Thesis (PhD)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Communication between doctors and patients in clinical settings is notorious for being difficult. This problem has inspired a wealth of empirical research from a variety of academic fields on the subject of doctor-patient communication. However, very little attention has been paid to the role of modern medicine's intellectual self-image as natural science in interactions within clinical medical settings. The aim of the current study was to philosophically investigate the influence of the medical profession's intellectual self-image on communication between doctors and patients. Jürgen Habermas' work on Universal Pragmatics was used to comment on doctor-patient communication as it is described in the existing empirical research literature. Michel Foucault's work on discourse and power was used to analyse and describe medical discourse and the nature of power in doctor-patient relationships. The outcome of this philosophical analysis leads to the conclusion that modern medicine's intellectual self-image has a pervasive and negative influence on communication between doctors and patients during clinical consultations. This is because medicine's positivist world-view results in an almost exclusive focus on the physical aspects of disease in clinical medicine. The patient's mind and his/her social world are not of great significance from the natural scientific perspective. Medical professionals may thus easily regard their clinical task solely as the physical treatment of physical disorders. They are very likely to consider many communicative activities as unrelated to their clinical task. Inadequate doctor-patient communication can easily affect the quality of medical care and patient outcomes in a negative manner, as well as diminish the quality of the doctor's occupational experience. For this reason I conclude that medicine's natural scientific intellectual self-image is not appropriate for the task of providing medical care to individual patients. Two additional reasons support this conclusion, namely the misidentification of clinical medicine as a natural science and the inappropriateness of a scientific conception of truth for the context of doctor-patient interactions. The implications of these conclusions are that the intellectual self-image and world-view of modern medicine should change to better agree with the nature of clinical practice and to make room for the psychological and social dimensions of the patient's life within health care. The medical profession should also revise its conception of science to a theory that acknowledges that interpretive reasoning and knowledge without guaranteed certainty are legitimate elements of science. I advocate for consciousness among the medical profession of the reality of medical discourse and its effects on doctors, patients and on their interaction with one another. / AFRIKAANSE OPSOMMING: Kommunikasie tussen dokters en pasiënte in kliniese omgewings is daarvoor berug om moeilik te wees. Hierdie probleem het 'n magdom empiriese navorsing vanuit 'n verskeidenheid van akademiese velde omtrent dokter-pasiënt kommunikasie geïnspireer. Baie min aandag word egter gewy aan die rol van moderne geneeskunde se intellektuele selfbeeld as 'n natuurwetenskap in interaksies in kliniese mediese omgewings. Die doel van die huidige studie was om die invloed van die mediese professie se intellektuele selfbeeld op kommunikasie tussen dokters en pasiënte filosofies te ondersoek. Jürgen Habermas se werk oor Universele Pragmatiek (Universal Pragmatics) is gebruik om kommentaar te lewer oor dokter-pasiënt kommunikasie soos wat dit beskryf word in die empiriese navorsingsliteratuur. Michel Foucault se werk oor diskoers en mag is gebruik om mediese diskoers en die aard van mag in dokter-pasiënt verhoudings te ontleed en te beskryf. Hierdie filosofiese ontleding gee aanleiding tot die gevolgtrekking dat moderne geneeskunde se intellektuele selfbeeld 'n deurdringende en negatiewe invloed op kommunikasie tussen dokters en pasiënte gedurende kliniese konsultasies het. Die rede hiervoor is dat geneeskunde se positivistiese wêreldbeskouing lei tot 'n byna uitsluitlike fokus op die fisiese aspekte van siekte in kliniese geneeskunde. Die pasiënt se verstand en gees (mind) en sy/haar sosiale wêreld is nie van groot belang vanuit die natuurwetenskaplike perspektief nie. Persone in die mediese beroep mag hul kliniese taak dus maklik as bloot die fisiese behandeling van fisiese afwykings beskou. Dit is baie waarskynlik dat hulle vele kommunikatiewe aktiwiteite as onverwant tot hul kliniese taak beoordeel. Ontoereikende dokter-pasiënt kommunikasie kan die kwaliteit van mediese sorg en pasiënte se gesondheidsuitkomste maklik negatief beïnvloed, en ook die kwaliteit van die dokter se ervaring van sy/haar beroep verlaag. Om hierdie rede maak ek die gevolgtrekking dat geneeskunde se natuurwetenskaplike intellektuele selfbeeld nie toepaslik is vir die opdrag om mediese sorg aan individuele pasiënte te lewer nie. Twee verdere redes ondersteun hierdie gevolgtrekking, naamlik die verkeerdelike identifikasie van kliniese geneeskunde as 'n natuurwetenskap en die onvanpastheid van 'n wetenskaplike konsepsie van waarheid vir die konteks van dokter-pasiënt interaksies. Die implikasies van hierdie gevolgtrekkings is dat die intellektuele selfbeeld en wêreldbeskouing van moderne geneeskunde moet verander om beter ooreen te stem met die aard van die kliniese praktyk en om ruimte te maak vir die sielkundige en sosiale dimensies van die pasiënt se lewe in gesondheidsorg. Die mediese professie moet ook haar konsepsie van die wetenskap hersien na 'n teorie wat erken dat interpreterende redenasie en kennis sonder gewaarborgde sekerheid, geregverdigde elemente van die wetenskap is. Ek pleit vir bewustheid onder die mediese professie van die realiteit van mediese diskoers en die effek daarvan op dokters, pasiënte en op hul interaksie met mekaar.

In order to address the effects of unequal relations of power inherent in expert medical knowledge and practice that contribute to health inequities, this project defines and instantiates the concept of rhetorical economies in public health through a case study of promotora practices. As everyday experts, promotoras support medically underserved communities through health education and counseling. This project defines rhetorical economies of public health as those practices and processes which deterritorialize medical expertise in order to produce and distribute new knowledge economies related to bodies, health, and disease across everyday and expert communities. This participatory research is shaped by a community partnership with a promotora at work in public health settings. Historical analysis of the emergence of biomedical perception provides the context for a feminist rhetorical, decolonial, and critical discourse analyses of public health messaging as well as of this promotora's work stories and pedagogies. This project draws from Chela Sandoval's (2000) articulation of "differential consciousness" to identify processes where everyday and embodied practice differentially engage dominant medical discourse in order to re/appropriate, subvert, and transform "spaces of power" in medical contexts. Rhetorical economies are the means through which these transformations are possible. Narrative and rhetorical analysis of a promotora's work stories and pedagogies reveal how neoliberal and racialized medical discourse reproduce political and economic marginalizations while reinscribing medicalized understandings of the body, health and disease. Using the framework afforded by González, Moll, & Amanti's (2005) "funds of knowledge" approach, this project illuminates how rhetorical economies function to recenter community ways of knowing in order to decolonize biomedical epistemologies and practices. This project provides the foundation for future research in how rhetorical economies act to re/appropriate dominant discourses and advance transformational change. Grounded in medical, feminist, and decolonial rhetorics, this project it will find application across the disciplines, including education, rhetorical studies, cultural studies, medical anthropology, medical humanities, community action research, disability studies, health communication studies, and public health.

Spanning the period from the early years of the Cold War to the early twenty-first century, Crossing Out argues that medical theories of gender variance which emerge in the middle of the twentieth century are bound by the Cold-War–era discursive limits within which they were articulated, and that the ideological content of those theories persists into late-century research and treatment protocols. I parallel these analyses with interrogations of literary representations of transgendered subjects. What emerges most powerfully from this analysis of literary works is their tendency to signify in excess of the medical foreclosures, even when they seem consistent with medical discourse. By reading these two discursive systems against each other, the dissertation demonstrates the ability of literary discourse to accommodate multifaceted subject positions which medical discourse is unable to articulate. Literature thus complicates the stories that medical culture tells, revealing complex and multivariate possibilities for transgendered identification absent from traditional medical accounts. In tracing these discursive intersections the dissertation draws on and extends Michel Foucault’s theory of subjugated knowledges and Judith Butler’s writings on the formation of gendered subjects. Chapter One establishes the Cold War context, and argues that there are significant continuities between 1950s theories of intersexuality and Cold War ideology. Chapter Two extends this analysis to take in theories of transsexualism that emerged in the same years, and analyzes the discursive excesses of a 1950s pulp novel representation of a transsexual. Chapter Three establishes that the ideological content of the medical theories remained virtually unchanged by the 1990s, and argues that multivalent literary representations of transgenderism from the same decade promise the emergence of unanticipated forms of gender identity that exceed medical norms. Chapter Four is concerned with transgendered children, as they are represented in medical writing and in young adult and children’s literature. Interrogating fiction which negotiates between established medical discourse and an emergent transgender discourse, the chapter argues that these works at once invite and subvert a pathologizing understanding of gender-variant children while simultaneously providing data that demands to be read through the lens of an emergent affirmative notion of trans-childhood.

Breast and penis augmentations are century old processes of body modification continuing in development and practice today. This Masters thesis is a content analysis of breast and penis augmentation print and internet advertisements to explore one facet of augmentation discourse presented in public space. Relevant theoretical literature includes fetish discourse and medical discourse as existing frameworks that conceptualize augmentation predominantly as a process of body fragmentation. After reviewing this literature, I expand to blend together perspectives from three body theorists, Maurice Merleau-Ponty, Michel Foucault and Judith Butler, as an alternate framework for embodiment. I then use content analysis to examine the data collected from 21 print sources and 27 internet sources. The data indicates fetish discourse, focusing on body fragmentation, is the dominant content in breast and penis augmentation advertisements; however, I argue in the conclusion that incorporating elements of embodiment into fetish discourse is a better perspective for future research.

Music-based healing is utilized as a healing tool in many cultural contexts around the world. This thesis examines the cultural practice of music therapy in the context of the larger discipline of medicine in the United States through an ethnographic study of music therapists in the Greater Atlanta area. It contextualizes this data with research in medical ethnomusicology that explores cross-cultural traditions of music in healing rituals. It also connects music therapy to the observation that forces of globalization are strongly correlated with an increase in rates of inequality, poverty, stress, and disease. This thesis discusses how Atlanta-area music therapists use music healing with patients suffering from physical and mental disease and how economic stratification impacts access to music therapy. It is concerned with deeper and not immediately evident processes taking place in music therapy, such as the role of music as a medium and facilitator in healing.

Spanning the period from the early years of the Cold War to the early twenty-first century, Crossing Out argues that medical theories of gender variance which emerge in the middle of the twentieth century are bound by the Cold-War–era discursive limits within which they were articulated, and that the ideological content of those theories persists into late-century research and treatment protocols. I parallel these analyses with interrogations of literary representations of transgendered subjects. What emerges most powerfully from this analysis of literary works is their tendency to signify in excess of the medical foreclosures, even when they seem consistent with medical discourse. By reading these two discursive systems against each other, the dissertation demonstrates the ability of literary discourse to accommodate multifaceted subject positions which medical discourse is unable to articulate. Literature thus complicates the stories that medical culture tells, revealing complex and multivariate possibilities for transgendered identification absent from traditional medical accounts. In tracing these discursive intersections the dissertation draws on and extends Michel Foucault’s theory of subjugated knowledges and Judith Butler’s writings on the formation of gendered subjects. Chapter One establishes the Cold War context, and argues that there are significant continuities between 1950s theories of intersexuality and Cold War ideology. Chapter Two extends this analysis to take in theories of transsexualism that emerged in the same years, and analyzes the discursive excesses of a 1950s pulp novel representation of a transsexual. Chapter Three establishes that the ideological content of the medical theories remained virtually unchanged by the 1990s, and argues that multivalent literary representations of transgenderism from the same decade promise the emergence of unanticipated forms of gender identity that exceed medical norms. Chapter Four is concerned with transgendered children, as they are represented in medical writing and in young adult and children’s literature. Interrogating fiction which negotiates between established medical discourse and an emergent transgender discourse, the chapter argues that these works at once invite and subvert a pathologizing understanding of gender-variant children while simultaneously providing data that demands to be read through the lens of an emergent affirmative notion of trans-childhood.

La presente ricerca ha come obiettivo l’analisi del ruolo del traduttore specializzato nel processo di composizione degli articoli di ricerca medici. In particolare, si occupa dell’analisi degli interventi di revisione di due traduttori specializzati, rispettivamente di madrelingua italiana e di madrelingua inglese, su cinque articoli di ricerca scritti da autori italiani in lingua inglese, successivamente pubblicati su riviste internazionali. L’analisi viene affrontata da duplice punto di vista qualitativo e quantitativo. I risultati individuano il tipo di intervento che ogni traduttore realizza nei testi. Inoltre, la ricerca evidenzia nell’intervento del traduttore di madrelingua italiana l’uso di strutture lessicali e fraseologiche meno frequenti nel discorso medico. È quindi possibile concludere che lo studio del processo di revisione del traduttore nella composizione degli articoli di ricerca medici rappresenta un valido strumento per l’analisi dell’uso della lingua inglese nelle comunità di ricerca multilingue. / This dissertation describes the role of the specialized translator in the process of the composition of medical research articles. The dissertation investigates the revisions of two specialized translators, respectively Italian and English native speakers, in five medical research articles written by Italian doctors in English and subsequently published in international specialised medical journals. An analysis of the revisions performed by the native and non-native speakers is undertaken using qualitative and quantitative research methods. The results of this analysis describe the respective changes that each translator makes to the texts, and explains how the final text is mediated differently by native and non-native speaking translators. The research highlights that the Italian translator introduces lexical and phraseologic features that are less frequently used in medical discourse. I conclude that this has implications for understanding the way in which English is used in multi-lingual research communication, and suggest that the study of the intervention of the translator in the process of medical research article composition is a useful way of analysing the developing profile of the use of English in multi-lingual research communities.

Trabalho realizamos uma análise do discurso médico sobre o aleitamento materno, durante a década de oitenta, após a implementação do PNIAM, em 1981, a partir de pesquisas em artigos do Jornal de Pediatria, a fim de compreender como ocorreram as modificações discursivas e institucionais sobre este tema. Atualmente encontramos inúmeras pesquisas sobre aleitamento materno, frutos da valorização da amamentação pela sociedade. No entanto, nem sempre o aleitamento foi valorizado e incentivado como nos dias atuais. Ao longo da história, o discurso médico refletiu o contexto vigente e serviu de sustentação aos interesses políticos sociais e econômicos. Modificou-se como parte de um processo, de uma construção. A análise do jornal revelou o predomínio da lógica higienista, sustentada por um discurso biologicista que naturalizou e disseminou a ideia de superioridade do leite materno. Com o objetivo de convencer os profissionais, instituições e a própria mulher, encontramos posições que refletem, sobretudo, as repercussões sociais decorrentes da entrada da mulher no mercado de trabalho. / This study was designed to make an assement of the medical discourse approach on breastfeeding during the 1980s, after implementation of the PNIAM National Program to Incentive Breastfeeding in 1981. Articles published in the Journal of Pediatrics were reviewed in order to gain insight on the discourse changes and public policy changes concerning the subject. The larger number of studies on breastfeeding available nowadays are imputed to the value placed on breastfeeding by society. Nevertheless, breastfeeding has not always been valued as it is today. Throughout the times, the medical discourse has reflected the at that point current context, serving political, social and economic interests. The general notion of breastfeeding has changed, seen as part of a process, of a construct. The inspection of the journals articles gas revealed the prevalence of the hygienist logics, supported by a biology-based discourse, which made natural and disseminated the notion of breastfeeding practices as superior when compared to other infant nutrition practices. The study concluded tha in order to convince health care workers, institutions and mothers, approaches to breastfeeding today reflect especially the social implications of the presence of women in the job market.

Trabalho realizamos uma análise do discurso médico sobre o aleitamento materno, durante a década de oitenta, após a implementação do PNIAM, em 1981, a partir de pesquisas em artigos do Jornal de Pediatria, a fim de compreender como ocorreram as modificações discursivas e institucionais sobre este tema. Atualmente encontramos inúmeras pesquisas sobre aleitamento materno, frutos da valorização da amamentação pela sociedade. No entanto, nem sempre o aleitamento foi valorizado e incentivado como nos dias atuais. Ao longo da história, o discurso médico refletiu o contexto vigente e serviu de sustentação aos interesses políticos sociais e econômicos. Modificou-se como parte de um processo, de uma construção. A análise do jornal revelou o predomínio da lógica higienista, sustentada por um discurso biologicista que naturalizou e disseminou a ideia de superioridade do leite materno. Com o objetivo de convencer os profissionais, instituições e a própria mulher, encontramos posições que refletem, sobretudo, as repercussões sociais decorrentes da entrada da mulher no mercado de trabalho. / This study was designed to make an assement of the medical discourse approach on breastfeeding during the 1980s, after implementation of the PNIAM National Program to Incentive Breastfeeding in 1981. Articles published in the Journal of Pediatrics were reviewed in order to gain insight on the discourse changes and public policy changes concerning the subject. The larger number of studies on breastfeeding available nowadays are imputed to the value placed on breastfeeding by society. Nevertheless, breastfeeding has not always been valued as it is today. Throughout the times, the medical discourse has reflected the at that point current context, serving political, social and economic interests. The general notion of breastfeeding has changed, seen as part of a process, of a construct. The inspection of the journals articles gas revealed the prevalence of the hygienist logics, supported by a biology-based discourse, which made natural and disseminated the notion of breastfeeding practices as superior when compared to other infant nutrition practices. The study concluded tha in order to convince health care workers, institutions and mothers, approaches to breastfeeding today reflect especially the social implications of the presence of women in the job market.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Psychoanalysts have begun to work at hospital institutions predominantly in late 70s. Various academic productions that deal with the relationship between psychoanalysis and its clinical work in the hospital point to an issue that emerge from the practice of each analyst inserted in this space, an issue that emerge from their relationship with desire. We consider that analytic listening, as a tool used to allow patients a different way to elaborate their suffering, brings into account the analyst's responsibility to sustain their praxis. In this perspective, this paper aims to conduct a study on the notion of responsibility for psychoanalysis and to question its challenges in hospital institutions facing the hegemony of the medical discourse, considering that the sustenance of psychoanalysisâ act becomes possible through transference relationship. The method used to achieve these goals was literature review and the study of clinical vignettes. We also performed a study on the state of knowledge of the productions of the last decade on psychoanalysis and hospital; then we have elaborated the notion of responsibility for psychoanalysis and contextualized the practice of the analyst in the hospital. We have finished the survey with vignettes that put into question the responsibility of the analyst and its effects. The results of this research imply that the responsibility of the analyst is in relation to the unconscious and that the position of the analyst and his ethics can provide access to a knowledge of the unconscious. / A entrada de psicanalistas na instituiÃÃo hospitalar inicia-se, predominantemente, no final da dÃcada de 70. As diversas produÃÃes acadÃmicas que versam sobre as relaÃÃes entre a psicanÃlise e seu trabalho clÃnico no hospital apontam para uma questÃo que insurge da prÃtica de cada analista inserido nesse espaÃo, questÃo que advÃm da sua relaÃÃo com o desejo. Consideramos que a escuta analÃtica como ferramenta utilizada para possibilitar ao paciente um modo de elaboraÃÃo outro sobre o seu sofrimento coloca em jogo a responsabilidade do analista em sustentar sua prÃxis. Nesta perspectiva, o presente trabalho tem como objetivo realizar um estudo sobre a noÃÃo de responsabilidade para a psicanÃlise e questionar os desafios da mesma na instituiÃÃo frente à hegemonia do discurso mÃdico, assinalando que a sustentaÃÃo de seu ato se torna possÃvel com a relaÃÃo transferencial. O mÃtodo utilizado para atingir tais objetivos foi a revisÃo bibliogrÃfica e o estudo de vinhetas clÃnicas. Realizamos ainda um estudo de estado de conhecimento sobre as produÃÃes da Ãltima dÃcada sobre psicanÃlise e hospital; em seguida elaboramos a noÃÃo de responsabilidade para a psicanÃlise e contextualizamos a prÃtica do analista no hospital. Finalizamos a pesquisa com vinhetas que colocavam em questÃo a responsabilidade do analista e seus efeitos. Os resultados dessa pesquisa concluem que a responsabilidade do analista à em relaÃÃo ao inconsciente e que a posiÃÃo do analista e sua Ãtica podem possibilitar o acesso a um saber do inconsciente.