural and immediate social environments contributing the gender health inequities and then proposing a process by which women overcome such injustices. While these results were not written to inform policy or practice, they do point to the need for novel methods of assessing health inequities and demonstrate the ability for literature and other sociological artifacts to be used in understanding how social determinants of health occur in contextualized, complicated settings.

Policy Implications

Growing attention to gender inequalities has spurred gender health equity into the forefront of policy and action. The Millennium Development Goal Three specifies that gender equity and female empowerment are key methods of improving the well-being and strength of a nation. The WHO’s Commission on Social Determinants of Health argues that the first two steps in addressing the root causes of health inequities is first knowing the socioeconomic context and position and secondly understanding the immediate social and physical environment of a group are.¹⁹ As seen in the social experiences of the four protagonists in this analysis, both the social determinants of health (Table 2) and the descriptive analysis of the process the women underwent was necessary to understand the inter-relationship with health, equity, and violence. Prevention and treatment of health concerns experienced by women depends on the ability to decontextualize gender as a contributing factor to differences in individual and group factors affecting women’s ability to be healthy. Current methods of assessing the effects of equity on health status are weak, using socioeconomic status and national incomes as proxies for equity instead of true measures of (un)fairness of the distribution of health resources by social groups.²⁰ Moreover, public health interventions to improve gender health equity do not always incorporate the socio-political context in which their target population exists, and may serve to reinforce rather than ameliorate health inequalities and inequities.^21,22

Incorporating all determinants of health equity, therefore, must be done to address the root of both gender and health inequities. By recognizing gender differences in social determinants of health, individual behaviors, cultural norms, and social policies within a given society, health inequities can be labeled and addressed. Until gender is recognized as a determinant of health both created and reinforced by both biology and culture, research and practice will continue to confuse gender as a static trait rather than a dynamic process.

Practice Implications

This analysis has implications for how health care practice can enhance known ways in which females experience connectivity and agency in their lives. These narratives reinforce current recognition of the gendered system of healthcare and calls to adopt more female-centric forms of health promotion and disease management.^23-25 A recent commentary by Phillips noted that medical research tends to decontextualize and homogenize gender, labeling it either as an individual trait or a group characteristic while ignoring the role of gender-related structural biases and inequities that can either undermine or reinforce health.⁶ Many of appeals to address gender inequity emphasize the need for self-healing in relation with others emphasized in the novels. Group formats, community education, buddy systems, peer role models can all be effective ways to validate women’s ways of knowing and promoting female health interventions to mirror the ways females are empowered.^26-29 Social support networks provide women with health information and networks of support, especially concerning sensitive concerns.³⁰

Linda Andrist³¹ proposed a model of feminist model of healthcare in which women could transform traditional power dynamics to maintain their strength. The model includes four central principles: symmetry in patient-provider interactions, access to information, shared decision-making, and social change of the culture of modern women’s health. Within Andrist’s call to “maintain symmetry”, she incorporates both a local and global feminine perspective, echoing the pathways the female protagonists took toward self-identity and health. On a local level, she urges providers to “listen to the everyday experiences of their patients” ^{31 (p269)} and understand the relational identity of women in order to understand their lifeworld, competing responsibilities to others, and in so doing counterbalance the traditional patriarchy of medical communication.

Beyond individual patients, however, social activism must occur in order to increase female access to health information and improve the historically misinformed and damaging state of female healthcare. Each of these objectives could easily be seen as assisting the four protagonists in helping them in their path toward self-reclamation and improved health. If they could access information about their health, confide in health providers their social and physical needs, and develop potential solutions that would support their priorities and lifeworlds, each would be more likely to not just receive the physical care they need but also understand their uniqueness and power in the process.

Several limitations to this analysis exist. This discussion disregards the frequent and distinct divergences between women’s experiences and only uses a limited number of narratives. Given the spectrum of politico-economic histories from which feminine identities were constructed (and the wider array not represented in this sample of novels), a more thorough analysis of similarities and differences is worthy of exploration but outside the current study’s scope. Furthermore, the analysis was conducted by two nurse researchers and reflects each our worldviews and biases.

In conclusion, this narrative analysis compares four female narratives to arrive at themes of gender health inequity across several cultures and time periods. Their stories reflect common calls for women’s health to build on the female identity as being in relation to others, and self-reclamation as an ongoing, contextualized struggle undergone by women that supports their health and safety. Our analysis reinforces recent movements to support gender equity and develop feminine models of healthcare that support shared access to care, decision-making, and social activism. Future research should be conducted to explore global female health models that provide empowering, connected healthcare to women impact gender health equity.