1 Elderly Care giving imbedded in national welfare-states

Elderly Care in Germany: gender structures of formal and
informal care and the gendered division of labor
Martina Wolfinger, Gertrud M. Backes, Ludwig Amrhein
Vechta University, Germany
Introduction
In Germany elderly care is regarded as a typically female activity. In both formal
and informal care, women dominate as care workers and main care givers. This
contribution focuses on the "gendered division of labor" and is based on current
data and examinations, which are submitted to gender theoretical analysis. Besides
the gendered structures of the German elder care system, general social and
cultural gender structures need to be considered. The welfare regime and its
transformation interconnected with gender regimes and care regimes serves as a
conceptual framework. Do the structures of professional education and the labor
market, the occupational and familial organization of care work contribute to a
discrimination against care givers and care workers? What form does a reproduction
of traditional gender relations and gender models (e.g. the male bread winner
model) take in informal elderly care in Germany? How is care work valued in
Germany, in particular, direct body related care work as opposed to the more distant
organization of care? What do these general and care-specific gender structures
actually mean for care givers of different social classes and milieus?
1 Elderly care giving embedded in national welfare states:
gender regime and care regime
Demographic changes arising from longer life expectancy and the lengthening of the
retirement phase are becoming ever more apparent. They change individual life in
old age, as well as the structures of society. According to Backes (1997) the old age
theme has developed in the last 150 years from an individual and socially limited
problem to a problem for society as a whole. Nowadays, all subsystems are
concerned, from economics to politics, from family ties and relationships to
recreation, education and culture. Traditional institutions, above all social security
systems, are increasingly unable to provide material protection, participation and
the freedom for individual development in old age. New solutions are called for to
deal with the "socialization of old age“(“Vergesellschaftung des Alters”) (ebd.). They
cannot, however, be gender indifferent owing to existing gender structures. They
need to be formulated in a “gender sensitive” way, as Backes (2005) demonstrates
using the example of elderly care. This “normative and instrumental uncertainty of
the societal dealing with age(ing)“ (Backes 1997) applies to earlier structures of
elderly care giving and helping. Faced with today’s social and demographic changes
these structures have reached the limits of their efficiency.
National welfare regimes embody regulations for care giving and must
accommodate demographic change, as well as changes in family structures, labor
1
markets and normative ideas. Elderly care giving is embedded in the welfare regime
and in the interconnected gender and care regimes. In the following analysis we use
these connections as a conceptual framework.
Esping-Andersen (1990, 1999), a prominent representative of comparative welfarestate-research, distinguishes three welfare types according to targets and benefits.
He calls them the liberal, the conservative (conservative-corporative) and the socialdemocratic (Table 1).
Table 1: Types of welfare regime
Liberal
Conservative
Social-democratic
High Recommodification
Middle range of Decommodification
High Decommodification
Liberal labor ethics
(for family-breadwinner)
High private
expenditures for
ageing / health
Minor – medium;
Minor – medium;
stable social
insurance
social basis security
Family
Minor
Central orientation on
the family
Minor
Conception of
equity
High social
inequality;
Stable social
inequality;
Minor social
inequality;
achievementorientated equity
corporative;
distributional equity
USA, Great Britain
Germany, Italy
Commodification
Privatization
Examples
demand-orientated
equity
Denmark, Sweden
(Esping-Andersen 1999, Opielka in 2006, own assortment and presentation)
Following the feminist review of Esping-Andersens` 1 original typology the
underlying (re-)production of “gender-relations” (“Geschlechterverhältnisse”)
(Becker-Schmidt 2004: 66) and the institutionalization of the “gender order”
(“Geschlechterordnung”) (i.S. Conell 1995) have come under scrutiny (Kreutzner
2006). The “gender specific socialization forms” (“geschlechtsspezifische
Vergesellschaftungsformen”) (Backes 1999) of women and men have to be
examined in their dependency on the historic-cultural and social basic conditions.
For this reason, in the following analysis we also include the life course, which is
linked to gender (as a social category). The concrete configuration of the “gender
specific socialization over the life course” (Backes 1999) and the “hierarchically
complementarily
gender
relations”
(“hierarchisch
komplementäre
Geschlechterverhältnisse”) is influenced by the situation (“Lebenslage”) (Backes
1999). In this context we can also formulate it as an “accumulation of the objective
and subjective gender specific hierarchically situation” (“Kumulation der objektiven
1
The typology in table 1 includes Esping-Andersen’s reaction to the feminist review
2
und subjektiven geschlechtsspezfisch hierarchischen Lebenslage”) over the life
course (ebda.). This accumulation is reflected in the variability and simultaneity of
gender specific risks and chances (in old age), not only in definitive (dis)advantages.
In the feminist welfare-state-research two main discourse lines have emerged (the
literature study of Betzelt 2007 offers an overview about the discourses). On the
one hand, it deals with the further development of the model typologies including
the gender regime. Here, emphasis is on the conditions of women’s access to the
labor market and their chances to manage their household autonomously. This topic
deals with the equal division of work and the role of the state and market in
discharging women from familial care work (Pfau-Effinger 1999). The concept of the
gender regime refers to the interaction of social polity, policies, the surrounding
politics and actual social practice in their effects on gender in the above mentioned
aspects. The second discourse line is closely interwoven with the concept of the
gender regime and focuses on care giving, the so-called "care debate" (Fraser 2001;
s. Betzelt 2007). Both discourse lines are relevant to answer the question: will
elderly care be transformed?
1.1 Welfare regime and gender regime
From a gender analytic point of view, the central criticism on the "classical"
comparative welfare-state-research is directed against centering the typologies on
employment (= andro-centered). It is linked with the definition of the national
output orientated on the gross national product. The concepts enlarged with a
gender perspective are based on the assumption that informal care is a social
service that contributes to national output just as the commodities management of
the private sector, the national service economy or non government organizations
(NGOs) do. Consequently, households must also be taken into consideration as
producers and not merely as beneficiaries of welfare (s. Gottschall 2001, Young
2001).
Building up on these three welfare types (see Table 1) three types of personal social
services (including care giving) can be distinguished: the service model, the servant
model and the family mix model. The following table (Table 2) gives an overview:
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Table 2: Typologies of personal social services
Servant model
Family mix model
Service model
Commodification
High womenemployment
Dis-employmentstrategies / low
women-employment
High womenemployment, above
all in the service
sector
Privatization
Increasing
marketised services
in the low-wages
labor market,
connected to strong
hierarchy (concerns
class, ethnicity,
sex/gender, and
within the same
sex)
Relative high range
on family care giving
and state benefits,
through tax policy
and transfer
payments;
Enlarged public
services, professional
care work
High social
inequality
Living standard on a
relatively high
average level, high
transfer payments
and insurance
benefits
Marginal social
inequality
Germany
Sweden
Conception of
equity
Examples
USA
Middle range of (most
marginal) low-wages
employment in the
care sector
High tax ratio and
bureaucracy
(Gottschall 2001; own assortment and presentation)
Until the 1980th, Germany was fitted the family mix model. Unquestioned, the family
was the place where the production of welfare benefits took place. As to family
income, the “male bread winner model” was still firmly anchored in social policy.
Even though women were increasingly integrated into the labor market, they were
perceived as “the additional earner” and their familial responsibilities as
predominantly non-market labor (=private field) (Pfau-Effinger 1999, Young 2001,
Stiegler 2007).
Since the mid-1990s, and within the framework of the Europeanization of welfarepolity, new political control elements have been created to counteract the "crisis of
the welfare state“, which is linked to economic relations and the "demographic
question". This has led to different welfare model approaches in EU member states.
These approaches refer especially to the (re)privatization of benefits and to the
increasing recommodification of all adults capable of working (including care givers,
who are mostly women) (Ostner 2002). The new "reciprocity" is implemented
nationally through different measures (von Wahl 2005, MacRae 2006). In Germany,
within the new general orientation on the “adult worker model”, everyone is obliged
to acquire his/her own social security through occupation. From a gender analytic
point of view we have to criticize the fact that the adult worker model does not take
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private care giving into account. Further differentiations are developed which
include occupation and informal care giving: In addition to the traditional “male
bread winner/ female care giver”, the “male breadwinner /female part-time earner”,
the “dual earner/ state care giver” the “dual earner /marketised care giver” models,
we must also recognize the “dual earner/ dual care giver” model (Betzelt 2007).
From our point of view, this differentiation is compatible with the typology of
personal social services, shown in Table 2.
The gender-regime concept enables us to understand the variance in the complex
interaction of public organizations and NGOs with the social practice and general
orientations in its influence on the gender-regime (Betzelt 2007: 5). In this case the
concept of variance refers not to the comparison between welfare states, but to the
different fields in which elderly care giving takes place and also on the results of
transforming the welfare regime over time. Using the gender regime concept as a
conceptual and analytical framework, it is possible to reveal how gender structures
are (re-)produced and how they continue to influence the situation of the women
and men concerned (Fraser 2001). The questions are: How is the gendered division
of labor created and modified? To what extent is care giving allocated to the private
field and individual responsibility?
We need to recognize that, even using the gender regime concept, the separation
between public (with mostly paid employment) and the private field (with mostly
unpaid work) is maintained. It is even possible that the thinking pattern of gender
dichotomy is reinforced. Up to this differentiation, however, policies and politics
recreate dichotomy and hierarchy. We can prove this thesis; firstly by the inequality
with which public/political discussion addresses the private field by comparison with
the employment field. Second the life risks of unemployed people are increasingly
granted on a low level and the obligation of re-commodification increases, under the
postulation of workfare. Autonomy is demanded, without picking out the underlying
dependency and the essential care work (Dingeldey 2006, Stiegler 2007, PfauEffinger 1999). According to Eckart (2004: 28) care is influenced by social power
relations and contains formal and informal rules, customs and interpretations. Care
is widely connected to gender order and the interpretations founded in gender
stereotypes.
1.2 Care regime
Using the term care in a gender analytic sense, we take into consideration the
totality of care work and care giving as a part of economic output.
Care work refers to work in households (private field) and in personal social
services. It includes domestic work, paid support, care and educational work. It also
includes the whole complex of typically feminine connoted work, such as voluntary
social work (Young 2001, Stiegler 1999, 2007). Basically, the discourse on care
offers the possibility to deal with the conditions of the working society in a critical
way and illuminate them from a social-theoretical perspective (Care-regime).
In the discussion about the evaluation of all these fields, activities and efforts,
gender analytic orientated welfare state research plays an essential role. Assigned
to Bourdieu (2005) they are culturally connoted as typically feminine and thus
assigned to the private field. A central element of the care debate is the demand for
5
social civil rights ("social citizenship") for care givers, which should be roughly
reached by an autonomous social security and through the de-commodification of
work capability (Gerhard 2003, Brückner 2004).
Twigg (2000: 393) argues that it is impossible to solve care owing to its specific
status of a warm and loving activity in the sense of a halo-effect. Hence, this
concept would be diffuse in informal care and distorting in professional care work.
Nevertheless, we use the concept of care, define it and delimit it from the legal
definition of elderly care in Germany (long-term care insurance: the German
“Pflegeversicherung” SGB XI). Based on the so-called care debate 2 we assume that
care is a condicio humana and not a gender related characteristic. Care involves the
cultivation and development of a human quality, and, at the same time, the
relationship of a person to the world and the things (in the continuity of dependence
and autonomy), as well as a professional and private competence, which could be
developed and paid-for. Care is relevant in all social fields. In the following
discussion the separation between private and professional field should be
understood as an analytic one. The separation of public and private field presents
itself as a continual process of demarcation and is the reason why complementary
hierarchy emerges. The interdependence of both fields is often neglected;
nevertheless, it should be considered explicitly (Eckart 1990: 13).
In Germany the concept of legally regulated elderly care can be defined in
supplement and in demarcation to care in the broader sense (defined above).
1.3 Legally regulated elderly care
The nursing concept encapsulates various connotations, which define neither the
aim nor the concrete conception of nursing (further discussion: s.
Dibelius/Uzarewicz 2006: 74 - 100; Schroeter/Rosenthal 2005: 20ff.). Care 3 /
nursing / care work legally defined by Germany’s regulations is important to acquire
an approach to our question. The definition in the long-term care insurance (SGB
XI) focuses on persons who are in need of care, so care means the need for help in
a higher measure and in a considerable way in the normal and recurring activities of
daily living (45 min. daily at minimum and at least 6 month). Not all “activities of
daily living” (ADL) are included. Care (SGBXI) means: body related care, food /
diet, mobility and housework. Care (SGB XI) is concerned with the home – familial
care giving, as well as with ambulant, part-time institutional or professional
institutional care.
Tension arises between the conception of care in a broader sense and nursing/care
(work) (SGB XI) for the following reasons: (1) Care in the broader sense is
perceived as an activity form which is more than care (SGB XI), and it can be found
in the private area, as well as in the professional field of elderly care. (2) Care in
the broader sense encompasses other activities and more care than prescribed in
the regulations (SGB XI).
2
For the German care-debate, including the reception of the international discourse, see Kohlen/Krumbruck 2008
Linguistically it is not possible to differentiate between the care concept in the broader sense and care in the legally
sense: Our differentiation takes place through the appendix (SGB XI) – to delimit care in a lawful sense.
3
6
2 Gender and care regimes in transformation: formal and
informal elderly care in Germany
Political bodies regulate the conditions of the elderly care giving in its professional
form and as a social practice. And on the other hand side the institutions (with their
respective gender regime) have to comply with the changing social orientations.
With their qualitative research on conflicts in the life-world of informal care Gröning
/ Radtke-Röwekamp (2007) assume that the analysis may not end at the level of
aggregates (women as care givers for elderly). It is therefore important to include
the social practice, which contains social relations, forms and reasons to assume a
responsibility. Cultural values and general orientations are important for the social
practice, too (Pfau-Effinger 2000). In Germany elderly care at home and in private
fields, as well as in professional sectors, are permeated by the discussed
sociopolitical regulations. These regulations also affect the gender related and
gender provided dichotomy and hierarchy of care giving. Therefore, it must be
treated as an interconnection that cannot be deduced through an analysis of causes
and effects. Finally the following levels are deduced for the analysis of the
interconnection between welfare state regulations, gender regime and care regime,
within the cultural dynamics (Beckmann 2007):
• general orientations, to work, gender, family
and
• policy fields (policies), political regulations
• informal norms and wishes, gender culture and care culture
and
• social practice
The following secondary analysis is orientated by these levels and refers to studies,
which are concerned with informal–familial elderly care, as well as with the
professional elderly care. Our question focuses on the law reform of the long-term
care insurance (SGB XI), which will be implemented by July, 2008. It represents a
further step in the transformation of the german welfare regime. The following
analysis is informed by the question of whether–and if so in which fields–we are
going to find indicators for transforming the elderly care giving system, referred to
as the gender and care regimes.
2.1 Political regulations and general orientations
The implementation of Germany’s mandatory long-term care insurance is the
answer to a 20-year long discussion on elderly care. The benefits of this insurance
contain a basic supply and it is not income-contingent (Enquete-Kommision 2005:
441-493, Röttger-Lippmann 2006: 160-171, Dibelius/Uzarewicz 2006: 25-35).
Essential points of criticism in the long-term care insurance concern its underlying
general orientations: the narrow definition of the nursing concept / care and the (re) familiarization of the responsibility and the priority of familial elderly care implying
that elderly care is carried out by relatives. This is assigned to the natural “female
working capacity”, and therefore needs no development of competence and no
7
income comparable with employment (Backes/Wolfinger/Amrhein 2008). The reform
of the long-term care insurance (SGB XI) which will be implemented by July, 2008
(see to the following: BMB 2008b) retains a lot of the systemic mistakes criticized
by many experts that are inherent in the long-term care insurance (EnquetteKommission 2005: 461-470). Financial benefits are increased slightly for care
realized by relatives or for ambulant services. In the levels of nursing care 4 II, III
and III+ financial benefits for stationary elderly care are also higher than hitherto.
Furthermore, the nursing concept has been extended (Care i.s. SGB XI): For
persons with a mental disease and without a nursing step, benefits have been
introduced and are generally increased. A new level of nursing care has been
created, which takes psychosocial support and light body-related care into
consideration, and is only available to certain groups of users.
As the implementation of the reformed long-term care insurance will not take place
until July 2008, the effects can only be assumed. The basic principles are
untouched, which set the course for organizational and institutional ascription of
assuming the responsibility to provide care. This reveals some important gender
political and family political results that are discussed in the following.
By implementing the long-term care insurance, social responsibility for elderly care
was originally transferred to the unified community. Restricted benefits, however,
require the production of a deductible. At the same time and within the reform it
was fixed and also maintained that ambulatory familial elderly care has precedence
over stationary elderly care. This basic sociopolitical decision, which delegates prime
responsibility for elderly care to the family in keeping with the social-ethical
subsidiary principle (“Subsidiaritätsprinzip”), stabilize gender relations and the
gender-related division of labor, as well as the gender specific structures of power
power and inequality in the field of elderly care. The resulting consequences for care
givers are less investigated.
Nor is the payment for family care giving (nursing money) adequate (nor that
payment is normally transferred to the person who is in need of care) when we
focus on the long hours the concomitant physical and psychical stress. The payment
of pension scheme contributions contains tough targets, for example, to reduce
employment to less than 30 hours per week and to provide care (SGB XI) for over
14 hours per week. Through the reform, in case of emergencies it will be possible to
get 10 days’ unpaid leave and up to 6 months “nursing time” (“Pflegezeit”). In the
event, the nursing money and social insurance contributions are partly paid by the
long-term care insurance. Even if nowadays in general a re-commodification of all
adults capable of work and acquisition is demanded and promoted by different labor
market policies, the adjustment will remain ambivalent as far as informal elderly
care is concerned.
Indeed, the occupation of care givers is a part of the legal regulations (especially in
the reform of SGB XI). Nevertheless, the gender regime of the outdated “male
bread winner model” is implicitly maintained. The role of the care giver is defined as
a (at the most) “part-time earner”. Even if the terminology of the legal regulations
4
The German long-term care insurance is organized in three levels of nursing care (“Pflegestufen”): level I = more
than 45 min. daily nursing ; level II = minimum 2 hours daily nursing; level III = minimum 4 hours daily nursing
around the clock and level III+ in the case of hardship.
8
refers to both genders, the content implicitly relapses into the existing gender order
and focuses on women as care givers (Kreutzner 2006: 31).
The basic conditions are created, for the purposes of subliminal requirements, as
real selection or exclusion principles are never formally mentioned (Bourdieu 1982:
176f.). The effect of this with regard to men could be that, even should they wish to
assume elderly care responsibility, it becomes nearly impossible. Before attempting
an analysis of the consequences of family-informal elderly care on social practice,
we must turn to the legal regulations and general orientations in occupational
elderly care.
In addition to many other rules, the long-term care insurance (SGB XI) regulates
the field of the professional elderly care in the ambulatory and stationary sectors.
SGB XI sets quality requirements that lead to organizational hierarchies. These
requirements are linked to different qualifications and favor “indirect care” over
“direct care”. At the same time tension exists between quality requirements and the
limited considerations. Pressure on costs arising from demands for economic
efficiency encourages the delegation of many activities to cheaper low or unskilled
employees. It also leads to a social hierarchy between the care employees, e.g.,
between skilled and unskilled (Wolfinger 2006). Furthermore, both laws pertaining
to the professional education of elder care givers and nurses must be mentioned.
Norms were created regulating both professions that were somatically (and less
psychosocial) oriented. The consequence is a deeper separation more hierarchy
between elderly care in a broader sense and elder care / nursing (SGB XI).
From an occupational sociological point of view elderly care lies at the intersection
of becoming a profession of the "direct" or "primary" elder care and the
professionalization of the "indirect" or "secondary" elder care. Care is described
mostly in a specific dichotomy. "Direct" care is understood as a directly personal
service which is body related, while all body distant activities are subsumed under
the "indirect" care, which include medical assistance, organizational and
administrative activities count as well as the nursing management and the nursing
sciences (Dibelius/Uzarewicz 2006, Raabe 2006, Voges 2002). These dichotomies
reflect not only categorizations of certain activities, but also the shaping of specific
professional educations and the attribution of the professional activity to a certain
hierarchically defined position within the field.
2.2 The social practice of care giving in the family-home
In Germany, familial-home care giving is predominantly carried out by women.
Statistics for 2002 show that approximately 73% of all care givers (SGB XI) were
women. From 1991 to 2002 the ratio of male care givers (SGB XI) rose from 17%
to 27%. The engagement of the caring sons has increased about 7 per cent (SGB
XI); this is in addition to the main area of male care giving, namely caring for a
partner (Schneekloth/Wahl 2005, Cornelißen 2005). First, from a gender-analytical
view we have to note that the statistics are in keeping with the concept of care as
defined by long-term care insurance (SGB XI) and therefore limited. The second
point is that only the so-called main care givers are counted. Additional care givers
or occasional helpers are not admitted. Concentration on the main care givers may
lead to an undervaluation of the contribution of other (e.g. male) care givers and
9
helpers (Künemund 2001: 92-104, Schupp/Künemund 2004; for a differentiated
valuation on the basis of a qualitative study, see Gröning/Radtke-Röwekamp 2007).
Can a change in the gender and care regime of elderly care be deduced from the
increasing engagement of male care givers? Or do the causes lie especially in the
consequences of the demographic development? With the available statistics we
cannot check whether earlier war-conditioned widowhood (“Singularisierung”) has
disappeared, nor whether sons increasingly assume care responsibility if no female
relatives are available.
In 2002 partner care made up the greater part of familial care with 28%. On
account of the higher life expectancy of women and their mostly lower age in
partnerships we have to suppose that these are mostly women who are taking care
of husbands / partners and that the inverse situation was rarer. Care giving by
daughters is the second most frequent constellation with 26%. Intergenerational
care (daughter / daughter-in-law / son) is around 42%. Care giving to non-relatives
in Germany takes a subordinated position with 8% (Schneekloth/Wahl 2005,
Cornelißen 2005). It is not possible to make a gender differentiated statement
about the caring relations and about the change of caring arrangements over time.
64% of the care givers are still of working age (under 64) and have consequently
not yet completed their own pension plan. Care givers also increasingly find
themselves in the so-called "sandwich situation", i.e. their parents begin to need
care, while their children are still living in the household. At the start of their care
giving activities, 47% of care givers are employed, either part-time or full-time.
10% quit their jobs completely, while 11% reduce their hours of work to enable care
giving. A comparison between 1991 and 2002 shows a growing ratio staying in
employment (from 21% to 26%), but it remains unclear in which occupational
forms (e.g., part-time) (Schneekloth/Wahl 2005: 79). 26% of care givers are in the
“younger retirement” age group (65-79 years old), and an increasing percentage
(3% in 1991, 7% in 2002) are themselves 80 years or older. In 2006 the ratio of
women in the pension fund paid by the long-term care insurance was over 90%,
that is the ratio of women of those family-informal care givers who are in maximum
part-time jobs (BMG2008a). Whether the tendency towards continued occupation
will be further strengthened (and to what extent) by the reform of the long-term
care insurance, especially with introduction of the “nursing time”, and whether the
transition to part-time employment will increase or remain stable, cannot be
forecast on the basis of the statistical data. Nevertheless, it does not seem bold to
assume that family-home care leads to a reinforcement of the “male bread winner /
female part-time earner“ model and reproduces the “double socialization” of women
(Becker-Schmidt 2004). This is connected to an “accumulation of the objective and
subjective gender specific hierarchically situation” (Backes 1999). This thesis can be
covered only marginally on the basis of available data.
The time used for care giving can offer a further clue for the gender-relations in this
field. After the time budget elevation (in 2001/2002) unpaid work in households and
family make up more hours than paid-work 5 . In addition, with 31 hours women
5
Includes job-seeking and unpaid activities, such as commuting time
10
fulfill more unpaid work than men (19½ hours). The inverse situation presents itself
when it comes to paid work, where women produce 12 hours and men about 22½
hours. In comparison to time budget elevation of 1991/92 when women reduced
their expenditure for household and family work by approximately 10%, while men
maintained their time use (Schäfer 2004).
According to the long-term care insurance (SGB XI) the approved nursing times are
limited (for details see above). The subjective evaluated expenditure of time spent
care giving is much higher; on average it is 4 hours more and may be as much as 8
hours. Care-receivers with cognitive impairments require higher time expenditures
(Schneekloth/Wahl 2005: 78).
The time expenditure for people who are in need of care and who are living in the
same household (which involves only a part of the family-home care) increased
between both time budget evaluations (1991/92 and 2001/02) by about 8%. The
gender-relation of assuming the responsibility of women to men increased from 2.2
to 2.3 in former East Germany, while in former Western Germany it fell from 2.0 to
1.9 (Schäfer 2004). In a non-representative time budget elevation which included
84 people who needed care and help (63 women / 21 men) subjective evaluation of
the time spent in care giving and helping was questioned (HeinemannKnoch/Knoch/Korte 2006). Following divergences were revealed–although not
strictly differentiated from a gender-analytic point of view–in care giving and
nursing arrangements; men mostly received care from wives and partners (nearly
22 hours per week), while women received care from daughters (in-law). The time
expenditure of husbands and professional care givers was roughly the same, at 5
hours.
Up to 64% of ambulatory familial care is given as a pure care by relatives and/or by
self-financed care (material benefits of SGB XI). 28% of those in need of care
receive a combination of private and professional care in the family (material
benefits or a combination of benefits) while only 8% receive the complete benefits
through the engagement of professional services (although this mostly involves
familial care as well) (Schneekloth/Wahl 2005). The utilization and capability of the
informal-familial care arrangements depends on many social factors. Studies have
shown that in addition to gender/sex, it is the (professional) education, occupation
and financial means of the care givers that are the deciding factor as to whether
familiar-informal or institutional care forms are chosen (Blinkert/Klie 2004). Where
adequate financial means exist, parts of the family-home care are transferred to
outsiders, and a creative range of choices opens up for care givers; physical and
psychical burdens can be reduced and social isolation can be avoided. Where
financial means are limited, however, care often has to be entirely delivered by the
main care givers, with consequences for their own health. Care arrangements seem
to depend on the situations of both parties, those in need of care as well as their
care givers (Theobald 2006). In a non-representative study on people in need of
care in Germany (EU-project CARMA), Theobald (2006, 2008) concludes that
members of the lower economic classes in Germany are more often cared for by
relatives and partners, while those with higher incomes are far more likely to turn to
privately hired helpers or professional services. Women who are in need of care
mostly request professional services, while men are more often cared for by
additional informal assistants and hired helpers (Theobald 2007). The women then
11
receive support via the "service model", while men receive care either informally
("family mix model") or/and according to the "servant model".
Different social milieus show typical differences about the range of knowledge and
active management of care arrangements (Heusinger/Klünder 2005). Generally, no
training or preparation takes place before assuming care responsibility, because the
need for care arrives suddenly, following an acute incident, or develops gradually
over a long period. It is possible that the explained division of labor models, which
includes specific gender-related competences, counteracts the usage of such
training or preparation and strengthen the acceptance that care is assigned to the
"female working capacity“ (cf. detailed Backes 2005, Wolfinger 2006: 119ff.).
The following thesis is to be deduced. The conditions for the “double socialization” of
women in professional and informal contexts and the responsibility for care giving
are indeed the premises for the attribution of care as a “natural” female activity
(“female working capacity”). Assigning these attributes and values according to
gender are efficient in the social practice, but in different ways, depending on the
situation. It seems that it is difficult for (employed) men living in this gender-order
and the underlying general orientations to assume a care responsibility. This is an
implicit reproduction of the gender-specific division of labor.
In their qualitative analysis of interviews with female care givers and their husbands
Gröning/Radtke-Röwekamp (2007) point out, that "classical" roles and attributions
are manifest even when primary images and rules for an equal labor division have
been dominant within their relationship. A further important clue is that husbands
and (in this case, female) children support and stabilize family-home care in
different ways. Nevertheless, (according to a further result from the interviews) by
assuming the care responsibility of informal elderly care the (female) care givers
take on more and more the inner familial alone responsibility, linked with the loss of
chances, while the (wider) family and environment withdraws (Gröning/RadtkeRöwekamp 2007: 65). Our thesis is, that in combination with other factors that
impact on the situation (for instance, the necessity of a part-time job and therefore
lower income) this decision or assumed responsibility leads to care givers
(especially daughters /in-law) having poorer social and financial security in their old
age than men (Backes 1999; cf. Becker-Schmidt et. al 1982, EndersDragässser/Sellach 2002,). We conclude that assumed care responsibility (according
to the care arrangement) leads to specific results for a care giver’s own situation in
old age and their options to obtain private and professional care. It may also mean
that a care giver is unable to stay at home if they themselves stand in need of care
at a later stage. So care giving is a part of the gender specific “hierarchically
complementary” socialization (Backes 1999) over the life course.
But these theses are not provable without longitudinal studies. Actually it is not
possible to analyze the developing consequences by assuming care responsibility.
The consequences are differentiated to the social situation of the care givers and
have to be distinguished after the care arrangements (inner- or intergenerational),
too. Backes (2005) assumes that the consequences concerns e.g. gender relations,
relationships, health, subjective stress experience, social integration, the availability
of material and immaterial resources and the construction of the financial provision
for old age.
12
2.3 Social practice of professional care work
In professional care work too, the ratio of women is high (86% = 162,988 workers
in ambulatory services and 85% = 401,640 workers in institutional care 2001; Pieck
et al. 2004: 36ff.). The majority of occupational forms in ambulatory services are
part-time and marginal employment, and only a third of all employees work full
time. In the stationary field, by contrast, the proportion of full-time employees is
roughly 50% (Peck et al. 2004: 18ff.).
Elder care as a qualified job obeys the rules of supply and demand in the job
market. One leading feature of the elder care profession lies in its relatively high
fluctuation rate. Apart from other factors, this is a sure sign of elder care being a
typical women's occupation, especially for women who want to return to work or
find a new occupation after maternity leave.
The result of a secondary evaluation of available studies carried out by
Borutta/Giesler (2006: 34) is that, in institutional settings, male employees are
between 27 and 39 years old, whereas around 95% of the female employees are 40
years old or over.
The connotation of care as a "female" activity (coupled to the "female working
capacity“) according to Twigg (2000: 408) does not depend on the biological sex of
the care giver. As the social fields are specifically gender connotated, gender specific
characteristics are also ascribed to the actors in those fields. This therefore affects
the sexual self-concept and the identity (Ummel 2001). Professional care becomes a
"gendered job" (Twigg 2000). Building up on a case analysis of the nursing
profession, Ummel (2001) demonstrates that both men and women who are
occupied in care work perpetuate gender specific differentiation, without a doubt by
the attribution of male / female characteristics and abilities. Despite a high
reflexivity and a wish for a freer gender habitus, the dual sexuality remains
(West/Zimmermann 1987, Villa 2006). This dichotomy is based on the “natural”
construction of sexual differences and thus also concerns the lived and life-practical
basis by gender (doing gender). It repels male care workers from the genderconnotated aspect of helping. It seems, that helping is evaluated closely related to
the attribution of motherhood and intuition, and they are inaccessible for men
because of their biological sex. The gender-specific segregation of the world of
employment, and here, in particular, the connotation of the nursing profession as a
"women's occupation", takes on a new depth as a result of these interconnections.
In the field of the care, empathy, direct body related interaction etc. are perceived
as biological and sexually pertinent attributes and not as professional competences
that are essential for care giving. Body related care is low valued and carries a
taboo status. Discussions on the professionalization of the field of elderly care are
wide ranging and ignore devaluations that concern sexual attribution and taboos as
central themes. To separate professional competence from gender/sex attributions,
the professionalization debate could be advanced by concentrating on specific
competences (e.g. empathy, a valuable competence that has to be learnt and
taught). One result of a further investigation of these processes could be the
deconstruction of gender specific "natural" characteristics and overcoming the
attribution of these activities to the private, informal "female" field. According to the
13
unanimous opinion of different authors (Allan 1993 zit. to Miers 2001: 188, Friesen/
Thiessen 2003) a new working concept could be developed. The reorganization of
professional education paths for elderly care work and nursing is possibly moving
precisely in the opposite direction, although one of its aims is to break through
hierarchies. Bourdieu (2005) offers suitable tools to undertake a gender analysis of
gender connotated working relations. He discusses how hierarchy is developed and
maintained. Instead of breaking down hierarchical structures, current reorganization
plans actually underpin them as the "controlled" are using the strategies and
interpretations of the "leaders" and thereby legitimizing their predominance.
Transferred to the professionalization debate in care work it happens through
focusing on vocabulary and methods of medicine and economy. Instead of escaping
from the subordinated position, probably the dominance of the "male" and "public"
connotated fields of the medicine and economy is thereby reinforced (Wolfinger
2006, c.f. Roth 2007). A pertinent point is made by Borutta/Giesler (2006: 33f.):
Male career paths in elderly care often begin with a cross entrance from “male”
connotated professions, such as medicine, law, theology or management. For
women’s careers they identify varied hindering factors, which can also be classified
under the “double socialization” (Becker-Schmidt 2004) of women, like part-time
employment, low professional education, family conditioned interruptions, gender
ascribed and introverted division of labor (competence of the women = direct care;
men = responsibly for indirect care and management) as well as limited chances for
career- and advanced-training. However, there are also conducive factors, which are
seldom pointed out as a central theme. For instance, men perceive an elderly care
profession as career restraining and are more likely to think about re-training
strategies. This leaves room for women’s careers, and also the option for relatively
easy entrance in relatively old age, as well as the possibility to make a "late career“
(ebd).
That the gender-related connotation of professions differentiations and hierarchies
arise in the field of the elderly care can be explained statistically (Pieck et al. 2004,
based on 2001 nursing statistics). In the stationary setting, 22% of all employees
are unskilled, 19% have completed a 1-year assistant's education, and 30% have a
three-year education in nursing or elderly care. The ratio of women to men
employees is roughly the same, especially in the assistant's occupations, but in the
professions with cross entrance, as Borutta/Giesler (2001) emphasize, the number
of male employees is much higher. With just 0.2%, nursing science makes up only a
tiny part of all employment, but here too, the proportion of men is higher (Pieck et
al. 2004: 19).
From a gender analytic view statistical data with regard to ambulatory services can
be possibly summarized as follows (Pieck et al. 2004: 18): The nursing profession
(33%) lies clearly above that of elderly care (17%). The ambulatory services seem
to be more attractive for nurses, perhaps the requirements in ambulatory services
correlate in a higher range with the competences of nurses. But it is possible too,
that that the hierarchical differences between ambulatory services and stationary
care are a result of subjective valuations, but yet this cannot be analyzed with the
available statistical data, nor with qualitative studies.
The need for economic efficiency resulting from the implementation of long-term
care insurance and gaps in the organizational and operational structures lead to
increased working stress of the predominantly female staff, especially in stationary
14
care (Amrhein 2005a, b). This leads to increases in sick leave absences and staff
fluctuations, which, in turn, leads to lower efficiency, more pressure on the
remaining employees and lower nursing quality. After an investigation (Landau
2001) activities in so-called body related "direct care” were classified as physical
and psychic stress (cf. Wolfinger 2006, esp. the aspect of the body). Twigg (1997,
2000) argues for professional care giving in the familial-home setting including
different power structures and stress situations. She points out that the power
about the space and during direct body-related care giving is distributed in different
ways, depending on the setting. Taking the dimension of gender/sex in relation to
care interactions into consideration could open up new approaches in situations that
are often experienced as stressful. In these situations, actors usually resort to
distancing and power emphasized behavioral strategies. Care givers wield a high
level of “informal power” in such contexts (cf. Amrhein 2005 a, b). Distancing
techniques (e.g., wearing gloves), the creation of a distancing hierarchical relation
(e.g. separation of physical touches and emotional intimacy) as well as the use of
medical-technical terms are established coping strategies of care givers (Twigg
1997, 2000, Wolfinger 2006). If care givers raise the subject of stress in teamdiscussions, they hit the social boarders of the team. They may feel–or actually be–
shut out from the team; they cannot master their frustration, fear and stress and
end up by quitting the job, either internally or in reality (Amrhein 2005 a, b). Such
conflicting and stressful situations in direct care are often the result of institutional
structures, in particular when the stationary institution shows signs of a "total
institution“ (Goffman) (Amrhein 2005 a, b).
To sum up: perhaps the way in which care giving as work is organized carries
weighty consequences for the health and pension expectancies of care workers
(Wolfinger 2006). The underlying mechanisms are marginal being investigated and
too little importance is given to the gender sensitive perspective. Moreover, more
analysis is needed to identify the precise nature of the socially unequal results that
await male and female workers in the exercise of this specific "gendered job".
Further subjects that call for study include the different gender specific career
paths, “doing gender“ in the realm of care giving, the effectiveness of "hierarchically
complementary gender relations“ within the occupational team, as well as within
social structures.
3 results
As here discussed, the welfare state orientation has an effect on the gender and
care regime via regulations, institutions and social practices. Gender relations in the
field of the elderly care effect the direct interaction between care givers and care
receivers, as well as the evaluation of the care. Gender hierarchy is manifest in
diverse forms within professional and private care giving and care receiving and in
both ambulatory and stationary settings. And elderly care takes place under the
impact of gender-related and about gender provided dichotomies and hierarchies.
15
At this point the following central theses can be summarized:
1. Gender structures in the formal and informal care work are expressions of the
welfare state and the underlying gender and care regimes and are manifest
as gender provided attributes, differences, hierarchies and connotations.
2. Elderly care giving is constructed under the impact of gender-related dichotomies
and hierarchies.
3. Structures are thereby created that become gender specific selection and
exclusion mechanisms. They function as borders and options for assuming
care responsibility in the occupational, as well as in the familial field.
4. Hierarchical gender relations are connected to other hierarchies, e.g. professional
(normative and symbolic dominance of professions) and social hierarchy, and
lead to gender specific accumulations or combinations of (dis)advantages.
5. These gender relations are reproduced in the professional as well as in the
informal-familial field over the life course and are reflected in a social division
of labor between the genders/sexes and linked to gender-related situations.
6. The definitions and valuations of care work as a caring and nursing activity for
elder people are created through interactively, institutionally and socially
produced gender attributions, gender representations and gender relations.
7. Gender structures in care are not solely the result of deliberate bargaining and
definition processes; they also exist as unplanned and non-intended byproducts of social processes and unconscious habitual behavior patterns.
Even if more attention is paid to wishes and images by a freer shaping of the
gender habitus or an equal division of labor, the underlying construction of
gender dichotomy complicates (or even makes impossible) the according
social practice.
8. In Germany care work takes place within the framework of an androcentrically
connotated welfare regime and in androcentric life, career and occupational
structures, which result in the discrimination of "divergent" female and male
working and life relations.
Gaps and demands for social-political and scientific discourse have been mentioned
and are listed here as a summary:
• In the welfare-regime and embedded general orientations dealing with elderly
care, a clear ascribing to the private field and a tabooing of the concrete
arrangement can be discovered in stress and time use, as well as in the
resulting outcome for society.
• In the wake of the transformation of the welfare regime, varied measures exist to
support Recommodification in Germany. Sociopolitical regulations pertaining
to elderly care stand in contradiction to this aim. This results in an ambivalent
picture in the view of the gender-political adjustment of the SGB XI. A central
demand within the care debate is directed at the introduction of social civil
rights for care givers by the means of independent social security. These
could be partially realized by the decommodification of work capability, on the
one hand, and by closing the separation of professional and private fields on
the other.
16
• The concrete normative definition of elderly care is narrowly informed and is
strongly orientated to body related help. In addition, essential aspects of
body-related care and helping, together with the necessary competence to do
the work, are ignored.
• The search for gender-sensitive, actual and expressive data on the situation of
care givers and care receivers in Germany, including the institutional contexts
in which care work is carried out, develops problematically. Official statistics
that are regularly collected within the framework of long-term care insurance
only refer to care receivers and to the ambulatory and stationary services
(including the staff). No legislation exists on the regular reporting of the
situation of non professional care givers in informal-home care. Answers to
questions, like who is taking care of elderly people, and under what kinds of
care arrangements, etc. are lacking. In addition, the official reports are based
on the normative care concept (SGB XI). For these reasons, conclusions on
gender/sex differentiated caring relations, caring arrangements and the
situations of care givers therefore lack robustness.
A consistent development of theory, empiric and practice is clearly necessary [and
lies in the best interest of policy makers]. The term care (SGB XI) needs to be
extended to incorporate gender theoretical and social gerontological dimensions. For
the future we have to be able to build on "gender sensitive elderly care“ (Backes
2005) that takes into consideration the effect of gender relations developed over the
life course, and the scopes of action and stress within a care giving situation. In
addition, we must take into account the transformation of the welfare state,
concrete demographic developments and normative changes in the field of elderly
care (ibd.: 379f). An evaluation of detailed quantitative and qualitative
(longitudinal) data about gender differentiated objective and subjective dimensions
of the situation of care givers and care receivers is vital. These data constitute the
basis for a gender sensitive and social scientific orientated analysis of the
connections between life course, gender/sex and care giving or care receiving. They
would allow dependable forecasts and intervention proposals in relation to “gender
specific old and new age(ing) risks” (Backes 1999), also with regard to shaping care
giving or care-receiving (Backes/Amrhein/Wolfinger 2008).
17
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Prof. Dr. Gertrud M. Backes
Vechta University
Centre for Research on Ageing and Society
Driverstr. 22
G-49377 Vechta
Email: [email protected]
Ludwig Amrhein
Scientific Assistant (Prof. Dr. Gertrud M. Backes)
Vechta University
Centre for Research on Ageing and Society
Driverstr. 22
G-49377 Vechta
Email: [email protected]
Martina Wolfinger
Scientific Assistant (Prof. Dr. Gertrud M. Backes)
Vechta University
Centre for Research on Ageing and Society
Driverstr. 22
G-49377 Vechta
Email: [email protected]
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