Women cannot afford “nice”: The unpaid labor of gendered caregiving

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Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Karen Kelly-Blake, PhD

Caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare.” -Audre Lorde

Much has been written about finding meaning in illness. Others have written about finding meaning in caregiving. But taking care of someone else’s s!#t has its own intrinsic meaning, and for much of the time, it’s not all good.

For some, doing this work may allow them redemption—to repent for past wrongs, or it might allow them to display their humanity in ways they have not done before. Some may experience joy with self-sacrifice. I wish you well. Amid the crucible, women are performing all sorts of gendered work, and especially gendered care work. What do I mean by that? Women perform the majority of caregiving work to family and friends, i.e. women are the ones taking care of someone else’s s!#t. This work is unpaid, labor intensive, and career limiting if not career destroying.

Multitasking woman with six arms illustration
Image description: An illustration of a faceless woman with six arms, each arm holding objects that represent a particular set of tasks: correspondence, computer work, food, entertainment, cleaning, and childcare. Image source: Multitasking Vectors by Vecteezy.

Care work offers few rewards, but it is necessary, and it is often silently expected of women. Unpaid labor that diminishes or denies opportunity for growth and sustenance is unfair, unjust, unsustainable, and wrong. Caregiver resilience may be a thing but is most likely a statement of privilege. Women do the work to the detriment of self-care, careers, outside friendships and interests, and other family relationships. Un- and under-paid gendered care work is a real and present danger to the overall wellbeing of women. As a society, we cannot keep telling women that this kind of gender discrimination in care work, especially for their family, is okay. It is not okay. Women must acknowledge all the ugliness that comes with taking care of someone else’s s!#t—the resentment, anger, frustration, disappointment, loss, fear, disgust, exhaustion, defeat.

So, who will do this work?

Dare I say, salaried home health assistants with all the benefits afforded fully employed persons—health insurance, retirement, educational assistance, PTO, etc. BUT then, who will do that work? Women, and more specifically women of color and immigrants. Whether women do it as unpaid family labor or as salaried health aides, women do care work. It may be reasonable to assume that the salaried worker may be better able to handle the emotional demands of the work. The unpaid family care worker is burdened with history, regrets, slights, insults, lies, disappointments, unforgiven and unforgivable acts, whereas the salaried care worker is not burdened with that baggage, and thus, may be a better and perhaps even a more caring caregiver. Absent the burden and weight of historical relationship bonds, women—as daughters, sisters, spouses, and mothers—may be able to find meaning in just being themselves.

Although the inequity of gendered work has always been there, the COVID-19 pandemic has shed revealing light on this inequity, just as it has on racism. Women are performing job duties remotely from home, becoming teachers, chefs, activity directors, housekeeping staff, laundry workers, and of course the calm in the storm, etc. Working the second shift does not go far enough in describing that reality—women hold on average about 100 jobs that are unpaid! These jobs historically have been the purview of women, but gendered work in the home is the cause of much friction in marriages. Moreover, women are balancing care of children with the care of parents, at times both their own and those of their spouse. Those women fortunate enough to retain their jobs and work remotely were immediately immersed in work that was unfamiliar and, in many cases, unwanted—24/7 care and attention to children, spouses, and others. For those caring for the ill, the disabled (mentally, physically, or cognitively), or the aged, or any individual with any range of functional and psychological limitation, the pandemic significantly increased the workload. Many people do this care work because they want to, out of whatever love and obligation they have for the care receiver. For others, there is no one else to do the work and it may feel, and indeed be, life limiting. Engaging in this work during a pandemic is especially challenging.

Oftentimes, a crash course in highly technical aspects of care (flushing ports, inserting feeding tubes, cleaning wounds, managing LVADs, etc.) leaves one completely bewildered. This disjuncture between necessary specialized care exposes the schism in care work that overwhelms and burdens.

Photo of woman on the floor with hands over her face
Image description: Image description: A woman sits on the floor leaning against the back of a couch. Her elbows are resting on her knees with her hands clasped together over her face, eyes closed. Image source: Pixabay.

Because of shelter-in-place orders, the pandemic has also heightened concerns about domestic violence, child abuse, elder abuse, and alcohol and substance use disorders. We consequently will need to ramp up behavioral health and trauma-informed care services. Sadly, history predicts how unlikely we are to effectively meet this challenge. Essential caregivers unable to work remotely have had to expose themselves and their children to increased risk of disease, because their children had to remain in daycare or in multigenerational spaces with no means to isolate.

Gendered care work can no longer hide under the auspices of family love and selflessness. Caregivers oftentimes die before the care receiver. There is nothing heroic or laudable about a preventable early death. Too much togetherness can breed resentment. There is always something needed, an ask or a want. There is little give in return. Even a sincerely offered “thank you” neither diminishes nor alleviates profound fatigue.

How do we mitigate the harmful effects of such inequitable gendered expectations?

  • Recognize the gender inequity of care work and the harm such blindness inflicts.
  • Pave the way for long-term care access, regulation, and insurance.
  • Pay care workers (both in institutional and home health settings) a salary with PTO, retirement, and benefits (educational and promotion opportunities).
  • Provide paid family leave for family and friend care workers, so that they can focus on the care work they want to do without worrying about economic self-harm.
  • Ensure enhanced respite care and family mental health support.

Taking care of someone else’s s!#t is hard, labor-intensive work, both physically and mentally, and it must be recognized as such. We can no longer silently accept the gender discrimination inherent in care work. We all must bear the burden and the weight, and take care of each other’s s!#t.

Disclaimers: The title is gendered caregiving, which, for the purposes of this blog, focuses on the traditional gender binary of women and men doing caregiving. While clearly in the minority, men do provide unpaid care work. I afford no special credit for doing this work because one is a man. It is akin to saying, “my husband is babysitting the kids”—um, no they are doing the hard work of parenting. My goal is to highlight the burden of care work that is performed primarily by women. Women do not get gold stars for work that they have historically been expected to do.

The author acknowledges her own lifelong role as a caregiver. I do not aim to speak to every person’s experience with doing this work. Instead, I seek to highlight that the continued gender inequity and unpaid labor of care work harms women. If we are to be a just society, it is imperative for us to take care of the caregivers.

Karen Kelly-Blake photoKaren Kelly-Blake, PhD, is an Associate Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine in the Michigan State University College of Human Medicine.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, July 30, 2020. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Kelly-Blake: The Burden of Serving: Who Benefits?; Patient dumping: why are patients disposable?Incarcerated AND Sick: At Risk for Pain, Injury, and DeathWhite Horse, White Faces: The Decriminalization of Heroin AddictionRacism and the Public’s Health: Whose Lives Matter?Concussion in the NFL: A Case for Shared Decision-Making?

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Ethics and Children with Differences in Sex Development and Gender Nonconformity

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Society once considered children born with atypical genital anatomy to be freaks of nature. Until recently, doctors labeled these children “hermaphrodites” and urged early appearance-altering surgery. While times have changed, somewhat, medical interventions continue despite mounting evidence of long-term harms associated with both medical and surgical “treatment.” In the last few years, family, public, and medical attention has increasingly focused on children who feel trapped in the body of the “opposite” sex and wish to live as the other gender. Controversy continues about how often these feelings persist into adulthood and when to use medical interventions, such as hormone blocking to prevent full pubertal development, to support the gender nonconformity. When should society constrain clinicians from intervening in these contentious arenas?

sept 28 calendar iconJoin us for Joel E. Frader’s lecture on Wednesday, September 28, 2016 from noon till 1 pm in person or online.

Joel E. Frader, MD, MA, is the A Todd Davis Professor of General Academic Pediatrics and Professor of Bioethics and Medical Humanities at Northwestern University’s Feinberg School of Medicine. He is the Medical Director of the Pediatric Palliative Care Program at Lurie Children’s Hospital in Chicago. He received a B.A. from Columbia University (1970), a M.D. from Tufts (1974), and a M.A. in Sociology from the University of Pennsylvania (1980) where he was a Robert Wood Johnson Clinical Scholar. He is active in and served in leadership positions for national organizations concerned with pediatrics and bioethics. He teaches, consults and conducts research in bioethics and palliative care, focusing on ethical issues involving children in the health care system and innovation in health care. He has special interest in ethics in organ transplantation, children with differences in sexual development (intersex) and gender nonconformity, decision making at the end of life, and the ethics of human subjects research.

In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

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Bathrooms, Binaries, and Bioethics

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series. Visit this page for more information.

By Jamie Lindemann Nelson, PhD

Bioethicists typically deal with the moral complexities that emerge when social institutions—the clinic and the lab, chiefly—try to fend off our bodily vulnerabilities or ease their physical and social consequences. Recently, however, major social institutions have acted to make some people’s bodily vulnerabilities harder to deal with, hampering their access to means of coping with them that otherwise are publicly available.

The vulnerability I refer to is the regular need to eliminate the waste our bodies generate; “some people” are transgender women and men, boys and girls; the culprits are a wide selection of American state legislatures. Spring 2016 may go down in the annals of infamy as the season when lawmaking bodies across the country became fixated on the subject of bathrooms. The South Dakota House of Representatives narrowly sustained the governor’s veto of a measure passed by large majorities in both legislative houses that would have forbidden transgender students to use bathrooms, locker rooms, and showers designated for use by members of the gender with which they identify. In Tennessee, a bill that extends the bathroom ban to public universities as well as middle and high schools unanimously passed out of committee. Briefly stalled due to public hearings at which transgender high school students eloquently testified, the bill was quickly revived and sent on, only to stall again; its future remains uncertain. Unwilling, perhaps, to encounter eloquent North Carolinian trans students, the legislature there called a special session to ram through a sweeping bill that undercut the ability of local governments to extend anti-discrimination protections to LGBTQ folks generally; this haste was prompted, apparently, by the specter of trans people being expressly welcome to gender-concordant loos in Charlotte. Unimpeded by vetoing governors or eloquent students, this measure is currently the law in North Carolina. Nor is this all. According to the Human Rights Campaign, 44 anti-trans measures are under consideration in 16 states.

The typical rationale for barring trans people from their lavatories is to protect privacy and safety. To speak gently, this is ill-considered: there is no reason to regard a transwoman as a particular threat to any other woman occupying the next stall. No cisgender man standing at a urinal has any special cause to fear the transman washing his hands at the sink. Any heightened danger of being menaced would run in the other direction: a transwoman forced to use accommodations designated for men might well have good reason to be concerned about her safety. Privacy is a more amorphous notion, but however it is meant, it seems unlikely to be furthered by forcing transmen to enter women’s lavatories, or forcing transwomen to use the gent’s.

Bioethicists, who generally favor clarity about risks and benefits as they concern bodies, should be among those pointing this out. They might also help spread the word that enforcing such measures heightens risks of pain, distress, and ill health to those who, during the course of a long work shift or school day, can’t bring themselves to use discordant facilities, or fear making themselves conspicuous by using whatever alternatives might be present. There is also disturbing evidence that barring trans people from facilities matching their gender identification contributes to their strikingly elevated suicide rates (Seelman).

But the matter doesn’t end with getting clear about who is more at risk than whom—if that were really at issue, none of these bills would have taken up any legislature’s time and money. What then is behind these efforts to crimp transpeople’s access to concordant lavatories, and thus to hamper their access to much of social life generally? A clue was provided by South Dakota state representative Stephen Haugaard. In a bravura performance of metaphoric derangement, Representative Haugaard called transgender a “virus that has broken out” across the nation, while also asserting that being transgender is a matter of decision. “When you feed the fire of this kind of confusion,” Haugaard said, “you’re going to add to the number of people who are going to make this choice.”

Not that these bills—which frequently stipulate that sex is determined by anatomy at birth, by chromosomes, or in accord with original birth certificates—need such dicta to reveal their intent; they do a pretty good job speaking for themselves. The language that blocks recognition of any kind of gender crossing makes it clear that the real target isn’t preserving anyone’s safety or privacy. The drive is to use the law, not only to limit trans presence in public spaces, but to fight the uptake and circulation of how transpeople understand themselves—in short, to delegitimize transgender people as such.

Anti-transgender laws are part of a general reactionary effort to hold certain people in the subordinate or frankly abject positions in which social traditions have assigned them—forced to give way on same-sex marriage, the imagined immutability of the gender binary is the new line in the sand. As bioethicists have noted, medical practices that engage trans people have played both sides of that line—both pathologizing and affirming the distinctive ways in which transgender constitutes an invitation to respond more richly to reality’s complexities. A challenge now for bioethics is to nurture the affirmative side of this legacy, helping to clarify for medical personnel and the public how what has been fancied a natural binary in fact is maintained by intricate expressions of social power. If bathroom access is where those who still root for reaction draw today’s line, let’s be sure that it is drawn in beach sand, and welcome the incoming tide.

jamie-nelsonJamie Lindemann Nelson, PhD, is a Professor in the Department of Philosophy at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, May 5, 2016. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

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Should Women Pay More for Health Insurance?

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series. For more information, click here.

By Leonard M. Fleck, Ph.D.

In a recent commentary in Time (Aug. 23, 2013), Hadley Heath argued that women ought to pay more for their health insurance than men. Fairness, she contended, required this. She was criticizing the requirement of the Patient Protection and Affordable Care Act [PPACA] that prohibited unequal insurance premiums for men and women. There seemed to be two primary reasons for her view: (1) Women live longer than men; (2) Women consume more health care than men. I will start by accepting both these statements as factually true. But I find deeply problematic the normative claim that women are not paying their fair share of health care costs.

Behind Ms. Heath’s normative conclusion is a premise for which she offers no argument. If I buy a more luxurious car, a larger home, or finer wines, then I ought to pay more for these goods than individuals who are content with a used Chevy, a 1000 square foot ranch home and Boone’s Farm. If I consume more health care because I have colorectal cancer and late-stage heart failure, then I ought to pay more for my health care than someone with a broken arm from falling off their polo horse. That is, needed health care should be thought of as just another consumer good, not as anything morally special. If someone wishes to use more health care, then they ought to pay more for that health care.

The wording in that last sentence ought to get our attention. Who is it who “wishes” to use more health care for their cancer and heart disease? Do I wish to use more health care in the way that I wish to have a second piece of turtle cheesecake? The very asking of the question makes manifest its absurdity. I need health care for my cancer or heart disease unless I am willing to accept a premature and painful death. This is what motivates us to think of needed and effective health care as being morally special instead of as just another consumer good to be distributed in accord with desire and ability to pay.

There is another unstated principle in Ms. Heath’s essay that is even more morally troubling than my first point. It is that those who use more health care, or are likely to use more health care, ought to pay more for that health care (or be denied it.) At any point in time the vast majority of women in our society are in excellent health, so it seems there is something silly about this whole debate. However, a large fraction of the uninsured and uninsurable in our society have that status because they have (or are likely to have) very costly health problems which insurers will not cover or for which insurers will charge unaffordable premiums. This is not a silly or trivial problem. At the moral core of the PPACA is the rejection of the idea that individuals with greater health needs must pay for their health care in proportion to need. That is the principal Ms. Heath is really attacking. Women are being used by her as a Trojan horse for attacking the moral fortress of the PPACA.

Finally there is the issue that women live longer than men on average. Again, the principle seems to be that if one lives longer, then it is assumed (maybe falsely) that one will use more health care during those extra elderly years. If that is the principle, however, then there is no good reason why women alone should bear those extra insurance costs. Rather, all persons who can be reliably predicted to achieve greater than average life expectancies ought to be saddled with extra insurance costs. This is hardly the sort of message we would want to give to citizens whom we are encouraging to make healthy lifetime choices for a longer life. The predictable outcome of such a message would be that economical men would rationally choose to spend yet more time watching sports on TV and guzzling beer while gulping down burgers and brats. Does that yield the logical conclusion that women should be charged more for health insurance?


Leonard FleckLeonard M. Fleck, Ph.D., is a Professor in the Center for Ethics and Humanities in the Life Sciences at Michigan State University and the author of Just Caring: Health Care Rationing and Democratic Deliberation.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Friday, October 11, 2013. With your participation, we hope to create discussions rich with insights from diverse perspectives. You must provide your name and email address to leave a comment. Your email address will not be made public.