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conceptual and applied global

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THE PSYCHOLOGY OF GENDER
AND HEALTH
This page intentionally left blank

     
THE PSYCHOLOGY
OF GENDER AND
HEALTH

CONCEPTUAL AND
APPLIED GLOBAL
CONCERNS
Edited by

M. Pilar Sánchez-López
Rosa M. Limiñana-Gras

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Cover Image: Hygeia, the daughter of the god of medicine, Asclepius. Hygeia was the goddess/
personification of health and prevention of illness, cleanliness, and hygiene. She was represented as a
young woman feeding a large snake coiled around her body. The snake was a beneficial and enlightening
character in cultures of old. An animal between two worlds, it was able to live underground and to shed
its skin. For Greeks, descent into the underworld (below consciousness and what is visible) is essential
in obtaining a cure—one must descend to see what is happening there, to find the cure, with a fresh skin.
Like the snake. Applying the gender perspective to health is also a descent, in some ways, below what
is visible. We obtain a “fresh skin”, that enables us to better understand the importance of gender as a
determining factor for health, and the need to include gender-related variables in order to correctly assess
the set of causes that produce differences in health. Hygeia feeding a snake is particularly associated with
the aim of this book.
 Contents

Contributorsix
Forewordxi
LONDA SCHIEBINGER

1. Health From a Gender Perspective: The State of the Art

M. PILAR SÁNCHEZ-LÓPEZ AND ROSA M. LIMIÑANA-GRAS

Determinants of Health 2
The Sex/Gender System 4
The Gender Perspective in Health: Integration of Sex and Gender
in the Analysis and Research of Health 10
Incorporation of the Gender Perspective to Interventions in Health 29
Book Preview 38
References43

I
CONCEPTUAL APPROACHES FOR GENDER
AND HEALTH
2. Gender-Based Perspectives About Women’s and Men’s Health
JUAN F. DÍAZ-MORALES

Gender and Health 55

Sex and Health Studies 58
Approaches of Gender as a Determinant of Health 68
Gender Self-Categorization and Gender Beliefs 71
Gender Perspectives About Health: Common Aspects 76
Acknowledgments78
References78

3. The Health Gender Gap: A Constrained Choice Explanation

PATRICIA P. RIEKER AND JENNAN G. READ

The Health Gender Gap in Global Perspective 88

Constrained Choices: A New Approach to Health Disparities 97
The Constrained Choice Framework and Processes 98
Applications of Constrained Choice 105

v
vi CONTENTS

Future Challenges for Constrained Choice 110

References113

4. Masculinities and Health: Whose Identities, Whose

Constructions?
CHRIS MCVITTIE, JULIE HEPWORTH AND KAREN GOODALL

Hegemonic Masculinity 121

The Limitations of Hegemonic Masculinity 124
Masculinities Reconsidered 127
Conclusion136
References137
Note on Transcription Notation 140

5. Transgender, Sexual Orientation, and Health

MARTA E. APARICIO-GARCÍA

Common Meanings: Gender, Self-Identity, Gender Identity, and Sexual

Orientation144
Health in Transgender People 149
Conclusion164
References165

II
CLINICAL AND HEALTH CONTEXTS
6. “He’s More Typically Female Because He’s Not Afraid to
Cry”: Connecting Heterosexual Gender Relations and
Men’s Depression
JOHN L. OLIFFE, MARY T. KELLY, JOAN L. BOTTORFF, JOY L. JOHNSON AND SABRINA T. WONG

Masculinities and Men’s Depression 178

Heterosexual Gender Relations, Health, and Illness 179
Theoretical Underpinnings of Gender Relations 180
An Empirical Study 181
Conclusion195
References195

7. Intimate Partner Violence Against Women: Prevention

and Intervention Strategies in Spain
ROSA M. PATRÓ-HERNÁNDEZ

An International Framework for Violence Against Women 200

The Magnitude of the Problem: Global and National Prevalence Estimates
of Intimate Partner Violence Against Women 204
 CONTENTS vii

The Severity of the Effects: Consequences of Violence on Women’s Health 208

Approaches to Gender-Based Violence 211
Strategies for Primary and Secondary Prevention 215
Intervention Strategies 219
Psychological Intervention With Victims and Perpetrators of Intimate
Partner Violence Against Women 222
References227

8. Examining Migrants’ Health From a Gender

Perspective
ANDREEA C. BRABETE

Situating European Migration 231

Women in Migration Studies From a Gender Perspective 233
The Healthy Immigrant Effect 235
Migrants’ Health From a Gender Perspective 236
Acculturative Stress and Its Impact on Health: Elements for a Psychological
Intervention With Migrants 239
Health Care: Barriers to Services and Health Programs 241
Intersectionality: A Necessity When Studying Migrants’ Health 244
References245

9. An Integrity Model, Existential Perspective in Clinical

Work With Men From a Gender and Health Perspective
NEDRA R. LANDER AND DANIELLE NAHON

Challenging the Myth of the Emotionally Defective Male 253

The Integrity Model in Working With Men: A Historical and Health
Promotion Perspective 255
Theoretical Underpinnings: The Integrity Model 258
The Integrity Model: An Existential Perspective in Working With Men 259
Working With Men: Case Example 264
Conclusions267
References270

10. Contributions of Gender Perspective to HIV Infection

ISABEL CUÉLLAR-FLORES

Genealogy of an Epidemic 275

Epidemiology and Distribution by Sex 277
Gender Inequalities in HIV 280
Sex and Gender Determinants in HIV 282
Contributions of Gender Perspective to HIV Prevention 286
Contributions of Gender Perspective to HIV Interventions 290
Psychology, Gender, and Pediatric HIV: Contributions From Clinical Practice 293
Conclusions300
References300
viii CONTENTS

11. Breastfeeding and Health: A Gender Perspective

LUCIA COLODRO-CONDE

A Historical Perspective of Breastfeeding 309

Breastfeeding as a Biopsychosocial Phenomenon 313
Femininity, Motherhood, and Breastfeeding 318
Breastfeeding, Health, and Gender 321
Psychological Interventions in Breastfeeding 328
Acknowledgment334
References334

12. Mainstreaming Gender Equality to Improve Women’s Mental

Health in England
KAREN NEWBIGGING

Psychology, Psychiatry, and Women’s Mental Health 345

The Case for Mainstreaming in Mental Health 346
Mainstreaming as a Potential Remedy 347
Mainstreaming in Practice 350
Revisiting Mainstreaming in Mental Health 356
Conclusions: Implications for Psychiatry and Psychology 357
References358

13. Health and Gender Perspective in Infertility

ROSA M. LIMIÑANA-GRAS

Infertility and Its Treatment 364

Health and Gender Determinants in Infertility 372
Health and Gender Differences in Infertility 382
Infertility in Reproductive Psychology: A Gender Perspective 388
References393

14. Epilogue
JOAN C. CHRISLER

Topics to Discuss in a Health Psychology Course 402

Conclusion404
References404

Index407


 Contributors

Marta E. Aparicio-García Complutense University of Madrid, Madrid, Spain

Joan L. Bottorff University of British Columbia, Kelowna, BC, Canada; Australian
Catholic University, Melbourne, VIC, Australia
Andreea C. Brabete Complutense University of Madrid, Madrid, Spain; University
of Montreal, Montreal, QC, Canada
Joan C. Chrisler Connecticut College, New London, CT, United States
Lucia Colodro-Conde QIMR Berghofer Medical Research Institute, Brisbane,
QLD, Australia
Isabel Cuéllar-Flores CoRISpe (National Cohort of Pediatric Patients with HIV
Infection of Madrid), Spain; EPSY (Research Group of Psychological Styles,
Gender and Health), Spain; Hospital Universitario Doce de Octubre, Madrid,
Spain
Juan F. Díaz-Morales Complutense University of Madrid, Madrid, Spain
Karen Goodall University of Edinburgh, Edinburgh, United Kingdom
Julie Hepworth Queensland University of Technology, Brisbane, QLD,
Australia
Joy L. Johnson Simon Fraser University, Vancouver, BC, Canada
Mary T. Kelly University of British Columbia, Vancouver, BC, Canada
Nedra R. Lander University of Ottawa, Ottawa, ON, Canada
Rosa M. Limiñana-Gras University of Murcia, Murcia, Spain
Chris McVittie Queen Margaret University, Musselburgh, United Kingdom
Danielle Nahon University of Ottawa, Ottawa, ON, Canada
Karen Newbigging University of Birmingham, Birmingham, United Kingdom
John L. Oliffe University of British Columbia, Vancouver, BC, Canada; University
of Queensland, Brisbane, QLD, Australia
Rosa M. Patró-Hernández University of Murcia, Murcia, Spain
Jennan G. Read Duke University, Durham, NC, United States
Patricia P. Rieker Boston University, Boston, MA, United States
M. Pilar Sánchez-López Complutense University of Madrid, Madrid, Spain
Londa Schiebinger Stanford University, Stanford, CA, United States
Sabrina T. Wong University of British Columbia, Vancouver, BC, Canada

ix
This page intentionally left blank

     
 Foreword

Doing research wrong costs lives and money. Ten drugs were recently
withdrawn from the US market because of life-threatening health effects;
eight of these posed greater threats for women. Not only did these drugs
cost billions of Euros to develop, but when they fail, they cause death and
human suffering. We can’t afford to get it wrong (United States General
Accounting Office, 2001).
Doing research right can save lives and money. An analysis of the US
Women’s Health Initiative Hormone Therapy Trial—a large, government-
funded study done in the 1990s—found that for every $1 spent, $140 were
returned. More importantly, the study saved lives; trial results lead to
4.3 million fewer postmenopausal women using combined hormone ther-
apy, which in turn resulted in 76,000 fewer cases of cardiovascular disease,
126,000 fewer breast cancers, and 145,000 more quality-adjusted life years.
Whereas most of the results were positive, the analysis found 263,000 more
osteoporotic fractures (Roth et al., 2014). We need more measures like this of
the actual benefits of sex and gender analysis in health research.
It is crucially important to identify gender bias in health research. But
analysis cannot stop there. We need to turn it around; we need to get it
right from the beginning; we need to harness the creative power of sex
and gender analysis for discovery in biomedicine and health research
(Schiebinger et al., 2011–2016).
Recognizing the importance of sex and gender to human health, grant-
ing agencies across Europe, Canada, and the United States now require
that these variables be included in publicly funded research. Since 1990,
The US National Institutes of Health (NIH) has required that women be
included in medical research, especially clinical trials. Since 2010, the
Canadian Institutes of Health Research (CIHR) has explicitly called for
sex and gender-based analysis (SGBA) in health research and supports
these requirements with training modules (because these topics still are
not incorporated into most medical school curriculum) (CIHR, 2012;
Mayo School of Continuous Professional Development [MSCPD], 2015).
In 2013, the European Commission required that both sex and gender be
included in Horizon 2020 research, where appropriate to the topic (Euro-
pean Commission, 2013). Finally, in June 2015, the US NIH released guide-
lines emphasizing the importance of sex as a biological variable (SABV) in
preclinical, clinical, and population health studies (Clayton, 2015; Clayton &
Collins, 2014; Collins & Tabak, 2014).

xi
xii FOREWORD

Despite these policy initiatives, the role of “gender” and its crucial interac-
tions with biological sex have generally been neglected in biomedical and
health research. It is now the responsibility of researchers to refine and sharpen
methods, questions, and research priorities. What are the relative contribu-
tions of sex (biological characteristics) versus gender (cultural attitudes and
behaviors) and intersecting social factors to human health? And how do we
study sex and gender, and their interactions in biomedical research?
The Psychology of Gender and Health addresses these questions, focus-
ing in particular on the psychology, economics, and politics of gender
and health in a global context. Sex is defined as being male or female (or
intersex) according to chromosomal complement and biological functions
assigned by chromosomal complement. Whereas biological sex differ-
ences are initiated by genes encoded on the sex chromosomes, all other
factors (eg, autosomal and mitochondrial genes) are believed to be equally
inherited by males and females. Sex, however, exists along a continuum in
which males or females differ on average.
Over the past 25 years, important sex differences in disease have been
identified. Well-known examples include the underlying pathophysiol-
ogy in patterns of women’s and men’s heart disease, where men typi-
cally have a severe pinching off of the coronary artery (that angiography,
the gold standard for diagnosing heart disease, has been developed to
detect), whereas women have a gradual narrowing of the coronary artery
(that angiography typically does not detect). Or we might mention osteo-
porosis in men and women, where men’s disease has historically been
underdiagnosed. Other examples include studies showing that low-dose
aspirin may be protective against cardiovascular disease for men but not
for women, that drugs metabolize differently in women and men, and
that pain differs by sex (Oertelt-Prigione & Regitz-Zagrosek, 2012; Regitz-
Zagrosek, 2012; Schenck-Gustafsson, DeCola, Pfaff & Pisetsky, 2012).
The study of sex differences (and similarities) is well underway with
organizations such as the Organization for the Study of Sex Difference,
devoted to this very question. Gender, by contrast, is less well understood
in health research. In particular, we lack agreed-upon methods for measur-
ing gender in ways that can be analyzed statistically while still preserving
the integrity of the phenomena. Gender refers to sociocultural values and
roles that shape attitudes and behaviors of men, women, and transgender
persons. Social factors often influence biology such that gender becomes
a modifier of biology (or sex). Gender is not only “gender identity” (how
individuals and groups perceive and present themselves). Importantly,
gender includes “gender norms” (spoken and unspoken cultural rules in
the family, workplace, institutional, or global culture that influence indi-
vidual attitudes and behaviors) and “gender relations” (power relations
between individuals of different gender identities); see sidebar (Schiebinger
et al., 2011–2016).
 FOREWORD xiii

A N A LY Z I N G G E N D E R — P O I N T S T O
KEEP IN MIND
  

1. G ender attitudes and behaviors vary by culture, historical era, ethnicity,

age, socioeconomic status, and other factors. For example, gender
norms may be very different on the US West Coast versus the East
Coast, or in Italy versus India.
2. “Femininities” and “masculinities” slide across continua and across
cultures. Both masculine and feminine behaviors may manifest in
any one individual. A single person may change behaviors over the
course of a day or a lifetime, since gender norms often depend on
context. A man, for example, may demonstrate “masculine” behavior
in the boardroom but more “feminine” behavior at home with his
children.
3. Gender does not necessarily match sex (Fig. 1).

100
Women
Men
Percent

50

0
0 100

Masculine Similar level of Feminine

gender-related masculine and gender-related
characteristics feminine characteristics
characteristics

FIGURE 1 Gender does not necessarily match sex. This figure shows the
distribution in men and women with premature acute coronary syndrome (ACS).
Pelletier et al. developed new methodology to analyze gender as a variable in order
to understand the association between gender, sex, and cardiovascular risk factors
among patients with premature ACS. Importantly, they found no sex difference; that
is, being a man or a woman did not predict accurately which patients were likely
to relapse or die within 12 months from diagnosis. The team found, however, that
gender matters. Patients with a higher “femininity” score, regardless whether they
were a man or a woman, were more likely to experience a recurrence of ACS. This
study showed that a man with a high femininity score was more likely to suffer a
recurrence, and a woman with a high masculinity score was not. From Pelletier, R.,
Ditto, B., & Pilote, L. (2015). A composite measure of gender and its association with risk
factors in patients with premature acute coronary syndrome. Psychosomatic Medicine, 77,
517–526. http://dx.doi.org/10.1097/psy.0000000000000186; Pelletier, R., Ditto, B., &
Pilote, L. (2016). Sex or gender: which predicts outcomes after acute coronary syndrome in
the young? Journal of the American College of Cardiology, 67(2), 127–135. http://dx.
doi.org/10.1016/j.jacc.2015.10.067. Reproduced with kind permission.

continued
xiv FOREWORD

A N A LY Z I N G G E N D E R — P O I N T S T O
K E E P I N M I N D —(cont’d)
4. I t is important not to overemphasize gender differences, but instead
to analyze and report within (intra-) and between (inter-) group
differences.
5. A “response bias” may exist, for example, when men and women
answer surveys. A gender difference reported may result, at least in part,
from gender differences in responding behavior. Feminine-identified
persons, for example, may be more likely to admit emotionality in
responding to a standard distress scale than men.
6. It is important to consider factors intersecting with sex and gender
(for example, age or socioeconomic status may be more significant
than gender).

This volume investigates how the “social” influences the “biological”

(and vice versa) in order to understand gender as a modifier of biology
and, hence, health. Of note, in this volume are chapters on masculinities,
femininities, and transgender identity, as these populations are shaped
by and shape social, economic, religious, media, education, and cultural
trends across the life course. The volume offers a panoply of examples
and methods for understanding the role of gender in health. Coming back
to our examples cited earlier, this volume adds the gender components
to biological differences. In cardiovascular disease, in addition to the fact
that women have different biological symptoms, they also have a longer
“door-to-balloon” time, because emergency workers and physicians, and
perhaps even the women themselves, believe that heart attacks strike pri-
marily men. Women are also given fewer tests, and are less well repre-
sented in research, treatment, and preventive measures. Osteoporosis also
has a gender as well as a biological determinant. Men, for example, may be
more physically active in occupations, such as construction work, or lei-
sure activities such as football, that build bone. Social norms and divisions
of labor, by contrast, prescribe less weight-bearing activity for women.
The authors also provide important gender insights to the puzzles of
mortality; women live longer, but have poorer health. Whereas biology
has been vigorously investigated in this regard, social impacts also need
to be taken into account. Smoking and alcohol consumption, for example,
shorten men’s lives, as do risk behaviors and violence. The chapters focus
on a rich variety of topics from intimate partner violence to migrants’
health to paternal postpartum depression to transgender and sexual ori-
entation in health, and the gender paradoxes driving suicide.
 FOREWORD xv

Gender, of course, is not one variable, but a cascade of questions,

factors, and methods that need to be integrated into health research.
This volume wonderfully sets out methods, questions, analyses, and
findings, which make it valuable reading. The European Union Gen-
der Medicine group is also preparing a large meta-analysis of gender
aspects of public health across Europe (EUGenMed Public Health Study
Group, Sex and Gender Aspects of Risk Factors for Non-Communica-
ble Diseases across Europe, major report in progress, 2013). Further,
the Gendered Innovations project at Stanford University is launching
new initiatives for studying gender variables in health research. The
time for fully analyzing sex, gender, and their interactions in health
has come. We welcome the rich perspectives provided in this volume,
and the opportunity to collaborate with colleagues globally on these
questions.

Londa Schiebinger
John L. Hinds Professor of History of Science, Stanford University
Director, Gendered Innovations in Science, Health &
Medicine, Engineering, and Environment

References
Canadian Institutes of Health Research (CIHR). (2012). Sex, gender and health research guide: A
tool for CIHR applicants. Retrieved from http://www.cihr-irsc.gc.ca/e/32019.html.
Clayton, J. A. (2015). Studying both sexes: a guiding principle for biomedicine. The FASEB
Journal, 30, fj.15–279554. http://dx.doi.org/10.1096/fj.15-279554.
Clayton, J. A., & Collins, F. S. (2014). Policy: NIH to balance sex in cell and animal stud-
ies. Nature, 509(7500), 282–283. http://dx.doi.org/10.1038/509282a.
Collins, F. S., & Tabak, L. A. (2014). Policy: NIH plans to enhance reproducibility. Nature,
505(7485), 612–613. http://dx.doi.org/10.1038/505612a.
EUGenMed Public Health Study Group. Sex and gender aspects of risk factors for non-communicable
diseases across Europe, major report in progress.
European Commission. (2013). Fact sheet: Gender equality in horizon 2020. Brussels, December
09. Retrieved from https://genderedinnovations.stanford.edu/FactSheet_Gender_0912
13_final_2.pdf.
Mayo School of Continuous Professional Development (MSCPD). (2015). Sex and gender-
based medical education (SGME) summit: A roadmap for curricular innovation. Retrieved from
http://sgbmeducationsummit.com/.
Oertelt-Prigione, S., & Regitz-Zagrosek, V. (Eds.). (2012). Sex and gender aspects in clinical medi-
cine. London: Springer Verlag. http://dx.doi.org/10.1007/978-0-85729-832-4.
Pelletier, R., Ditto, B., & Pilote, L. (2015). A composite measure of gender and its associa-
tion with risk factors in patients with premature acute coronary syndrome. Psychosomatic
Medicine, 77, 517–526. http://dx.doi.org/10.1097/psy.0000000000000186.
Pelletier, R., Ditto, B., & Pilote, L. (2016). Sex or gender: which predicts outcomes after acute
coronary syndrome in the young? Journal of the American College of Cardiology, 67(2),
127–135. http://dx.doi.org/10.1016/j.jacc.2015.10.067.
Regitz-Zagrosek, V. (Ed.). (2012). Sex and gender differences in pharmacology. Berlin-Heidelberg:
Springer Verlag. http://dx.doi.org/10.1007/978-3-642-30726-3.
xvi FOREWORD

Roth, J., Etzioni, R., Waters, T., Pettinger, M., Rossouw, J., Anderson, G., et al. (2014). Eco-
nomic return from the women’s health initiative estrogen plus progestin clinical trial: a
modeling study. Annals of Internal Medicine, 160(9), 594–602. http://dx.doi.org/10.7326/
m13-2348.
Schenck-Gustafsson, K., DeCola, P., Pfaff, D., & Pisetsky, D. (Eds.). (2012). Handbook of clinical
gender medicine. Basel: Karger. http://dx.doi.org/10.1159/isbn.978-3-8055-9930-6.
Schiebinger, L., Klinge, I., Paik, H.Y., Sánchez de Madariaga, I., Schraudner, M., & Stefanick,
M. (Eds.). (2011–2016). Gendered innovations in science, health & medicine, engineering, and
environment (genderedinnovations.stanford.edu). Retrieved from http://ec.europa.eu/
research/gendered-innovations/.
United States General Accounting Office. (2001). Drug safety: Most drugs withdrawn in recent
years had greater health risks for women. Washington, DC: Government Publishing Office.
 C H A P T E R

1
Health From a Gender
Perspective: The State of the Art
M.Pilar Sánchez-López1, Rosa M. Limiñana-Gras2
1Complutense University of Madrid, Madrid, Spain; 2University of Murcia,
Murcia, Spain

The complex construct of gender interacts with biological and genetic differences
to create health conditions, situations and problems that are different for women and
men as individuals and as population groups. This interaction, and how it plays out
across different age, ethnic and income groups, should be understood by health pro-
viders and health policy makers. (p. 102) United Nations (1998) Report, Women and
Health, Mainstreaming the Gender Perspective into the Health Sector
  
The concept of health, as well as the responsibilities toward the tar-
get population of health interventions, has been changing and evolving
in parallel and in response to the historic changes in the sociopolitical
context. Although the biomedical model, referring almost exclusively
to biological factors, is still in force in biotechnological applications
in the field of health, the current conception of health recognizes and
underscores ever more inclusively the relevance of psychological, social,
economic, and political aspects that interact as determinants of health,
emphasizing that the concept of health is not only a scientific issue,
but also social and political, understanding as such the relationships of
power within society.
In this sense, gender, as a central analytical category in health studies,
has contributed to the development of this extensive concept of health,
turning into an increasingly expanding field of research. Its development,
both in the fields of biomedical and of social sciences, will facilitate the
promotion of policies that recognize its magnitude and importance in
public health issues.
This chapter aims to provide readers with a review of the most rel-
evant concepts and developments concerning gender and health, which
will allow correcting gender biases and stereotypes that are common both

The Psychology of Gender and Health

http://dx.doi.org/10.1016/B978-0-12-803864-2.00001-8
1 © 2017 Elsevier Inc. All rights reserved.
2 1. HEALTH FROM A GENDER PERSPECTIVE

in the general public and among psychology students and professionals.

In the first sections, we present a brief description of the necessary social,
economic, physical, and psychological factors for the adequate study of
health, including gender analysis at the intersection with all of them, and
the most current conceptualizations of sex and gender and their relation-
ship will be developed. Gender, understood as the result of interactions
in a specific social and cultural context, and far from its consideration as
a stable attribute of the individual, is presented herein as a much more
complex and changing reality that emphasizes the social and cultural
nature of the distinction between feminine and masculine, questioning
essentialist (West & Zimmerman, 1987) or dichotomous definitions. We
insist on the need to include gender-related variables in order to correctly
assess the set of causes that produce differences in health, and we review
the main approaches to gender in research, their integration in different
theoretical frameworks, and their impact on health programs, projects,
policies, and outcomes.
From psychology the integration of these approaches is carried out
from a differential, multidimensional approach, accounting for the impact
of sex and gender on health and the development of diverse health-­
relevant masculinities and femininities. The integration of sex and gender
in the analysis of health also imposes the challenge of incorporating tools
and measures that permit a correct interpretation of research outcomes,
adequately operationalizing these dimensions. Finally, this chapter also
aims to illustrate, with some examples, how gender interacts with social
determinants, generating inequalities that affect health in different stages
and contexts.

DETERMINANTS OF HEALTH

The appropriate approach to the study of health, both of the individual

and the population, must take into account all the social, economic, physi-
cal, and psychological factors liable to have some influence on health, and
it must provide the necessary indicators to clarify, guide, implement, and
evaluate health interventions. In general, it is usually accepted that these
determinants comprise factors such as income and social status, social
support perceived by people, the level of schooling, employment (or its
lack) and conditions at work, the social and physical environment, health
habits, the person’s development across the life cycle, their biological
and genetic heritage (including their sex), the health-related services of
their environment, culture (ethnic and cultural identity), life conditions,
geographic location, age, sexual orientation, personal characteristics, and
many other factors. Along with and interacting with them, gender is also
a determinant of health.
 Determinants of Health 3

These determinants may influence the risks, possibilities, behaviors,

and manifestations of health and illness throughout a person’s life. All
the factors, and the interactions among them, are important in order to
enjoy good health; they create the ecological niches, the varied and com-
plex situations that, interacting with personal characteristics, allow each
individual to display healthy or unhealthy behaviors that will influence
health, and that will vary from one population to another and from one
group/individual to another within the same population (Greaves, 2011;
Johnson, Greaves, & Repta, 2007).
The influence of each of these determinants on people’s health can
vary depending on their sex and gender. Deepening our knowledge
and understanding of the role played by sex and gender in health can
contribute to improving the health of individuals and populations. It
is known that sex can influence health; for example, women and men
who suffer from the same disease may present different symptoms (eg,
myocardial infarction) and may respond differentially to drugs and
treatments (eg, to psychotropic drugs), depending on their hormonal,
physiological, and morphological characteristics. Or some diseases
(eg, prostate cancer) only affect one of the two sexes, affect one more
massively (eg, breast cancer), or have different consequences for men
than for women (eg, smoking appears ever more clearly as a risk factor
for breast cancer in women).
It is also known that gender is another important factor that influences
health. For example, take the case of respiratory diseases caused by poor
combustion of cooking materials, which are more common among women
because owing to the traditional female role, women normally spend
more time cooking. Also note that the different roles and responsibilities
that are assigned to a person as a function of being male or female, which,
for example, can cause masculinity to be associated with force, resistance,
and, in short, with resilience. This can influence men who accept this mas-
culine role to be reluctant to ask for help or consult health profession-
als, and to be more prone to take risks and have accidents (World Health
Organization [WHO], 2007). In contrast, traditional femininity is associ-
ated with delicacy and softness, which can cause women who accept this
rule to consider it inappropriate for them to participate in physical activi-
ties. This attitude can damage their health, both physically and mentally
(Observatorio de Salud de la Mujer, 2005).
Thus the level of health of a person or a population can improve or
worsen depending on the presence of multiple factors that interact with
each other. These factors are of different types and include characteristics
ranging from the individual to the social, work, environmental, and health
contexts. The inclusion of the gender perspective in the analysis of these
factors involves assessing how gender interacts with all of them, gener-
ating inequalities that affect the health of people at very different times
4 1. HEALTH FROM A GENDER PERSPECTIVE

and in many different ways, which can range from the unequal degree of
exposure to different risks for men and women to differences in the health
care received.

THE SEX/GENDER SYSTEM

In order to study the relationships between sex, gender, and health, the
aspects that make up this system must first be clarified. What is gender,
what is sex, how is the sex/gender identity established, and what are rela-
tionships, roles, and stereotypes of gender?

Sex and Gender What’s the Difference?

The concepts of sex and gender, although related, are clearly distinct
and not interchangeable; however, they are sometimes confused and used
interchangeably in contemporary scientific literature. The term sex refers
to a biological construction, whereas the term gender refers to a social con-
struction, and the conceptual distinction when using these two terms is of
utmost importance to ensure the accuracy of the scientific research meth-
odologies employed. Clarity in the terminological distinction between sex
and gender must be present, starting with the identification and opera-
tionalization of the study variables, through data collection processes,
and ending with the presentation of results (Gahagan, Gray, & Whynacht,
2015; Krieger, 2003).
To use a classical definition, according to the World Health Orga-
nization (WHO) (2011a), the term sex involves the reference to biologi-
cal characteristics (chromosomal, gonadal, hormonal, brain, and genital
dimorphism) and includes aspects relating to reproduction and sexuality.
As seen, it is a multidimensional concept, but one which ends up becom-
ing a binary notion (man–woman), although most of the elements that
compose it (eg, hormonal and chromosomal differences) are actually a
continuum. This conversion of a continuous dimension into a dichoto-
mous category causes problems and confusion when designing, manag-
ing, and interpreting health behavior outcomes related to the influence
of the variable sex. Finally, the term sex is used also, correctly, in the dif-
ferential tradition of psychology, in research comparing the behaviors of
men and women, without reference to gender-related aspects. In this case,
it refers to “differences between sexes,” without making assumptions
about whether these differences are biological, psychological, or social, or
because of an interaction between them. When this term is used, the male
sex is differentiated from the female sex (eg, to quote only classical works,
Anastasi, 1937; Maccoby & Jacklin, 1974; Tyler, 1947; and, as a “modern
classic,” Ellis et al., 2008).
 The Sex/Gender System 5

Gender, also according to WHO (2011a), refers to the characteristics of

women and men, which vary from society to society, and which are con-
structed historically and culturally. Whereas sex is a biological difference,
gender is used to define the ways of social construction in relation to the
feminine or masculine nature of the behavior considered normal for each
of the sexes. Thus unlike sex, gender will be a changing and dynamic cat-
egory that will vary according to societies, cultures, and historical periods
(Simonds & Brush, 2004).
Therefore gender is a relational category seeking to explain how certain
types of differences between human beings are established. It establishes a
social order that has traditionally been explained on the basis of biological
sex, although this has been refined and questioned, indicating that even
sexual differences should not be considered as purely anatomical facts,
because the construction and interpretation of anatomical differences is
in itself a historical and social process (Benhabib, 1992). The term gender,
therefore, implies reference to roles, relationships, personality traits, atti-
tudes, behaviors, values, influences, and power relations that are cultur-
ally constructed and that a given society attributes differentially to one or
the other sex (Lovaas, 2005). Being a social category implies that no traits
or behaviors inherently belong a priori to any particular group or to a
particular gender.
Finally, gender is also often considered a bipolar concept (masculine vs.
feminine). However, as in the case of sex, this bipolarity does not reflect
the broad variety of experiences, identities, and behaviors that constitute
gender. Human beings feel and express their gender along a continuum of
characteristics and behaviors, not by mutually exclusive categories. And,
as in the case of sex, the transformation of a dimension into a bipolar cat-
egory sometimes produces errors in the interpretation of health behaviors.
In modern times, the inclusion of the term trans, with all the nuances that
can and should be made, is an attempt to be sensitive to this nonpolar-
ity. There is, moreover, no necessary, exact, and, unique correspondence
between man and masculinity or between woman and femininity. Sex
and gender interact with each other naturally, but they do not completely
determine each other. When gender identity or expression differs from
the biological sex, the generic term of transgender is used (Teich, 2012),
and its comprehension and inclusion in the analysis of health requires a
more extensive and complete vision of gender, which will be included in
Chapter 5 of this book. In other chapters, such as Chapter 13, reference is
made to different aspects of transgenderism and health, in this case with
respect to infertility.
Gender therefore is based on learning; it is a process that begins very
early in life. Four concepts related to this learning process tend to be dis-
tinguished: gender identity, gender roles, gender stereotypes, and gender
relations, which we will examine in greater depth in the following sections.
6 1. HEALTH FROM A GENDER PERSPECTIVE

The Social Construction of Gender Identity

The concept of gender identity refers to multidimensional, heteroge-
neous, evolving, and open processes, which are in permanent construc-
tion. It is the result of an evolutionary process by which social norms and
expectations are internalized. It refers to the individual’s psychological
sense of being a man or a woman, with the social and psychological behav-
iors that society designates as masculine or feminine. In fact, it is a learning
process with socially adaptive value, in which the maternal and paternal
models and the social roles of close adults are of great importance. Indeed,
the family and the school are socializing agents in the acknowledgment
that each subject establishes his or her own gender category. In Chapter 4
the authors point out the process of constructing masculine identity and,
subsequently, how this process relates to health.
These processes by which people become men and women are not
exempt from social and cultural conditioning, and they usually take place
within a structure that postulates the complementarity of the sexes and the
regulations of heterosexuality (Lamas, 1995). Such is the case with male
hegemony and its construction, given a detailed examination in Chapter 4.
One of the conclusions arrived at by the authors is that it is not that the
concept has no place in understanding men’s health; rather it is the case
that its relevance and utility remain to be demonstrated. In the Western
culture, for example, they contribute to the acquisition of patterns of cour-
age and protection in boys and of attraction and kindness in girls. Gen-
erally, group membership is established in an asymmetrical relationship
between different groups, and it constitutes the foundations of individu-
als’ collective identification. In most cultures, and certainly in the Western
one, men (as a generic) belong to the dominant groups, whereas women
(also as a generic) belong to the dominated groups (Lorenzi-Cioldi, 1998).
Gender violence, dealt with in Chapter 7, is an excellent example of this,
because its very denomination implies asymmetry of power between men
and women.
Of course, the media are also involved in these socialization processes
through the massive reproduction of essentialist information and, there-
fore, they contribute to the dualistic assumption of gender (Chrisler, 2013).
This information assigns the status of opposites, natural and necessary
to these gender roles, forgetting or ignoring that within the great human
diversity, men and women are more similar than different, as evidenced
by the review of the results of empirical research (eg, Hyde, 2005).
Why is gender identity so decisive in people’s lives? Gender identity
enables each person to be located on this gender continuum that was dis-
cussed in the previous section. This identification established by each per-
son influences his or her feelings and behaviors (Teich, 2012), and has to
do with the feeling of being a man or being a woman, but it is different
 The Sex/Gender System 7

from the sexual orientation (a person can have a feminine identity and
feel attracted to men, to women, to both, or to neither). In the majority of
cases, gender identity develops depending on the social context, which
determines the expression of the gender that is appropriate to the bio-
logical sex. That is, when a person learns to be considered as a woman
or a man, they also learn which behaviors they should express, which
emotions they should have, which relationships they can maintain, which
possibilities are offered, and which kinds of work are more appropriate.
In Chapter 6, a good example is presented regarding the way of thinking
as to how a type of masculinity is constructed (ie, being tough, stoic, and
neglecting self-care, as the authors point out); there may be a clash in the
specific individual with lack of social power to attain these characteris-
tics. This may give rise to depression, for example. Moreover, Chapter 9
centers on the myth of the emotionally defective man, casting doubt on
what at times are assumed to be “classic” male characteristics and insist-
ing on the repercussions brought about by these considerations in mascu-
line therapy. However, it is necessary to note, as reflected in the chapters
of this book, that the complex and permanent interaction of the dual
reality sex/gender in these identity processes does not always allow free
adhesion to gender expectations or standards; on the contrary, most of the
time this occurs with the participation of many factors that are beyond
the individual’s awareness and therefore beyond free choice. The influ-
ence of socially and culturally constructed rules and stereotypes in men’s
and women’s lives and health is as strong as it is invisible (Chrisler, 2013).
Gender, understood as a result of interactions in a specific cultural and
social context and, beyond, its consideration as a stable attribute of the
individual (West & Zimmerman, 1987), is presented as a much more com-
plex and evolving reality in which gender socialization processes are open
and in permanent construction, and in which the decision to “do gender”
is far from a personal choice (See Chapter 3 on the Bird and Rieker frame-
work of Constrained Choice, applied to help explanation of disparities in
health). Gender identity should therefore be analyzed as a cross-sectional
reality, for which analysis requires an interdisciplinary approach and a
questioning of the binary categories that constitute a real threat to psy-
chological development and the access to a broader and more realistic
gender awareness.

Gender Relationships, Gender Roles, and Gender Stereotypes

The incorporation of the category “gender” to refer to the social con-
struction of feminine and masculine underscores the relational dimensions
and the cultural and changing nature of the distinction between feminine
and masculine, and questions the essentialist definitions, favoring the
social and symbolic aspects over the biological ones in the explanation of
8 1. HEALTH FROM A GENDER PERSPECTIVE

the differences and similarities between men and women (Arango, León,
& Viveros, 1995). Gender relations define how people should interact with
others and how others relate to them, depending on their attributed gen-
der, and they should be analyzed within the cultural context in which they
develop.
Gender roles are the form in which a person’s gender identity is
expressed. They are standards of behavior that the social group defines as
appropriate for men and women, and they influence people’s daily lives;
they are the rules that tell them how they should feel, what to expect, what
gestures are correct, how to dress, what they can aspire to, how to express
themselves, and how to relate. From these definitions, the roles of women
and men are described symbolically as expressions of femininity and mas-
culinity, and they are regulated until they become rigid stereotypes that
limit individual behavior and development.
Lastly, stereotypes are the most commonly studied examples of social
categorization (Tajfel & Turner, 1979), and in the formation of all these
identity processes, they hold an important position (Martínez Benlloch,
2007). The concept of stereotype evokes concepts of prejudice and dis-
crimination when its meaning is negative, or a simplification of very sche-
matic characteristics in a more positive sense. In both cases, it is a rigid
and structured set of beliefs that are shared by members of society, refer-
ring to personal characteristics (personality traits, attributions, expecta-
tions, motivations, interests) or typical behaviors of a specific group. They
are “mental shortcuts” based on an abusive use of generalizations and
images that allow the confirmation of some of the subjects’ beliefs and
their adaptation to their environment (Ashmore & del Boca, 1981). They
are internalized in processes of social interaction and they promote the
positive assessment of the ingroup and the justification of the person’s
perceptions of the outgroup. Stereotypes are often based on three main
characteristics: age, sex, and race (Fiske, 1998; Stangor, 2000). As they are
a subjective construction, they include beliefs, expectations, and causal
attributions, which means that stereotyped thoughts do not always coin-
cide with reality, because they are basically mental images proceeding
from high cognitive elaboration.
Table 1.1 summarizes some of the features that have been pointed out
to describe the masculine and feminine stereotypes in current Western
culture (Fernández, 2004; Martínez Benlloch, 2007; Moser, 1989; Sánchez-
López, 2013a).
From the stereotypes about what men and women are like, sexism,
understood as the attitude toward a person or group on the basis of his
or her sex, is constructed. As in any attitude, in sexism three components
are differentiated: (1) the cognitive component, understood as the way in
which the target of the attitude is perceived. It is made up of thoughts,
ideas, beliefs; these are stereotypes; (2) the emotional component, consisting
 The Sex/Gender System 9

TABLE 1.1 Stereotyped Gender Roles

Masculine Stereotype Feminine Stereotype

Roles Family role as protector and Reproductive role; functions of

provider; functions of main
economic provider and protector
of those assigned to the most
vulnerable/weak groups
(women and children)
parenting and emotional support
of the family and reproduction of
the social order (socialization of
sons and daughters, maintenance
of family ties and mutual support,
transmission of cultural assets)

Productive role (paid); functions of Domestic productive role (unpaid):

economic provider and leadership functions of managing and doing
in the social and/or political area, housework
which generates power

Traits Active, determined, competitive, Dedicated to others, emotional,

independent, persistent, self- kind, aware of others’ feelings,
assured, psychic strength understanding, warm

Physical Athletic, corpulent, muscular, Beauty, elegance, sexiness, eternal

characteristics strong, vigorous, tall youth
Cognitive skills Analytical, abstract thinking; Concrete thinking, artistic, creative,
mathematical-scientific skills social intelligence; verbal skills

Adapted from Martínez Benlloch, I. (2007). Actualización de conceptos en perspectiva de género y salud. En
Colomer, C. & Sánchez-López, M.P. (2007). Programa de Formación de Formadores/as en Perspectiva de Género
en Salud: Materiales Didácticos. Madrid: Ministerio de Sanidad y Consumo and Sánchez-López, M. P. (2013a). La
salud desde la perspectiva de género: el estado de la cuestión. En M.P. Sánchez López (Ed.), La salud de las mujeres.
Análisis desde la perspectiva de género (pp. 17–40). Madrid: Síntesis.

of feelings or emotions derived from beliefs about the target of the atti-
tude; these are prejudices, marked by ambivalence; that is, by the coexis-
tence of positive feelings and rejection; and (3) the behavioral component
or tendency to act, which is expressed in discrimination.
Usually two types of sexist attitudes are mentioned: the hostile and
the benevolent attitude (Glick & Fiske, 1997, 2001, 2011). Manifestations
of hostile sexism still persist in those cultures that consider dominating
paternalism as valuable, that defend women’s inferiority and the com-
petitive differentiation of gender, that contrast the structural power of
men (which enables them to control the political, economic, religious,
and legal institutions) with the dyadic power of women (based on their
reproductive capacity and dependence relations), and that endorse het-
erosexual hostility, which considers that women’s sexual power is dan-
gerous and manipulative. Men’s hostility has been confirmed in some
studies as an attempt to control women and intimidate them, to keep
them “in their place,” not challenging the authority and power attrib-
uted to men (­Jackman, 1999, 2001). As described in Chapter 7, vio-
lence against women is considered a gender-based violence because of
10 1. HEALTH FROM A GENDER PERSPECTIVE

the obvious effect of traditional gender norms and attitudes related to

inequality between men and women.
Benevolent sexism is characterized by positive attitudes that stimulate
prosocial behavior and foster relationships of intimacy, but they conceal
exclusion processes. Attitudes underpinning it are mostly protective pater-
nalism (ie, women must be cared for and protected) and complementary
gender differentiation (ie, women’s contribution to life issues, primarily
being a mother and wife, is very valid because their capabilities and fea-
tures complement those of the men). Benevolent sexism is considered an
important factor hindering social change in groups suffering from preju-
dice and discrimination, because it makes it easier for members of these
groups to assume and agree with their position of inferiority (eg, Expósito,
Herrera, Moya, & Glick, 2010; Jackman, 1994).

THE GENDER PERSPECTIVE IN HEALTH:

INTEGRATION OF SEX AND GENDER IN THE
ANALYSIS AND RESEARCH OF HEALTH

The distinction between sex and gender and the recognition of their
interaction in individual development are increasingly common in health
studies. However, the importance of this distinction is still not sufficiently
recognized, and both terms still continue to intermesh in some scientific
studies and official documents on health policy (Connell, 2012).
Historically, research and the design of health programs have placed
much more emphasis on the differences between the sexes than on the
complex interaction between sex, gender, and health (Oertelt-Prigione,
Parol, Krohn, Preissner, & Regitz-Zagrosek, 2010). It is known that the
different ways in which men and women fall ill cannot only—or even
often—be explained by genetic differences with a biological foundation
and traditionally attributable to sexual differences. Therefore it is neces-
sary to introduce the concept of gender to explain some differences that
depend on our way of life, our expectations, and other social and cul-
tural aspects. The chapters of this book will go more deeply into different
aspects of these relationships between sex, gender, and health.
Numerous works (eg, Bendelow, Carpenter, Vautier, & Williams, 2002;
Bird & Rieker, 2008; Chrisler, Golden, & Rozee, 2012; Hunt & Annandale,
2011) and all the chapters of this book show how the fact of taking gender
into account helps us to understand how the cultural and social environ-
ment in which the person is immersed can have a major impact on the dif-
ferential exposure of women and men (and of boys and girls) to risks and
accidents, on their access to basic resources to achieve good health, and
on aspects such as the appearance, severity, and frequency of illnesses, as
well as the reactions they provoke, socially and culturally. However, public
 THE GENDER PERSPECTIVE IN HEALTH 11

policies in gender and health commonly use categorical interpretations of

gender that are still insufficient to make the active role of gender visible as
a social process that needs to be recognized in all its complexity as a deter-
minant of health (Gahagan et al., 2015). Hence the need to provide health
professionals with tools that can call attention to these changing processes
as much as possible, making them operative in all the stages required for
their effective incorporation into health interventions. We expect that the
works that are part of this book will contribute to making health profes-
sionals aware of the need to systematically include the gender perspective
in the development of public health programs and policies.
In itself, gender involves numerous dimensions, especially gender iden-
tities, gender roles, and gender-based relationships (Johnson, Greaves, &
Repta, 2009), as we have seen in previous paragraphs. With regard to health,
these roles, identities, expressions, norms, and gender-based relationships
may be risk factors or, conversely, protective factors (Pan American Health
Organization, 2010). Various studies, indeed, show that gender-based rules
(ie, the expectations that some social groups have about which behaviors and
roles correspond to men and to women) and the transposition of these rules
to the institutions and cultural practices exert a clear influence on the well-
being and health of people in general (Brabete & Sánchez-López, 2012; Burns
& Mahalik, 2011; Limiñana-Gras, Sánchez-López, Saavedra-San Román, &
Corbalán-Berna, 2013; Mahalik & Burns, 2011; Mahalik, Burns, & Syzdek,
2007; Mahalik, Lagan, & Morrison, 2006; Mahalik, Levi-Minzi, & Walter, 2007;
Sánchez-López, Cuéllar-Flores, & Dresch, 2012; Sánchez-López, Rivas-Diez,
& Cuéllar-Flores, 2013; Shelley, 2008; WHO, 2007) and all the chapters of this
book. Chapter 3 of this book, for example, gives an account of this complex-
ity through an innovative multilevel model, synthesizing the social and bio-
logical explanations of gender differences in health, and providing interesting
examples of how the social environment differentially shapes men and wom-
en’s individual agency and health-related opportunities and choices.
The diverse social institutions (family, culture, media, educational
system, laws, religious and political powers) influence and determine
expectations, experiences, roles, and gender-based relationships. These
institutions can perpetuate social and cultural norms, images, and ideals of
femininity and masculinity that do not necessarily correspond to the cur-
rent reality, or that prevent people’s development. They can also increase
the pressure and stress of the men and women who do not fit into certain
roles, who do not accept certain responsibilities, and who do not follow
the prescribed rules (Pan American Health Organization, 2010; Shelley,
2008). For example, Chapter 4 of this book uses a discursive perspective
that enables us to understand how individuals negotiate gender with
regard to health and the lack of it. This is because, as the authors point
out, the meanings of health-related behaviors are inextricably linked to
what is femininity and masculinity.
12 1. HEALTH FROM A GENDER PERSPECTIVE

Likewise, gender roles can exert economic and cultural pressures that
will variously affect women and men’s health; they can influence what
kind of occupation is “appropriate,” depending on whether one is a man
or a woman, or how to divide tasks related to paid and unpaid work,
which in turn can produce different risks and vulnerabilities for men and
for women. In short, they can produce differences in needs, behaviors,
and health-related statuses. For example, as we will see in Chapter 11,
women are normally made responsible for feeding their children in their
first months of life, which, in addition to being an obstacle in their profes-
sional development, can have negative consequences for their health.
Therefore not only sex and gender, but also sex and gender have been
shown to be able to influence the vulnerability or exposure to certain risk
factors, diseases, or health problems, and ultimately to produce inequali-
ties in health (Mikkonen & Raphael, 2010). Understanding these factors
that contribute to health inequalities and attempting to resolve them helps
achieve the essential conditions to meet the needs of individuals and
groups in order to reduce or modify harmful and risk behaviors. That is,
understanding is necessary to decrease the barriers and promote health
throughout the life cycle (Blas, Sommerfeld, & Kurup, 2011; Marmot,
2010). An example of this can be found in the different impact exerted
by HIV in men and women depending upon the time of their life cycle
in which they find themselves and varying possibilities provided by an
analysis from the gender perspective in its treatment and prevention, as is
developed in Chapter 10.
Of course, not every health difference between women and men, or boys
and girls, implies gender inequality. This concept is reserved for those dif-
ferences that are unnecessary, avoidable, and unfair. It is often considered
that these differences may be the result of chance or genetic and biological
factors, but they generally arise because people have unequal access to
key factors that influence health, such as income level, level of schooling,
employment, and social support networks, to name only a few. Therefore
to achieve full gender equity in health would not necessarily translate into
equal rates of mortality and morbidity in women and men, for example,
but into the elimination of avoidable differences in opportunities to enjoy
health and not to fall ill, suffer disabilities, or die from preventable causes.
Likewise, gender equity in health does not necessarily imply equal quotas
of resources and services for men and women; equity implies a differential
allocation and reception of resources, according to the particular needs of
each person and in each specific socioeconomic context.

Sex, Gender, and Health Outcomes

No matter what statistical sources one chooses to consult, both national or
international (Global Burden of Diseases, Injuries, and Risk Factors Study,
Another random document with
no related content on Scribd:
thousand inhabitants, while villages not of sufficient
importance to be designated on the maps, have populations
varying from ten to thirty thousand. These villages line the
banks of the Pei-ho and the main road to Peking by hundreds.
The troops were never entirely clear of them. … So hurried had
been the flight of the inhabitants that hundreds of houses
were left open, such household possessions that could not be
carried away being tousled about in great disorder. Of all
that dense population, only a few scattered hundreds of aged,
decrepit men and women, and some unfortunate cripples and
abandoned children, remained. A great majority of these were
ruthlessly slain. The Russians and Japanese shot or bayoneted
them without compunction. Their prayers for mercy availed not.
If these miserable unfortunates chanced to fall into the hands
of American or British troops they had a chance for their
lives, but even our armies are not free from these wanton
sacrifices. Every town, every village, every peasant's hut in
the path of the troops was first looted and then burned. A
stretch of country fully ten miles in width was thus swept.
Mounted 'flanks in the air' scoured far and wide, keen on the
scent of plunder, dark columns of smoke on the horizon
attesting their labors. In this merry task of chastising the
heathen Chinese, the Cossacks easily excelled. … Like an
avenging Juggernaut the Army of Civilization moved. Terror
strode before it; Death and Desolation sat and brooded in its
path. Through such scenes as these, day after day, the army
glided. A spirit of utter callousness took root, and enveloped
officers and men alike. Pathetic scenes passed without comment or
even notice. Pathos, involved in a riot of more violent
emotions, had lost its power to move."

T. F. Millard,
A Comparison of the Armies in China
(Scribner's Magazine, January, 1901).

Another eye witness, writing in the "Contemporary Review,"

tells the same sickening and shameful story, with more
 vividness of description and detail: "As a rule," he remarks,
"the heathen Chinee suffers silently, and dies calmly. He has,
it is true, a deep-rooted hatred of war, and sometimes a
paralysing fear of being shot down in battle. But he takes
beheading, hanging, or death by torture with as much
resignation as did Seneca, and a great deal less fuss. And he
bears the loss of those near and dear to him with the same
serenity, heroism, or heartlessness. But he does not often
move to pity, and very seldom yearns for sympathy. The dire
sights which anyone might have witnessed during the months of
August and September in Northern China afforded admirable
illustrations of this aspect of the national character. The
doings of some of the apostles of culture were so heinous that
even the plea of their having been perpetrated upon wild savages
would not free them from the nature of crimes. I myself
remember how profoundly I was impressed when sailing on one
calm summer's day up to the bar of Taku towards the mouth of
the river Pei-ho. Dead bodies of Chinamen were floating
seawards, some with eyes agape and aghast, others with
brainless skulls and eyeless sockets, and nearly all of them
wearing their blue blouses, baggy trousers, and black glossy
pigtails. Many of them looked as if they were merely swimming
on their backs. …

{133}

"The next picture that engraved itself upon my memory had for
its frame the town of Tong-kew. … On the right bank [of the
Pei-ho] naked children were amusing themselves in the infected
water which covered them to the arm-pits, dancing, shouting,
splashing each other, turning somersaults, and intoxicating
themselves with the pure joy of living. A few yards behind
them lay their fathers, mothers, sisters, brothers, dead,
unburied, mouldering away. On the left bank, which was also
but a few yards off, was the site of Tongkew: a vast expanse
of smoking rubbish heaps. Not a roof was left standing; hardly
a wall was without a wide breach; formless mounds of baked
mud, charred woodwork, and half-buried clothes were burning or
smouldering still. Here and there a few rootless dwellings
were left, as if to give an idea of what the town had been
before the torch of civilisation set it aflame. Everyone of
these houses, one could see, had been robbed, wrecked, and
wantonly ruined. All the inhabitants who were in the place
when the troops swept through had been swiftly sent to their
last account, but not yet to their final resting-place. Beside
the demolished huts, under the lengthening shadows of the
crumbling walls, on the thresholds of houseless doorways, were
spread out scores, hundreds of mats, pieces of canvas,
fragments of tarpaulin, and wisps of straw, which bulged
suspiciously upwards. At first one wondered what they could
have been put there for. But the clue was soon revealed. In
places where the soldiers had scamped their work, or prey
birds had been busy, a pair of fleshless feet or a plaited
pigtail protruding from the scanty covering satisfied any
curiosity which the passer-by could have felt after having
breathed the nauseating air. Near the motionless plumage of
the tall grass happy children were playing. Hard by an
uncovered corpse a group of Chinamen were carrying out the
orders they had received from the invaders. None of the living
seemed to heed the dead. …

"Feeling that I never know a man until I have been permitted

to see somewhat of his hidden springs of action and gauge the
depth or shallowness of his emotion, I set myself to get a
glance at what lay behind the mask of propriety which a
Chinaman habitually wears in Tongkew as in every other town
and village in the Empire. As soon as the ice seemed broken I
asked one smiling individual: 'Why do you stay here with the
slayers of your relatives and friends?' 'To escape their fate,
if we can,' was the reply. 'We may be killed at any time, but
while we live we must eat, and for food we have to work.'
'Were many of your people killed?' I inquired. 'Look there,'
he answered, pointing to the corpses in the vast over-ground
churchyard, 'and in the river there are many more. The
Russians killed every Chinaman they met. Of them we are in
great fear. They never look whether we have crosses or medals;
they shoot everyone.' 'You are a Christian, then?' I queried.
'Yea, a Christian,' he eagerly answered. 'And I,' 'And I,'
chimed in two others. Ten minutes' further conversation,
however, brought out the fact that they were Christians not
for conscience' sake but for safety, and they were sorely
afraid that they were leaning on a broken reed. The upshot of
what they had to tell me was that the Europeans, mainly the
Russians, looked upon them all as legitimate quarry, and
hounded them down accordingly. They and theirs, they declared,
had been shot in skirmishes, killed in sport, and bayoneted in
play.

"But the ever-recurring refrain of their narrative was the

massacre in cold blood of the three hundred coolies of Taku. …
The story has been often told since then, not merely in the
north but throughout the length and breadth of China. The
leading facts, as narrated on the spot, are these: Some three
hundred hard-working coolies eked out a very cheerless
existence by loading and unloading the steamers of all nations
which touched at Taku. For the convenience of both sides they
all cooped themselves up in one boat, which served them as a
permanent dwelling. When times were slack they were huddled
together there like herrings in a barrel, and when work was
brisk they toiled and moiled like galley slaves. Thus they
managed to get along, doing harm to no man and good to many.
The attack of the foreign troops upon Taku was the beginning
of their end. Hearing one day the sharp reports of rifle
shots, this peaceable and useful community was panic-stricken.
In order to save their dreary lives they determined to go ashore.
Strong in their weakness, and trusting in their character of
working men who abhorred war, they steered their boat
landwards. In an evil hour they were espied by the Russian
troops, who at that time had orders, it is said, to slay every
human being who wore a pigtail. Each of the three hundred
defenceless coolies at once became a target for Muscovite
bullets. It must have been a sickening sight when it was all
done. …

"The river Pei-ho, could it bear witness in words to the

dramas of blood enacted on its banks by Europeans, would have
many a tale to tell as grewsome as that of the slaughter of
the three hundred coolies. … I lived for twelve or thirteen
days on that foul river, and never was I more profoundly
impressed than by what I saw in its waters and on its banks.
The first day after I had left Tientsin I was towed by
untiring coolies through a land thickly studded over with what
had once been human dwellings, but were now high heaps of
smouldering rubbish. … A wave of death and desolation had
swept over the land, washing away the vestiges of Chinese
culture. Men, women, boys, girls, and babes in arms had been
shot, stabbed, and hewn to bits in this labyrinth of streets,
and now, on both banks of the river, reigned the peace
described by Tacitus. …

"Fire and sword had put their marks upon this entire country.
The untrampled corn was rotting in the fields, the pastures
were herdless, rootless the ruins of houses, the hamlets
devoid of inhabitants. In all the villages we passed the
desolation was the same. … The streets and houses of
war-blasted cities were also the scenes of harrowing
tragedies, calculated to sear and scar the memory even of the
average man who is not given to 'sickly sentimentality.' In
war they would have passed unnoticed; in times of peace
(hostilities were definitely over) they ought to have been
stopped by drastic measures, if mild means had proved
ineffectual. I speak as an eye-witness when I say, for
example, that over and over again the gutters of the city of
Tungtschau ran red with blood, and I sometimes found it
impossible to go my way without getting my boots bespattered
with human gore. There were few shops, private houses and
courtyards without dead bodies and pools of dark blood. … The
thirst of blood had made men mad. The pettiest and most
 despicable whipper-snapper who happened to have seen the light
of day in Europe or Japan had uncontrolled power over the life
and limbs, the body and soul, of the most highly-cultivated
Chinaman in the city. From his decision there was no appeal. A
Chinaman never knew what might betide him an hour hence, if the
European lost his temper. He might lie down to rest after
having worked like a beast of burden for twelve or fourteen
hours only to be suddenly awakened out of his sleep, marched a
few paces from his hard couch, and shot dead.
{134}
He was never told, and probably seldom guessed, the reason
why. I saw an old man and woman who were thus hurriedly
hustled out of existence. Their day's work done they were
walking home, when a fire broke out on a little barge on the
river. They were the only living beings found out of bed at
the time, and in the pockets of the woman a candle and some
matches were stowed away. Nobody, not even the boat-watchman,
had seen them on or near the boat. They were pounced upon,
taken to the river's edge, shot and buried. It was the work of
fifteen minutes or less. …

"The circumstantial tales told of the dishonouring of wives,

girls, children, in Tientsin, Tungtschau, Pekin, are such as
should in normal beings kindle some sparks of indignation
without the aid of 'sickly sentimentality.' … I knew well a
man whose wife had been dealt with in this manner, and then
killed along with her child. He was one of the 'good and loyal
people' who were on excellent terms with the Christians; but, if
ever he gets a chance of wreaking vengeance upon the
foreigners, he will not lightly let it slip. I knew of others
whose wives and daughters hanged themselves on trees or
drowned themselves in garden-wells in order to escape a much
worse lot. Chinese women honestly believed that no more
terrible fate could overtake them than to fall alive into the
hands of Europeans and Christians. And it is to be feared that
they were right. Buddhism and Confucianism have their martyrs
to chastity, whose heroic feats no martyrology will ever
 record. Some of these obscure, but rightminded, girls and
women hurled themselves into the river, and, finding only
three feet of water there, kept their heads under the surface
until death had set his seal on the sacrifice of their life.
This suicidal frenzy was catching. … So far as I have been
able to make out, and I have been at some pains to investigate
the subject, no officers or soldiers of English or
German-speaking nationalities have been guilty of these
abominations against defenceless women."

E. J. Dillon,
The Chinese Wolf and the European Lamb
(Contemporary Review, January, 1901).

CHINA: A. D. 1900 (August 15-28).

Occupation of Peking by the allied forces.
International jealousies.
License to some of the soldiery.
Shameful stories of looting and outrage.
Formal march through the "Forbidden City."

"Early on the morning of the 15th [of August]—the day after

the siege of the Legations was raised—General Chaffee [the
American commander] advanced his men from the Chien Mên, which
he had held overnight, and drove the Chinese from gateway to
gateway back along the wide-paved approach to the far-famed
'Forbidden City.' From the wall at the Chien Mên the American
field battery shelled each of the great gateways before the
infantry advanced, and Captain Reilly, who commanded the
battery, was killed while directing the operations—a bullet
striking him full in the face and passing out through the back
of his head. In him was lost a popular and efficient officer. The
movements of the Americans were watched with no little anxiety
by certain of the allies, who evidently feared that General
Chaffee was about to enter and seize the Forbidden City
itself. The French, who had only that morning arrived, were
apparently very keen to establish a claim by joining in the
attack, for they took their mountain guns to the top of the
wall opposite the Legations, and began blazing away in the
direction of the approaches to the Palace. It so happened that
by this time the Americans had penetrated nearly to the
gateway of the Palace itself, and this French fire, so
suddenly opened, was directed upon them, instead of, as the
French General thought, upon the enemy. General Chaffee rode
down himself from the Chien Mên to where the guns were placed
on the wall, and from below conducted a spirited conversation
with the French General and M. Pichon. 'Stop firing those
guns,' the General shouted up from 60 ft. below, 'you are
killing my men.' Not understanding, the French General replied
to the effect that he was firing for the honour of France, and
M. Pichon joined in with similar protestations. General
Chaffee's protests increased in vigour, and the force,
perhaps, rather than the lucidity of them eventually induced
the French General to desist from firing upon the Americans
for the honour and glory of 'la patrie.' The Russians also
displayed a marked desire to participate in the operations in
front of the Palace, coming up after the fighting was
practically finished and attempting to occupy a part of the
position won by the Americans. Again General Chaffee had to
speak forcibly to persuade the Russians to retire. General
Chaffee cleared and occupied the whole length of the
approaches—a series of noble paved courtyards—from the Chien
Mên to the south gate of the Palace, before which he set a
strong guard. His doings were quite evidently being watched
with suspicion, and in the afternoon a conference was held, at
which it was solemnly agreed by the representatives of the
allies that in the meantime, pending the arrangement of some
concerted plan, the Forbidden City should not be entered. In
other parts of the city the work of clearing out the enemy was
meanwhile progressing, the Japanese and Russians operating on the
east and to the north, and the British to the south in the
Chinese city.

"It was thought that an expedition would have been undertaken

 by the French to relieve the besieged in the Pei-tang. Help
could have been obtained for the asking, and it is difficult
to understand why no effort was made to reach the unfortunate
people, who, be it noted, were still being attacked, and whose
position, for all that was known, might have been desperate to
the last degree. The story of the long and weary weeks of
fighting round the stately cathedral pile—alas, now, now
battered and rent!—must be written by no outsider from
hearsay, but first hand by a survivor. As heard from the lips
of Père Favier, it is, indeed, a thrilling narrative in many
respects, surpassing in wonder even its sister story of the
defence of the Legations. … The relief was effected the
following morning by a combined force of French and Russians,
with whom also were the British Marines under Major Luke, R.
M. L. I., the whole under the command of the French general.
When this force arrived it was found that the Japanese had
already practically raised the siege, having started earlier
and worked along on the north-west of the Imperial City,
driving the Chinese before them. However, the Japanese had not
actually penetrated into the Pei-tang defences, and the French
had the satisfaction, after all, of being first in to receive a
joyful welcome from their long-suffering fellow-countrymen.
{135}
The raising of the siege was signalized by the slaughter of a
large number of Chinese who had been rounded up into a cul de
sac and who were killed to a man, the Chinese Christian
converts joining in with the French soldiers of the relieving
force, who lent them bayonets, and abandoning themselves to
the spirit of revenge. Witnesses describe the scene as a
sickening sight, but in judging such acts it is necessary to
remember the provocation, and these people had been sorely
tried. …

"The French general had given orders to Major Luke to remain

with his men to guard a bridge in the rear while the relief of
the Pei-tang was being effected. Afterwards the main body of
the relieving force was pushed on through the Imperial City,
leaving the British contingent behind. After waiting some time
Major Luke came to the conclusion that he must have been
forgotten, and, leaving a guard on the bridge, followed on in
the track of the French troops, to find that they had
penetrated into the Imperial City along the wall of the Palace
as far as the Meishan (Coal Hill), from the pagodas on which
the tri-colour was flying. The Russians had taken up a
position near the North Gate of the Palace, and he was only
just in time to secure the temple building at the foot of the
Meishan, and the camping-ground alongside of it. There was
great enthusiasm between the Russians and French, who cheered
each other as their forces appeared, in marked contrast to the
coolness with which the arrival of Major Luke and his men was
received. … The Russians are camped round the old place and
will permit no one in to see over it; in fact, in this part of
the city French or Russian sentries make it difficult to see most
of the many objects of art or interest. …

"Now that the common bond of interest in the success of the

relief expedition was removed, the points of difference at
once began to appear, and the underlying jealousy and
suspicion with which it seems each nation regards almost every
other manifested itself in various ways, particularly in the
unseemly race for loot and the game of general grab that now
started up, the methods of which were indicated above with
regard to the seizure of the Meishan. The Japanese seized the
Board of Revenue and must have found a huge amount of money
there, to judge by the length of the line of pack mules that
it took to carry it away. Through a mistake, it is said, on
the part of the Americans, the French got possession of the
Palace of Prince Li, said to contain treasure to the extent of
many millions of dollars. The Russians also got some treasure,
seizing on a large bank.

"Inside the Forbidden City, the Chinese say, there is fabulous

wealth in treasure stowed away or buried, and it is
principally lest this should prove true that so much jealousy
exists about the privilege of entering. Of course, the
question is also of great importance politically, and after
several diplomatic conferences it was eventually decided that,
on a date still to be arranged, the Ministers and Generals of
all the Powers should enter at the same time and proceed
together through the Palace, ascertaining the nature and value
of its contents and then sealing the whole place up and
withdrawing to await instructions from the home Governments. …
As regards the larger game of grab, the Russians succeeded in
winning the last large prize, the Wan Shen Shan, or new Summer
Palace, seven miles out near the western hills, racing for it
against a body of Japanese and coming in a quarter of an hour
ahead, having had a long start. So the story goes, but it is
not easy to check such stories, both Japanese and Russians
being very reticent about their relations with each other. One
thing only is certain, that the Russians are in jealous
possession of the Wan Shen Shan. Two British officers who rode
out there a couple of days ago in uniform were refused
admission to the grounds.

"Alongside of this official looting, private looting on the

part of the foreign soldiers was freely permitted during the
first few days; in fact, the city was abandoned for the most
part to the soldiery, and horrible stories of the kind common
in war, but nevertheless and everlastingly revolting, were
current—stories of the ravishing of women in circumstances of
great savagery, particularly by the rough Russian soldiers and
their following of French. The number of Chinese women who
committed suicide rather than submit to dishonour was
considerable. A British officer of standing told me he had
seen seven hanging from the same beam in the house of
apparently a well-to-do Chinaman. These stories, and I heard
of many more, reflect credit upon Chinese womanhood and
something very different upon the armies of Europe, which are
supposed to be the forerunners and upholders of civilization
in this particular campaign. However, this period of licence
was not of long duration. The soldiers having had their fling,
 the city was divided, by arrangement, into districts, each
under the control of one of the Powers, proclamations were
issued reassuring the remaining peaceable citizens and
encouraging others to return, and gradually the work of
restoring law and order and confidence is progressing. …

"Where is the Chinese Government? Fled to Je-hol? No one seems

to know for certain. It is only certain that on the morning of
the 14th the Empress-Dowager and her following, and the
Imperial Court, fled by the west gate of the city and
disappeared. This flight took place while the Japanese were
actually engaged in shelling the Tse-kwa Mên and the city
wall. If they had succeeded in their first attempt on the gate
in the morning, the flight of the Court might have been
prevented. The Empress and her advisers had a narrow escape. …

"August 28. After deliberations occupying a full fortnight the

question of what was to be done with the Forbidden City has
been settled, at any rate, for the time being. The main
problem presented was not new; Lord Elgin had to face it forty
years ago. Considerations of immediate political expediency
guided his action then, as they have dictated the course
adopted now. He spared the Imperial Palace, and burnt instead
the Yuen Ming Yuen, or Summer Palace, seven miles from Peking.
As a result the fact that British troops ever entered Peking
does not appear in Chinese history, indeed the idea is
ridiculed by Mandarindom. Remembering this, many people here
thought it would be desirable in the present instance to burn
the Imperial Palace, after carefully removing the art
treasures, and thus, if possible, impress upon the whole
Chinese nation some idea of the enormity of the crime which
their Government has committed against civilization at large.
{136}
On the other hand, it was held that if this were done the
Imperial Court, through loss of 'face,' could never return to
Peking, and this contingency appealed strongly to the
representatives of both Russia and Japan, who conceived that
the interests of their respective countries demanded the
retention of Peking as the capital. What the representatives
of the other Powers thought has not transpired, nor does it
matter much at present, the overwhelming position of Russia
and Japan combined making all opposition to their proposals
futile. Germany may insist upon burning the Palace when he
forces have all arrived, and those who think it ought to be
done hope that she will; but in the meantime the conference of
commanding officers, in consultation with the Ministers,
decided not to do more than march a small force of foreign
troops through the 'sacred precincts' from the South Gate to
the North, after which these were to be again closed, leaving
the Palace intact. There was to be no looting. Everything was
to be done to provide against the idea arising that the place
had been desecrated. The ceremony was merely to be a display
of military power. …

"Arrangements were made for certain Chinese officials to be

present during the ceremony and also for a number of
attendants to open up the various halls through which the
troops would require to pass, and to close the doors behind
the 'barbarians' when they finally withdrew. Yesterday there
were reports of further friction and possible further
postponement of the ceremony, but by evening these had died
away and the programme had assumed at last a definite shape.
According to it the various troops were to parade this morning
between 7 and 8 outside the Tien-an Mên, the Inner Gate of the
Imperial City. There at the time appointed they were drawn up,
and the interest of a great historic event began. The Imperial
Palace, or Forbidden City, is an enclosure about two-thirds of
a mile long from north to south and about half a mile broad
from east to west. It is surrounded by a high wall. Outside
this wall on the west, north, and east lies a broad moat. From
the south it is approached by a series of immense paved
courtyards divided one from the other by high and massive
gateways, above which rise imposing pavilions with
yellow-tiled overhanging roofs, flanked by great towers built
in the same style and similarly roofed with Imperial yellow.
This Forbidden City or Imperial Palace enclosure is situated
within the Imperial City, a larger enclosure, also surrounded
by a high tile-topped wall. It was outside the Inner Gateway
to this Imperial City that the troops were drawn up. The
Russians took up their position on the centre, close to the
stone bridge in front of the Tien-an Mên; the Japanese were
opposite the gateway on the left; the British to the right of
the Russians in a wide paved avenue running east and west
outside the inner wall of the Imperial City. The remainder of
the allies were drawn up to the rear of the Russians and
Japanese in the wide avenue running north and south from the
Outer Gateway (Ta-ching Mên). As a pageant it was not a
success. Soldiers on service do not make a fine show. … Inside
the Tien-an Mên the central stone road continues for about
half a mile down a broad, flagged avenue running between
handsome temple buildings on either hand, until the Wu Mên, or
south gate, of the Forbidden City is reached. It is an
imposing entrance. The gateway itself is high and massive, and
the towers on top are particularly fine. Thus far, on the
morning of the 15th, the American troops fought, driving the
Chinese before them into the city. The self-denial displayed
by General Chaffee on that occasion has not, perhaps, received
proper recognition. There was at that time no agreement to
hold him back, and he might have pressed on and taken the
palace and hoisted the Stars and Stripes over it. It would
have been a fine prize, and the temptation must have been
great, but General Chaffee, acting, possibly, under the advice
of Mr. Conger, the United States Minister, refrained—a
noteworthy act. This gateway has been held by an American
guard ever since, and American troops have been quartered in
the approach to it. …

"After it was over the generals and staff officers and the
Ministers and other privileged persons returned by the way we
had come through the Forbidden City. Tea was provided by the
Chinese officials in the summer-house of the palace garden,
 the quaint beauties of which there was now time to appreciate.
Beautiful stone carvings and magnificent bronzes claimed
attention. The march through had occupied about an hour, and
another was spent sauntering back through the various halls
and courtyards. As the halls were cleared the Chinese
attendants hastily closed the doors behind us with evident
relief at our departure. A few jade ornaments were pocketed by
quick-fingered persons desirous of possessing souvenirs, but
on the whole the understanding that there was to be no looting
was carried out. Arrived at the courtyard where their horses had
been left, the generals and staff officers mounted and rode
out of the palace, and the rest of us followed on foot. The
gates were once more closed and guards were stationed outside
to prevent anyone from entering. The Forbidden City resumed
its normal state, inviolate, undesecrated. The honour of the
civilized world, we were told, had been thus vindicated. But
had it?"

London Times,
Peking Correspondence.

CHINA: A. D. 1900 (August-September).

The flight of the Imperial Court.

The following account of the flight of the Court from Peking

to Tai-yuen-fu was given to a newspaper correspondent, in
October, by Prince Su, who accompanied the fugitive Emperor
and Dowager-Empress, and afterwards returned to Peking:

"The day the Court left Peking they travelled in carts to

Kuan-shi, 20 miles to the north, escorted by 3,000 soldiers of
various commands. This composite army pillaged, murdered, and
outraged along the whole route. At Kuan-shi the Imperial
cortege was supplied with mule litters. The flight then
continued at the rate of 20 miles daily to Hsuan-hua-fu, where
a halt was made for three days. This place is 120 miles from
Peking. Up to this time the flight had been of a most
 panic-stricken nature. So little authority was exerted that
the soldiers even stole the meals which had been prepared for
the Emperor and the Dowager-Empress. Some improvement was
effected by the execution of several for murder and pillaging,
and gradually the various constituents of the force were
brought under control.
{137}
Many of the Dowager-Empress's advisers were in favour of
remaining at Hsuan-hua-fu, on account of the comparatively
easy means of communication with the capital. The majority,
however, were in such fear of pursuit by the foreign troops
that the proposition was overruled. The flight was then
resumed towards Tai-yuen-fu. Before leaving Hsuan-hua-fu,
10,000 additional troops under Tung-fuh-siang joined the
escort. The newcomers, however, only added to the discord
already prevailing. The Dowager-Empress did little else but
weep and upbraid those whose advice had brought them into such
a position. The Emperor reviled everyone irrespective of his
opinions. The journey to Tai-yuen-fu took 26 days, the longest
route being taken for fear of pursuit. On arriving there the
formation of some kind of Government was attempted, but owing
to the many elements of discord this was found to be next to
impossible. Though many edicts were issued they could not be
enforced. Neither party cared for an open rupture, and affairs
rapidly assumed a state of chaos. Prince Su further said that
the Emperor did not desire to leave Peking, preferring to
trust himself to the allies, but his objections were not
listened to and he was compelled to accompany the flight."

The final resting-place of the fugitive Imperial Court for

some months was Si-ngan-fu, or Sin-gan Fu, or Segan Fu, or
Sian Fu (as it is variously written), a large city, the
capital of the western province of Shensi.

CHINA: A. D. 1900 (August-December).

Discussions among "the Powers" as to the terms to be made
with the Chinese Government.
Opening of negotiations with Prince Ching and Li Hung-chang.

Immediately upon the capture of Peking, Li Hung-chang

addressed appeals to the Powers for a cessation of
hostilities, for the withdrawal of troops from Peking, and for
the appointment of envoys to negotiate a permanent peace.
Discussion among the governments followed, the first definite
outcome of which appeared in the announcement of an intention
on the part of Russia to withdraw her troops from Peking as
soon as order had been re-established there, and of a
disposition on the part of the United States to act with
Russia in that procedure. This substantial agreement between
the two governments was made public by the printing of the
following dispatch, dated August 29, from Mr. Adee, the
American Acting Secretary of State, to the representatives of
the United States in London, Paris, Vienna, Berlin, Rome, and
Tokio:

"The Russian Charge d'Affaires yesterday afternoon made me an

oral statement regarding Russia's purposes in China to the
following effect:—'That, as she has already repeatedly
declared, Russia has no designs of territorial acquisition in
China; that, equally with the other Powers now operating
there, Russia sought the safety of her Legation in Peking and
to help the Chinese Government to repress the troubles that
arose; that incidentally to the necessary defensive measures
on the Russian border, Russia has occupied Niu-chwang for
military purposes, and as soon as order is re-established she
will withdraw her troops from the town if the action of the
other Powers be no obstacle; that the purpose for which the
various Governments have co-operated for the relief of the
Legations in Peking has been accomplished; that taking the
position that as the Chinese Government has left Peking there
is no need for the Russian representative to remain, Russia
has directed her Minister to retire with his official
personnel from China; that the Russian troops will likewise be
withdrawn, and that when the Government of China shall regain the
reins of government and can afford an authority with which the
other Powers can deal, and will express a desire to enter into
negotiations, the Russian Government will also name its
representative.' Holding these views and purposes, Russia has
expressed the hope that the United States will share the same
opinion.

"To this declaration our reply has been made by the following
memorandum:—'The Government of the United States has received
with much satisfaction the reiterated statement that Russia
has no designs of territorial acquisition in China and that,
equally with the other Powers now operating in China, Russia
has sought the safety of her Legation and to help the Chinese
Government to repress the existing troubles. The same purposes
have moved, and will continue to control, the Government of
the United States, and the frank declarations of Russia in
this regard are in accord with those made to the United States
by the other Powers. All the Powers, therefore, having
disclaimed any purpose to acquire any part of China, and now
that the adherence thereto has been renewed since relief
reached Peking, it ought not to be difficult by concurrent
action through negotiations to reach an amicable settlement
with China whereby the treaty rights of all the Powers shall
be secured for the future, the open door assured, the
interests and property of foreign citizens conserved, and full
reparation made for the wrongs and injuries suffered by them.

"So far as we are advised, the greater part of China is at

peace and earnestly desires to protect the life and property
of all foreigners, and in several of the provinces active and
successful efforts to suppress the 'Boxers' have been taken by
the Viceroys, to whom we have extended encouragement through
our Consuls and naval officers. This present good relation
should be promoted for the peace of China. While we agree that
the immediate object for which the military forces of the
Powers have been co-operating—the relief of the Ministers in
Peking—has been accomplished, there still remain other
 purposes which all the Powers have in common, which have been
referred to in the communication of the Russian Charge d'
Affaires, and which were specifically enumerated in our Note
to the Powers.

"These are:—To afford all possible protection everywhere in

China to foreign life and property; to guard and protect all
legitimate foreign interests; to aid in preventing the spread
of disorders in the other provinces of the Empire and the
recurrence of such disorders; to seek a solution which may
bring about permanent safety and peace in China; to preserve
the Chinese territorial and administrative entity; to protect
all rights guaranteed by treaty and international law to
friendly Powers; and to safeguard for the world the principle
of equal and impartial trade with all parts of the Chinese
Empire. In our opinion, these purposes could best be attained
by the joint occupation of Peking under a definite
understanding between the Powers until the Chinese Government
shall have been re-established and shall be in a position to
enter into new treaties containing adequate provisions for
reparation and guarantees for future protection.

{138}

"With the establishment and recognition of such authority the

United States would wish to withdraw its military forces from
Peking and remit to the processes of peaceful negotiation our
just demands. We consider, however, that the continued
occupation of Peking would be ineffective to produce the
desired result unless all the Powers unite therein with entire
harmony of purpose. Any Power which determines to withdraw its
troops from Peking will necessarily proceed thereafter to
protect its interests in China by its own method, and we think
this would make a general withdrawal expedient. As to the time
and manner of withdrawal, we think that, in view of the
imperfect knowledge of the military situation resulting from
the interruptions of telegraphic communication, the several
military commanders in Peking should be instructed to confer
and to agree together upon the withdrawal as a concerted
movement, as they agreed upon in advance.

"The result of these considerations is that, unless there is

such a general expression by the Powers in favour of the
continued occupation as to modify the views expressed by the
Russian Government and lead to a general agreement for
continued occupation, we shall give instructions to the
commander of the American forces in China to withdraw our
troops from Peking after due conference with the other
commanders as to the time and manner of withdrawal.

"The Government of the United States is much gratified by the

assurance given by Russia that the occupation of Niu-chwang is
for military purposes incidental to the military steps for the
security of the Russian border provinces menaced by the
Chinese, and that as soon as order is established Russia will
withdraw her troops from those places if the action of the
other Powers is not an obstacle thereto. No obstacle in this
regard can arise through any action of the United States,
whose policy is fixed and has been repeatedly proclaimed."

Even before the communication received from Russia, the

government of the United States had taken steps to withdraw
the greater part of its troops. "On the 25th of August," says
the American Secretary of War, in his annual report, November
30, 1900, "General Chaffee was directed to hold his forces in
readiness for instructions to withdraw, and on the 25th of
September he was instructed to send to Manila all the American
troops in China with the exception of a legation guard, to
consist of a regiment of infantry, a squadron of cavalry, and
one light battery."

The expressions from Russia and the United States in favor of

an early withdrawal of foreign troops from Peking, and the
opening of pacific negotiations with the Chinese government,