Women in medicine
|Women in society|
Historically and presently, in many parts of the world, women's participation in the profession of medicine (as physicians or surgeons for instance) has been significantly restricted. However, women's informal practice of medicine in roles such as caregivers or as allied health professionals has been widespread. Most countries of the world now provide women with equal access to medical education. However, not all countries ensure equal employment opportunities, and gender equality has yet to be achieved within medical specialties and around the world.
- 1 Modern medicine
- 2 History
- 3 See also
- 4 References
- 5 Bibliography
- 6 External links
In 1540, Henry VIII of England granted the charter for the Company of Barber Surgeons Company of Barber-Surgeons; while this led to the specialization of healthcare professions (i.e. surgeons and barbers), women were barred from professional practice. Women did, however, continue to practice during this time. They continued to practice without formal training or recognition in England and eventually North America for the next several centuries. Women's participation in the medical professions was generally limited by legal and social practices during the decades while medicine was professionalizing. However, women openly practiced medicine in the allied health fields (nursing, midwifery, etc.), and throughout the nineteenth and twentieth centuries, women made significant gains in access to medical education and medical work through much of the world. These gains were sometimes tempered by setbacks; for instance, Mary Roth Walsh documented a decline in women physicians in the US in the first half of the twentieth century, such that there were fewer women physicians in 1950 than there were in 1900. However, through the latter half of the twentieth century, women had gains generally across the board. In the United States, for instance, women were 9% of total US medical school enrollment in 1969; this had increased to 20% in 1976. By 1985, women constituted 16% of practicing US physicians.
At the beginning of the twenty-first century in industrialized nations, women have made significant gains, but have yet to achieve parity throughout the medical profession. Women have achieved parity in medical school in some industrialized countries, since 2003 forming the majority of the United States medical student body. In 2007-2008, women accounted for 49% of medical school applicants and 48.3% of those accepted. According to the American Association of Medical Colleges (AAMC) 48.3% (16,838) of medical degrees awarded in the US in 2009-10 were earned by women, an increase from 26.8% in 1982-3.
However, the practice of medicine remains disproportionately male overall. In industrialized nations, the recent parity in gender of medical students has not yet trickled into parity in practice. In many developing nations, neither medical school nor practice approach gender parity.
Moreover, there are skews within the medical profession: some medical specialties, such as surgery, are significantly male-dominated, while other specialties are significantly female-dominated, or are becoming so. In the United States, female physicians outnumber male physicians in pediatrics and female residents outnumber male residents in family medicine, obstetrics and gynecology, pathology, and psychiatry.
Women continue to dominate in nursing. In 2000, 94.6% of registered nurses in the United States were women. In health care professions as a whole in the US, women numbered approximately 14.8 million, as of 2011.
Biomedical research and academic medical professions—i.e., faculty at medical schools—are also disproportionately male. Research on this issue, called the "leaky pipeline" by the National Institutes of Health and other researchers, shows that while women have achieved parity with men in entering graduate school, a variety of discrimination causes them to drop out at each stage in the academic pipeline: graduate school, postdoc, faculty positions, achieving tenure; and, ultimately, in receiving recognition for groundbreaking work. (See women in science for a broader discussion.)
The involvement of women in the field of medicine has been recorded in several early civilizations. An Egyptian, Merit Ptah (2700 BC), described in an inscription as "chief physician", is the earliest woman named in the history of science. Agamede was cited by Homer as a healer in Greece before the Trojan War. Agnodike was the first female physician to practice legally in 4th century BC Athens. Metrodora was a physician and generally regarded as the first medical writer.
During the Middle Ages, convents were an important place of education for women, and some of these communities provided opportunities for women to contribute to scholarly research. An example is the German abbess Hildegard of Bingen, whose prolific writings include treatments of various scientific subjects, including medicine, botany and natural history (c.1151-58). She is considered Germany's first female physician.
Women in the middle ages participated in many healing techniques and capacities. According to historical documents, small numbers of women occupied almost all ranks of medical personnel during the period. They worked as herbalists, midwives, surgeons, barber-surgeons, nurses, and traditional empirics. Women treated everyone, not only women as historians once thought. The names of 24 women described as surgeons in Naples between 1273 and 1410 are known, and references have been found to 15 women practitioners, most of them Jewish and none described as midwives, in Frankfurt between 1387 and 1497. Women also engaged in midwifery and healing arts without leaving any trace of their activities in written records, and practiced in rural areas or where there was little access to medical care. Society in the Middle Ages limited women’s role as physician. Once universities established faculties of medicine during the thirteenth century, women were excluded from advanced medical education. Licensure began to require clerical vows for which women were ineligible, and healing as a profession became male dominated. Because surgeons and barber-surgeons were often organized into guilds, they could hold out longer against the pressures of licensure. Like other guilds, a number of the barber-surgeon guilds allowed the daughters and wives of their members to take up membership in the guild, generally after the man’s death. According to documents, Katherine la surgiene of London, daughter of Thomas the surgeon and sister of William the Surgeon belonged to a guild in 1286. Documentation of female members in the guilds of Lincoln, Norwich, Dublin and York continue until late in the period. Midwives, those who assisted pregnant women through childbirth and some aftercare, included only women. Midwives constituted roughly one third of female medical practitioners.
The southern Italian coastal town of Salerno was an important center of medical learning and practice in the 12th century. There, the physician Trota of Salerno gathered a number of her medical practices in several written collections. One work on women's medicine that was associated with her, the De curis mulierum ("On Treatments for Women") formed the core of what came to be known as the Trotula ensemble, a compendium of three texts that circulated throughout medieval Europe. Trota herself gained a reputation that spread as far as France and England. There are also references in the writings of other Salernitan physicians to the mulieres Salernitane ("Salernitan women"), which give some idea of local empirical practices.
Dorotea Bucca was another distinguished Italian physician. She held a chair of philosophy and medicine at the University of Bologna for over forty years from 1390. Other Italian women whose contributions in medicine have been recorded include Abella, Jacobina Félicie, Alessandra Giliani, Rebecca de Guarna, Margarita, Mercuriade (14th century), Constance Calenda, Calrice di Durisio (15th century), Constanza, Maria Incarnata and Thomasia de Mattio.
For the medieval Islamic world, little specific is known about female medical practitioners although it is likely that women were regularly involved in medical practice in some capacity. Male medical writers refer to the presence of female practitioners (singular, tabība) in describing certain procedures or situations. For example, the late 10th/early 11th century Andalusi physician and surgeon Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi, in explaining how to excise bladder stones, notes that the procedure is difficult for male doctors practicing on female patients: because of the need to touch the genitalia, the male practitioner must either find a female doctor who can perform the procedure, or a eunuch physician, or a midwife who takes instruction from the male surgeon. In other words, even though direct evidence for female practitioners is rare, their existence can be inferred. As al-Zahrawi's example also suggests, midwives played an important role in the delivery of women's healthcare. For these practitioners, there is more detailed information, both in terms of the prestige of their craft (Ibn Khaldun calls it a noble craft, "something necessary in civilization") and in terms of biographical information on historic women. To date, no known medical treatise written by a woman in the medieval Islamic world has been identified.
Western medicine in China
Traditional Chinese Medicine that is based on the use of herbal medicine, acupuncture, massage and other forms of therapy has been practiced in China for thousands of years. However, Western Medicine was introduced to China in the 19th Century, mainly by medical missionaries sent from various Christian mission organizations, such as the London Missionary Society (Britain), the Methodist Church (Britain) and the Presbyterian Church (US). Benjamin Hobson (1816-1873), a medical missionary sent by the London Missionary Society in 1839, set up a highly successful Wai Ai Clinic (惠愛醫館)  in Guangzhou, China. The Hong Kong College of Medicine for Chinese (香港華人西醫書院) was founded in 1887 by the London Missionary Society, with its first graduate (in 1892) being Sun Yat-sen (孫中山). Sun later led the 1911 Xinhai Revolution (Chinese Revolution (1911)), which changed China from an empire to a republic. The Hong Kong College of Medicine for Chinese was the forerunner of the School of Medicine of the University of Hong Kong, which started in 1911.
Due to the social custom that men and women should not be near to one another, the women of China were reluctant to be treated by male doctors of Western medicine. This resulted in a tremendous need for female doctors of Western Medicine in China. Thus, female medical missionary Dr. Mary H. Fulton (1854-1927)  was sent by the Foreign Missions Board of the Presbyterian Church (USA) to found the first medical college for women in China. Known as the Hackett Medical College for Women (夏葛女子醫學院), this College was located in Guangzhou, China, and was enabled by a large donation from Mr. Edward A.K. Hackett (1851-1916) of Indiana, US. The College was dedicated in 1902 and offered a four-year curriculum. By 1915, there were more than 60 students, mostly in residence. Most students became Christians, due to the influence of Dr. Fulton. The College was officially recognized, with its diplomas marked with the official stamp of the Guangdong provincial government. The College was aimed at the spreading of Christianity and modern medicine and the elevation of Chinese women's social status. The David Gregg Hospital for Women and Children (also known as Yuji Hospital 柔濟醫院)  was affiliated with this College. The graduates of this College included CHAU Lee-sun (周理信, 1890-1979) and WONG Yuen-hing (黃婉卿), both of whom graduated in the late 1910s and then practiced medicine in the hospitals in Guangdong province.
Early modern era
This section requires expansion. (October 2011)
Historic women's medical schools
When women were routinely forbidden from medical school, they sought to form their own medical schools.
- Women's Medical College of Pennsylvania (MCP; founded 1850 as Female Medical College of Pennsylvania)
- London School of Medicine for Women (founded 1874 by Sophia Jex-Blake)
- Edinburgh School of Medicine for Women (founded 1886 by Sophia Jex-Blake)
- Saint Petersburg State Medical University (founded 1897 as Female Medical University)
- Tokyo Women's Medical University (founded 1900 by Yoshioka Yayoi)
- Hackett Medical College for Women, Guangzhou, China, founded in 1902 by Presbyterian Church (USA).
Historic hospitals with significant female involvement
- Woman's Hospital of Philadelphia, founded in 1861, provided clinical experience for Woman's Medical College of Pennsylvania students
- New England Hospital for Women and Children (now called Dimock Community Health Center), founded in 1862 by women doctors "for the exclusive use of women and children"
- New Hospital for Women (founded in the 1870s by Elizabeth Garrett Anderson and run largely by women, for women)
- South London Hospital for Women and Children (founded 1912 by Eleanor Davies-Colley and Maud Chadburn; closed 1984; employed an all-woman staff)
- Merit Ptah (2700 BC), earliest cited female physician
- Agamede, pre-Trojan War healer
- Agnodike was the first female physician to practice legally in 4th century BC Athens.
- Trota of Salerno 12th century physician who collected many of her empirical practices in writing. Part of her work was incorporated into the so-called Trotula compendium of writings on women's medicine and cosmetics.
- Hildegard of Bingen (1098–1179) is considered Germany's first female physician. She conducted and published comprehensive studies of medicine and natural science.
- Dorothea Erxleben (1715–1762), the first female doctor granted a M.D. in Germany.
- James Miranda Barry (179?-1865), a renowned female doctor who passed as a man to gain a medical education and practice medicine.
- Lovisa Årberg (1801–1881), first female doctor and surgeon in Sweden.
- Amalia Assur (1803–1889), first female dentist in Sweden and possibly Europe.
- Ann Preston, (1813–1872), first female dean of any medical school.
- Elizabeth Blackwell (1821–1910), first woman to graduate from medical school in the US; MD 1849, Geneva College, New York.
- Rebecca Lee Crumpler, (8 February 1831 – 9 March 1895), first African American female physician in the United States, awarded her M.D. in 1864 by Boston University.
- Lucy Hobbs Taylor (1833–1910), the first female dentist in the United States.
- Elizabeth Garrett Anderson (1836–1917), pioneering female doctor and feminist in Britain; co-founder of London School of Medicine for Women.
- Madeleine Brès (1839–1925), the first French female MD 
- Sophia Jex-Blake (1840-1912), English physician, feminist and teacher.
- Madeleine Brès (1842 – 1921), the first French woman to obtain a medical degree.
- Nadezhda Suslova (1843–1918), the first Russian female MD, a graduate of Zurich University
- Frances Hoggan (1843–1927), first British woman to receive a doctorate in medicine (1870).
- Edith Pechey-Phipson (1845–1908), pioneering English doctor in the India; MD 1877, University of Bern and Licentiate in Midwifery, 1877 Royal College of Physicians of Ireland.
- Mary Scharlieb (1845-1930), pioneer British female physician.
- Margaret Cleaves (1848–1917), pioneering doctor in the brachytherapy; M.D. 1873.
- Anastasia Golovina, also known as Anastassya Nikolau Berladsky-Golovina, and Atanasya Golovina (1850-1933), the first Bulgarian female doctor.
- Ogino Ginko (1851-1913), first licensed and practicing female physician of western medicine in Japan.
- Aletta Jacobs (1854-1929), first woman to complete a university course in the Netherlands, and the first Dutch female MD.
- Hope Bridges Adams Lehmann (1855-1916), first female general practitioner and gynecologist in Munich, Germany.
- Ana Galvis Hotz (1855-1934), first Colombian woman, and from Latin America, to obtain a medical degree.
- Maria Cuțarida-Crătunescu (1857–1919) the first female doctor in Romania
- Dolors Aleu i Riera (1857–1913), first female medical doctor from Spain, 1879.
- Kadambini Ganguly (1861–1923), the first Indian woman to obtain a medical degree in India having graduated from the Calcutta Medical College in 1886.
- Annie Lowrie Alexander (1864–1929), first licensed female physician in the Southern United States
- Elsie Inglis (1864–1917) Pioneering Scottish doctor and suffragist, born in India. MD Edinburgh School of Medicine for Women, worked at Rotunda Hospital, Dublin
- Anne Walter Fearn (1865-1938) Doctor in Shanghai, China, for almost 40 years.
- Marie Spångberg Holth (1865-1942), the first woman to graduate in medicine in Norway, which occurred in 1893, when she graduated from the Royal Frederiks University of Christiania.
- Anandi Gopal Joshi (1865-1887), the first Indian woman to obtain a medical degree having graduated from the Woman's Medical College of Pennsylvania in 1886.
- Susan La Flesche Picotte (1865-1915), the first Native American woman to obtain a medical degree.
- Emma K. Willits (1869–1965), believed to be only the third woman to specialize in surgery and the first to head a Department of General Surgery at Children's Hospital in San Francisco, 1921-1934.
- Bertha E. Reynolds (1868-1961), among the first women licensed to practice medicine in Wisconsin, serving the rural communities of Lone Rock and Avoca
- Vera Gedroitz (1870–1932), the first professrix of surgery in the world
- Maria Montessori (1870–1952), one of the first female MDs in Italy; renowned educator
- Florence Sabin (1871-1953), the first woman elected to the US National Academy of Sciences.
- Hannah Myrick (1871–1973), helped to introduce the use of X-rays at the New England Hospital for Women and Children
- Yoshioka Yayoi (1871–1959), one of the first women to gain a medical degree in Japan; founded a medical school for women in 1900.
- Marie Equi (1872–1952), American doctor and activist for women's access to birth control and abortion.
- Laura Esther Rodriguez Dulanto (1872–1919), the first Peruvian woman to have obtained a medical degree.
- Karola Maier Milobar (born 1876), became the first female physician to practice in Croatia in 1906.
- Selma Feldbach (May 5, 1878 - April 2, 1924) was the first Estonian woman to become a medical doctor.
- Andrea Evangelina Rodríguez Perozo (1879-1947), the first female medical school graduate in the Dominican Republic.
- Muthulakshmi Reddi (1886–1968), one of the early female medical doctors in India and a major social reformer.
- María Elisa Rivera Díaz (b. 1887), one of the first four women from Puerto Rico to earn a medical degree (which she did in 1909); the other three were Ana Janer in 1909, Palmira Gatell in 1910, and Dolores Piñero in 1913. María Elisa Rivera Díaz and Ana Janer graduated in the same medical school class in 1909 and thus could both be considered the first female Puerto Rican physician.
- Anna Petronella van Heerden (1887–1975), the first Afrikaner woman to qualify as a medical doctor. Her thesis, which she obtained a doctorate on in 1923, was the first medical thesis written in Afrikaans.
- Matilde Hidalgo (1889–1974), the first Ecuadorian woman to have obtained a medical degree.
- Lee Sun Chau (周理信, 1890-1979), one of the first female Chinese doctors of Western Medicine in China.
- Concepción Palacios Herrera (1893-1981), the first female physician in Nicaragua.
- Tsai Ah-hsin (1899-1990), colonial Taiwan's first female physician.
- Safieh Ali (1900-?), first Turkish woman to have obtained a medical degree.
- Henriette Bùi Quang Chiêu (1906-2012), first female doctor in Vietnam.
- Yvonne Sylvain (1907-1989), the first female doctor in Haiti. She was the first woman accepted into the medical school of the University of Haiti, and earned her medical degree there in 1940.
- Virginia Apgar (1909–1974), significant work in anesthesiology and teratology; founded field of neonatology; first woman granted full professorship at Columbia University College of Physicians & Surgeons.
- Elizabeth Abimbola Awoliyi (1910-1971), first female physician in Nigeria.
- Badri Teymourtash (1911–1989), the first Iranian female medical doctor, educated in USA and Belgium.
- Kathryn Stephenson (1912-1993), first American woman board-certified as a plastic surgeon
- Margaret Allen, first female heart transplant surgeon in the USA - transplant performed in 1985 
- Jane Elizabeth Hodgson (1915–2006), pioneering provider of reproductive healthcare for women and advocate for women's rights.
- Mary Malahele-Xakana (1917-1982), the first black woman to register as a medical doctor in South Africa (in 1947).
- Barbara Ross-Lee (b. 1942), first African American female dean of a U.S. medical school (1993), Ohio University College of Osteopathic Medicine.
- Nancy Dickey (b. 1950), first female president of the American Medical Association
- Nancy C. Andrews (b. 1958), first female Dean of a top ten medical school in the United States (2007), Duke University School of Medicine.
- Clara Raquel Epstein (b. 1963), first Mexican-American woman U.S. trained and U.S. board certified in neurological surgery and the first female neurosurgeon and youngest recipient of the prestigious Lifetime Achievement Award in Neurosurgery.
- Milica Šviglin Čavov (b. unknown), the first Croatian female doctor. She graduated from the Medical School in Zürich in 1893, but was not allowed to work in Croatia.
- Estela Gavidia (b. unknown), the first woman to graduate as a doctor in El Salvador, which occurred in 1945.
- Ana Janer (b. unknown), one of the first four women from Puerto Rico to earn a medical degree; the other three were María Elisa Rivera Díaz in 1909, Palmira Gatell in 1910, and Dolores Piñero in 1913. Ana Janer and María Elisa Rivera Díaz graduated in the same medical school class in 1909 and thus could both be considered the first female Puerto Rican physician.
- Susan Gyankorama De-Graft Johnson (b. unknown), was the first woman to qualify as a physician in colonial Ghana.
- Madeline Nyamwanza-Makonese (b. unknown), the first Zimbabwean female doctor, the second African woman to become a doctor, and the first African woman to graduate from the University of Rhodesia Medical School.
- Ernestina Paper (b. unknown), first Italian woman to receive an advanced degree (in medicine), 1877.
- Kornelija Sertić (b. unknown), the first woman to graduate from the Medical School in Zagreb, which occurred in 1923.
Women's health movement in the seventies
The seventies marked a great increase of women entering and graduating from medical school[where?]. From 1930 to 1970, a period of 40 years, about 14,000 women graduated from medical school. From 1970 to 1980, a period of 10 years, over 20,000 women graduated from medical school. This increase of women in the medical field was due to both political and cultural changes.
Two laws in the United States lifted restrictions for women in the medical field -- Title IX of the Higher Education Act Amendments of 1972 and the Public Health Service Act of 1975, banning discrimination on grounds of gender. In November 1970, the Assembly of the Association of American Medical Colleges rallied for equal rights in the medical field.
At the same time, women's ideas about themselves and their relation to the medical field were shifting due to the women's movement.
A sharp increase of women in the medical field led to developments in doctor patient relationships, changes in terminology and theory. One area of medical practice that was challenged and changed was gynecology. Wendy Kline  talks about the blurring of "clinical" and "sexual" that occurred in the medical field in the late 40s into the 60s, particularly in gynecology. Kline says that "to ensure that young brides were ready for the wedding night, they [doctors] used the pelvic exam as a form of sex instruction ." In Ellen Frankfort’s book Vaginal Politics, Frankfort talks about the "shame" and "humiliation" felt during a pap test; "I was naked, he was dressed; I was lying down, he was standing up; I was quiet, he was giving orders "
With higher numbers of women enrolled in medical school medical practices, like gynecology were challenged and changed. One medical student is quoted in Kline’s book as saying, "Since I experienced my own exams as a humiliating procedure, I feared inflicting the same humiliation on another person. " In 1972 the University of Iowa Medical School, was one school that instituted a new training program for pelvic and breast examinations. Students would act both as the doctor and the patient, allowing each student to understand the procedure, and create a more gentle, respectful, examination. This method was quite different from the previous practice in which doctors were taught to assert their power over patients. With changes in ideologies and practices, throughout the 70s, by 1980 over 75 schools had adopted this new method.
With women entering the medical field and women’s rights movements came also the women’s health movement which sought alternative methods of health care for women. This came through the creation of self-help books, most notably Our Bodies, Ourselves: A Book by and for Women. This book gave women a "manual" to help understand their body. It challenged hospital treatment, and doctor’s practices. Aside from self-help books, many help centres were opened: birth centres run by midwives, safe-abortion centres, and classes for educating women on their bodies; all with the aim of providing non-judgmental, warm, and comfortable care for women. Kline speaks to this claim women were taking on their body in relation to the medical world; women felt that "not only should women have access to information about their bodies... they should also help to create this knowledge. " The women’s health movement, along with women involved in the medical field opened the doors for research and awareness for female illness like breast cancer and cervical cancer.
While scholars in the history of medicine had developed some study of women in the field—biographies of pioneering women physicians were common prior to the 1960s—the study of women in medicine took particular root with the advent of the women's movement in the 1960s, and in conjunction with the women's health movement. Two publications in 1973 were critical in establishing the women's health movement and scholarship about women in medicine: First, the publication of Our Bodies, Ourselves in 1973 by the Boston Women's Health Collective, and second, "Witches, Midwives, and Nurses: A History of Female Healers", a short paper by Barbara Ehrenreich and Deirdre English also in 1973. The Ehrenreich/English paper examined the history of women in medicine as the professionalization of the field excluded women, particularly midwives, from the practice. Ehrenreich and English later expanded the work into a full-length book, For Her Own Good, which connected the exclusion of women from the practice of medicine to sexist medical practices; this text and Our Bodies, Ourselves became key texts in the women's health movement. The English/Ehrenreich text laid out some early insights about the professionalization of medicine and the exclusion of women from the profession, and numerous scholars, such as Diana Elizabeth Long, have greatly built upon and expanded this work.
- American Medical Women's Association
- Female education
- History of medicine
- History of nursing
- List of first female physicians by country
- Laurel Thatcher Ulrich, A Midwife's Tale: The Life of Martha Ballard Based on Her Diary, 1785-1812 (1991)
- Rebecca Wojahn, Dr. Kate: Angel on Snowshoes (1956)
- See generally, "Women's Human Rights", 1998, Human Rights Watch (available online).
- The History of Women in Surgery, by Debrah A. Wirtzfeld, MD
- See generally Barbara Ehrenreich & Deirdre English, Witches, Midwives, and Nurses (1973).
- Walsh, 1977.
- Morantz-Sanchez, Preface.
- "Applicants to U.S. Medical Schools Increase; Women the Majority for the First Time", Association of American Medical Colleges, Nov. 3, 2003, press release ("Women made up the majority of medical school applicants for the first time ever").
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- Dixie Mills, "Women in Surgery - Past, Present, and Future" (2003 presentation), Association of Women Surgeons; available at AWS website.
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- The term was coined by S.E. Berryman in "Who Will Do Science?", 1983; see Louise Luckenbill-Edds, "2000 WICB / Career Strategy Columns (Archive)", Nov. 1, 2000, WICB Newsletter, American Society for Cell Biology.
- A. N. Pell, "Fixing the Leaky Pipeline: Women Scientists in Academia", Journal of Animal Science, v.74, pp. 2843-2848 (1996), available online at (PDF) Journal of Animal Science, FASS.org.
- Jacob Clark Blickenstaff, "Women and Science Careers: Leaky Pipeline or Gender Filter?", Gender and Education, v.17, n.4, pp. 369-386 (Oct. 2005).
- National Academy of Sciences, Beyond Bias and Barriers: Fulfilling the Potential of Women in Academic Science and Engineering.
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- Monica H. Green, ed. and trans., The 'Trotula': A Medieval Compendium of Women’s Medicine (Philadelphia: University of Pennsylvania Press, 2001).
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