The current issue of Asian Medicine emerges from the presentations made and discussions held during the panel ‘Women and Gender in Medicine and Healing Across Asia’ at the Asian Medicine: Cultivating Traditions and the Challenges of Globalisation conference in Bhutan, September 2009 (organised by IASTAM, the International Association for Traditional Medicine in collaboration with the Institute for Traditional Medicine Services, Thimphu). The original papers given at that panel spanned topics such as female medical practitioners in the history of Korean medicine, reproduction in late imperial and contemporary China, Islamic embryology, and women and gender in Tibetan medicine. While this issue focuses on the Tibetan medical contributions alone, it draws on insights gained from the wider discussions at the panel. It also includes other articles from scholars whose research is particularly relevant to the topic. The intention of this special issue is to present current research focusing on women and gender within the field of Tibetan medical and cultural practices. It presents articles that explore social, cultural, economic and medical aspects of women’s health, as well as historical and contemporary roles and perspectives of female doctors and patients found within the medical landscape of a broadly defined Tibet. These contributions serve as points of reflection for this introductory essay, in which we review past and ongoing activities, explore analytical trajectories and innovative approaches in interdisciplinary research on women, gender and medicine in Tibet.
This introduction has three parts: the first reviews gendered productions, transmissions and practices of Tibetan medicine; the second part discusses the representation of women in medical literature and illustrations, while the third and last part addresses Tibetan medicine and reproductive health. So far, in the history of Tibetan medicine, called Sowa Rigpa (the ‘science of healing’, gso ba rig pa), most of its practitioners and authors have been men. Both the learning and practice of Sowa Rigpa and its associated texts have been closely connected to monastic institutions. This however, is only part of the (his)story. Sowa Rigpa was also learnt outside monasteries, within medical lineages, where knowledge and practice was often transmitted from father to son, uncle to nephew, and, as we shall see, from father to daughter, uncle to niece, and mother to daughter and son. Here we find the concept of the ‘house’ that derives from anthropological kinship theory a useful and encompassing tool for analysing the transmission and practice of Tibetan medicine outside lay and monastic institutions, for it draws out the relations between what in Tibetan are termed medical lineages (sman gyi rgyud) and medical houses (sman grong). We discuss whether, as has been suggested in earlier work by Janet Gyatso and Hanna Havnevik, Tibetan medicine has posed a relatively open field for women and, if so, how women’s status in medicine compares to their position in other domains of Tibetan socio-cultural life and Buddhist institutions. The following two sections discuss overlaps and often paradoxical views of the female body and of women’s achievements in Tibetan societies, as reflected in bodies of Buddhist and medical texts, practices and experiences. Lastly, before the conclusion we discuss the relatively limited role played by Sowa Rigpa in the field of reproductive health, and examine the ways in which gender representations, derived from classical medical texts and illustration, survive in contemporary writing on women’s disorders.
Sowa Rigpa: the science of healing across regions
Sowa Rigpa has long been studied and practiced in socio-culturally, economically and geographically diverse contexts across the Himalayas, the Tibetan plateau and even Mongolia, Buryatia and Kalmykia. Taking the long history and these vast expansions into account, this review cannot be exhaustive.1 Samuel, for one, states that just as other medical traditions of knowledge and practice, biomedicine included, Tibetan medicine ‘was not a uniform craft practiced precisely in the same way by all its practitioners’.2 Across this regional and geographical diversity of Sowa Rigpa we witness the common phenomenon of a move away in its transmission and practice from predominantly Buddhist epistemological and socio-cultural frameworks. Historically, we have also seen little actual regulation and standardisation of the range of Sowa Rigpa practitioners and their work within and across regions, even if attempts to that effect were made as early as the seventeenth century, for instance, by the Fifth Dalai Lama’s regent, Desi Sangye Gyatso. Nowadays, medical practices, pharmaceutical production and medical knowledge transmission throughout the transnational ethnoscapes and technoscapes3 of Sowa Rigpa are brought increasingly into the fold of national (or regional) governmental regulations and professional organisations. At the same time Sowa Rigpa is more often passed on and practiced in secular institutions.
These changes are also reflected in the very terminology used to denote the medical system. Perhaps as a result of the contact between practitioners of Tibetan Medicine and practitioners of various forms of biomedicine, in the context of colonialism, Communism and exile, what in the Tibetan language used to be, and in some instances continues to be called Sowa Rigpa—i.e. one of the ten branches of the Tibetan Buddhist arts and sciences or rig gnas bcu—is now more commonly referred to as ‘Tibetan medicine’ (bod sman), and in English, ‘traditional Tibetan medicine’. Before the twentieth century, there was little need to identify the diverse bodies of Sowa Rigpa knowledge, practice and experience as either Tibetan or ‘traditional’; they were simply referred to by Tibetans as ‘medicine’ (sman) or as Sowa Rigpa.4
The shift from Sowa Rigpa to ‘Tibetan medicine’ denotes, at least in the context of the People’s Republic of China (PRC), much more fundamental transformations: from a Sowa Rigpa predominantly studied, developed and practiced within a Tibetan Buddhist framework, towards a set of practices that are increasingly located in the realms of what may be referred to as ‘science’, but defined primarily by biomedical models.5 In the Tibetan areas of the PRC, this reconfiguration of Tibetan medicine has partly been led by the powerful party state, requiring practitioners at many points to consciously and ambiguously separate ‘medicine’ (sman) from ‘religion’ (chos) and ‘superstition’ (rmongs dad).6 This process has taken different forms in Tibetan exile and amchi (a mchi) communities in India and Nepal,7 and with Tibetan medicine entering the global arena of ‘complementary and alternative medicine’ (CAM).8 Common to these changes on both sides of the Himalayas is the concurrent influence of the day-to-day practice and agency of practitioners and patients, embracing ideas of ‘science’ and ‘modernity’ in various ways. Notably, the turn towards institutionalisation and secularisation has not only led to new syllabi and training modalities, but also to an increase in the numbers of female doctors, and more recently, female medical authors.
While recent publications have used Sowa Rigpa to refer to the diverse styles and schools across the regions,9 and ‘Tibetan medicine’ to refer mainly to a more standardised and institutionalised practice, we hold that this distinction might depict a forced difference not shared by many practitioners. Hence, we follow practitioners’ perspectives as much as we can, and otherwise use ‘Sowa Rigpa’ and ‘Tibetan medicine’ interchangeably.10
Sowa Rigpa as gendered medicine
What in the literature on practitioners and patients of Sowa Rigpa can assist us in gendering Tibetan medicine and Tibetan medical texts? We begin with a review of the two main contexts in which Sowa Rigpa was practiced and transmitted up until the middle of the twentieth century—monasteries and medical colleges on the one hand and kin-based lineages on the other—exploring how these shaped and gendered the constituency of doctors (a mchi or sman pa) and their work. Important to the transmission of Tibetan medical knowledge is the concept of ‘lineage’ (rgyud) in general, and ‘medical lineages’ (sman gyi rgyud) in particular. Through medical lineages, shared either among relatives or among religious teachers and their disciples, medical knowledge was passed on in written and oral forms. Teachers and apprentices in the medical lineages in monasteries, medical colleges and families, were most often, albeit not always, men.11
Major historical trajectories of medical knowledge are found within Tibetan monasteries and medical institutions connected with them, as well as dedicated medical colleges and, more recently, in state-funded schools.12 The traditional medical colleges, such as those at Labrang or Kumbum, were housed within large monasteries and had particular entry requirements. They followed a more or less set curriculum and only admitted monks.13 Even in those monasteries, large or small, without dedicated medical colleges, medicine was often practiced and taught as one of the ten Buddhist sciences.14 Monastic libraries held texts from all branches of Buddhism, often including the fundamental medical text Four Tantras (rgyud bzhi).15 Hence, monasteries often provided the space and facilities for the transmission of medical knowledge from a teacher to a student, or to a group of students. Even in cases where no teacher was present, it was not uncommon for monks to learn through self-study and short-term apprenticeship.
Medical knowledge transfer between a religious teacher and his disciples could be found both inside and outside of the formal medical colleges that began to emerge as integral establishments of some important large Gelugpa monasteries after the seventeenth century. In the Nyingmapa traditions and in smaller monasteries, knowledge was commonly passed on from a religious teacher to his disciples. Although sometimes teacher and student were also related through kinship, this was not usually the case. Lineages were therefore produced by various ritualistic elements, such as empowerments (dbang), initiations (rlung) and orally transmitted tantric practices (man ngag). They might have included overtly Buddhist teachings for doctors.16
Despite the apparent dominance of monk amchi and teachers, we should neither assume that every monastery in Tibet had a resident doctor, nor suppose that a resident doctor would also treat the laity.17 From our studies of medical practices in rural areas, we believe that the role and presence of monastic doctors might have been overestimated in the accounts of some western writers.18 At the same time, the monk doctors represented the elite of Sowa Rigpa knowledge and practice, and this remains to some extent the case today.
Much less is known about the situation of medical study and practice in Tibetan nunneries. So far no nunnery has been reported to have housed a formal medical college. Yet through the groundbreaking work of Tashi Tsering, we now know of some Tibetan nuns who were knowledgeable and skilled in medicine.19 The biographies of these, as well as of other nun amchi discovered since then—including Ani Ngawang (c. 1930–2006, Nyemo) and Ani Pema Lhamo (c. 1922–2005, Ngamring)20 —remain to be explored.
The establishment of the Mentsikhang in Lhasa by the Thirteenth Dalai Lama in 1916 created a new context for the study and practice of medicine. While sharing substantial Buddhist features in its layout, curriculum and practice, the new school also opened its door to lay male students. This model of teaching both monks and lay students was later adopted by the Tashilunpo Labrang in Shigatse after establishing ‘Kyikyinaka (skid skyid nad ka) Medical College’, operative from 1954 to 1958.21 Following the escape of the Dalai Lama and thousands of Tibetans into exile in India, one of the first cultural institutions established by the exile government was the Men-Tsee-Khang in Dharamsala. Together with the Mentsikhang in Lhasa as well as the Tibetan Medical Colleges in Lhasa and Xining (established in the 1980s–90s), they represent the main new Tibetan medical teaching institutions open to the laity in which men study alongside women. Gender diversity (if not always equity) has also been the case in most privately initiated and/or NGO sponsored small Tibetan medical schools in Nepal and Tibet, such as at the Lho Kunphen school in Lo Manthang (Mustang), and the Tibetan medical schools in Lhundrup (Lhasa Prefecture) and Darchen (Ngari Prefecture).22 Before we turn to the new kinds of female practitioners graduating from these institutions, we return to the second trajectory of medical knowledge production and learning, the medical lineages outside of monastic and medical college contexts. According to currently available scholarship, in this mode of transmission, female practitioners were more prominent than in the monastic sphere.
Female doctors and ‘medical houses’
Most of the female doctors who practised before 1980 and who we know about, have gained their skills through kinship relations. The common practice, however, was to pass on medical knowledge to a male heir; this is still explained by Tibetans in terms of kinship ideology in general and patrilineal descent in particular. Tibetan ideas of patrilineal kinship are grounded in theories of procreation and medical theories of the body’s formation and constitution, in which the two substances of rus (bones) and sha (flesh, i.e. blood (khrag) in medical texts) are fundamental. Rus is transferred via the white reproductive substance (khu ba) of the father to the bones of a conceived child, while sha is transferred via the red reproductive substance of the mother (khu ba, khrag) to constitute the flesh. Of these, the bones form the matrix of the body, i.e. they constitute the fundament for the person’s physical and mental abilities.23 The flesh, on the other hand, has only limited implications for the constitution of personhood. While the bone lineage (rus rgyud) is a direct and continuous line, the flesh lineage (sha rgyud) cannot continue for more than two generations. This is because the woman’s red reproductive substances result indirectly from her father’s bones (white substance) rather than directly from her mother’s flesh (red substance), and therefore from her patrilineage, rather than from her matrilineage.
This theory of procreation and formation of the body has implications for gender patterns in the transmission of medical knowledge within families. In our conversations in Central Tibet, lay medical practitioners often expressed the view that a medical lineage would persist more strongly and therefore benefit the family and society in a more lasting manner when passed on to a son rather than to a daughter. In fact the possibility of a daughter inheriting a medical lineage was often ridiculed. The positive evaluation of a continuous patrilineage obviously supports the usual choice to teach medicine to a male heir. This is also strengthened by a normative virilocal residence pattern, through which the sons remain in their natal household following marriage, while the daughters move to their husband’s household.
In such patri-dominated social organisation, we would expect little or no female presence in the medical field. This has, however, not always been the case. There are by now many known examples, as most recently reported by Tashi Tsering,24 of female doctors who were trained by a male relative. Some of these were daughters in a family with no sons, such as Khandro Yangga (Kham Riwoche), Lobsang Dolma (Kyirong) and Dröla (Sakya).25 Others were wives of medical doctors and worked as amchi in their own right.26 Yet others were trained alongside their brothers.27 How can we explain these cases? Are they merely exceptions to the rule?
In dealing with the ever-present exceptions in descent organisations we have been inspired by discussions in the anthropology of kinship.28 By exploring medical lineages as ‘medical houses’, we hope to open new spaces to appreciate and analyse, historically and ethnographically, why women who were in the household of a doctor could be taught medicine despite the dominant ‘bone’ lineage paradigm. Lévi-Strauss defines the house as a ‘moral person’ in this way:
[A] corporate body holding an estate made up of both material and immaterial wealth, which perpetuates itself through the transmission of its name, its goods, and its titles down a real or imaginary line, considered legitimate of kinship or of affinity and, most often, of both.29
While material wealth is often emphasised in the studies of ‘houses’, we see medical knowledge as immaterial wealth (together with the house name, its reputation and social standing). Nevertheless, we identify medical text collections, medicine making equipment and medical substances as important (and valuable) material parts of ‘medical houses’. Together these are transferred through a real or imaginary line and importantly, legitimized through the language of patrilineal descent. This, we should emphasise, seems most relevant in Central Tibet, and less so in Amdo (Northeastern Tibet) where patrilineal descent remains more important in a number of ways not found elsewhere in the Tibetan cultural area.30
The anthropological house perspective sheds new light on what have been termed ‘medical lineages’ in Tibet. These lineages of medical knowledge were in fact often found in what were in some cases called sman (medicine) grong (house). Well known examples in the literature include the ‘Sakya Mentrong’ and the ‘Lhunding Mentrong’.31 Membership into these ‘medical houses’ is gained through filiation (independent of sex) and marriage (or in some cases adoption), i.e. both sons and daughters acquire full membership upon birth. Furthermore, in the next generation, the children of house members gain membership through filiation as well. In this way, both sons and daughters (as well as in-marrying husbands, or mag pa) become potential apprentices to the knowledge of ‘medical houses’. In addition, ‘medical houses’ were also found at the so-called labrang (bla brang), or corporate property holding houses of incarnate lamas (sprul sku).
Analysing medical lineages as ‘medical houses’ enables interpretations that are more open to gender variations. Female practitioners are not merely exceptions, but become a nexus around which an estate of immaterial wealth (knowledge, social capital and merit) and material wealth (texts, medicines and equipment) can accumulate.
Why is it then, in practice, that the majority of apprentices in these ‘houses’ are sons or nephews? We suggest the reasons are two-fold: on the one hand, the bias reflects broader gender models and expectations in Tibetan societies and, on the other hand, it reflects perceptions of the female and male body and mind. Both of these issues will be returned to below. But first, looking back in history, who were the few women we know of who practiced medicine, and how and from whom did they learn?
So far only two female Tibetan medical doctors, whose life and work spans the early to the middle of the twentieth century, have attracted serious scholarship: Khandro Yangga (mKha’-’gro dByangs-dga’) originally from Kham, and ‘Lady Doctor’ Lobsang Dolma (bLo-bzang sGrol-ma) from U-Tsang. Their biographies and Lobsang Dolma’s own writings provide insights into their life and work, and not least their specialisation within Sowa Rigpa.32
According to Tashi Tsering’s and Jampa Trinley’s work, Khandro Yangga was born in 1907, and was a brilliant child. Following her early knowledge of Tibetan language and poetry, and possibly given that she was the only child, her father started to teach her medicine. Being an influential doctor himself, he negotiated his daughter’s entrance into the Mentsikhang in Lhasa, where she was taught ‘opening of the eyes’ (mig ’byed), i.e. cataract surgery. From adolescence Khandro Yangga excelled in surgical skills, earning fame and respect in Tibet and beyond.33 Following the political turmoil of China’s invasion and subsequent power transfer in Lhasa, she remained at the Mentsikhang, practising surgery and general treatments, until 1962. In that year the new leadership identified her as a specialist in women’s and children’s medicine, and she was asked to serve as the first director of the newly established ‘Women’s and Children’s Department’. This ended her surgical practice, which had by that time become regarded as the professional domain of newly arrived Chinese biomedical eye specialists at another hospital in Lhasa. During the Cultural Revolution (1966–1976) Khandro Yangga was severely punished. Today, her son continues to practice medicine in Lhasa, indicating, as we have argued, that ‘medical houses’ continue independent of a broken patrilineage.
Born almost 30 years after Khandro Yangga, Lobsang Dolma’s story shares similarities with her predecessor, but also differs in significant ways. The daughter in an influential family with no sons, Lobsang Dolma was offered educational opportunities with high-ranking lamas of Kyirong, where she grew up. 34 As with Khandro Yangga, she proved to be a remarkable student of Tibetan language and was given the opportunity to continue with studies in astrology and later medicine. In 1961, she fled to India, where she initially worked as a foster mother and with road construction, and later started what became an enormously popular private medical clinic in Dalhousie. Only in 1972, she was invited to work at the Dharamsala Men-Tsee-Khang, after having tried to enter the institution ten years earlier, and failed on account of being a woman.35 In 1978, she was asked to resign from the institute, and then set up and ran another very successful private clinic. Lobsang Dolma was one of the first Tibetan doctors to travel to western countries and to teach and treat patients there. Before she passed away in 1989 she had become a central figure in the exile community, famous for her treatments and pharmaceutical skills. She had taught her two daughters, Pasang Gyalmo and Tsewang Dolkar Khangkar, who also attended the Men-Tsee-Khang College. While Pasang Gyalmo continues to work at the clinic in Dharamsala, Tsewang Dolkar Khangkar is now based in Delhi and is perceived to be the holder of this ‘medical house’.36
Thinley Dolkar (1931–1956) and Tinley Paldon (b. 1939) are two other well-known female doctors. Their father, Rinzin Lhundrup Paljor Nyerongshag, trained them alongside their brothers. Tinley Paldon’s own daughter, Dekyi Pedron Nyerongshag, also works as a Tibetan medical physician and is now based in the US.37
Tashi Tsering presents a list of more than ten female amchi who practiced in Tibetan areas before the Chinese invasion. Based on fieldwork in U-Tsang, Theresia Hofer has begun to collect stories of other female doctors, most often nuns.38 One such account is that of Ani Pema Lhamo (c. 1922–2005), a nun from Dewachen Nunnery, who practised in the area of Ngamring, and later around Lhasa.39 She was chosen as the single heir to her (male) teacher’s medical lineage, receiving his texts and medical equipment. Moreover, there are stories from Ngamring from the 1940s and 1950s describing a number of nuns who learned medicine from a Nyingmapa lama from Kham who practised in the area. Among them was Ani Ngawang, who later became the abbess of Chiu Gonpa Tekchoeling nunnery in Nyemo, where she taught Tibetan medicine to both monks and nuns (See Figure 1).
Kyungtrul Rinpoche (Khyung-sprul ‘Jig-med Nam-mkha’i rDo-rje, 1897–1955), the famous Bon Lama and medical doctor who travelled and worked in the Changthang areas of Nagchu as well as Ngamring and later Ngari, is also known to have taught medicine to several nuns, including a now 84-year-old nun and resident of Gurukyam monastery, Western Tibet.40 The kinship connections of these female amchi and their teachers are not clear. Some were related to their teachers, but others were not.
Historically, there seem to have been only few areas of medicine that were unavailable to female doctors. One of the taboos for women amchi was the making of tsho thal—purified mercury used in numerous precious pills (rin chen ril bu).41 Blood-letting was mentioned to us as improper conduct for female amchi, but this claim needs further investigation. These prohibitions can be contrasted with examples of female amchi who are in fact skilled and well-known for making tsho thal. One of them, the aforementioned nun amchi, Ani Ngawang in Nyemo, was highly regarded for an eye medicine she compounded, which contained selfmade tsho thal. Moreover, she had passed on this skill of mercury purification (and its associated knowledge) to several of her students, both nuns and monks, who continue to make tsho thal and her eye medicine today.42 Another nunnery reported to make tsho thal is Tragkar Rikhö (Brag-dkar Ri-khod) in Kardze in Kham, where a medicine containing their locally made tsho thal is even referred to as dge ma [btso bkru] zla shel (‘nun’s [purified mercury] mirror of moon’-pill).43
Havnevik and Gyatso suggest that the activities of Khandro Yangga, Lobsang Dolma and others could indicate that the medical field enjoyed a relative freedom from the rigid gender hierarchies prevalent in the main institutions of Tibetan society, and through that, gave room to talented female practitioners. Therefore, medicine with its ‘relatively swift verifiability of its efficacy’,44 might have presented a comparatively ‘open’ field of knowledge and practice for those who could demonstrate positive results, including talented women.
Despite these observations, we find female doctors seriously under-represented in almost all traditional writings on Tibetan (medical) history. This also holds true for modern writings, we contend.45 In our attempts to go beyond the constraints and male biases of textual records by conducting oral history and ethnographic research, the lack of female doctors’ voices and accounts is still apparent.
Yet, since the beginning of the 1980s, in many urban and some rural areas, there has been a considerable growth in the numbers of female Tibetan medicine practitioners. This is a phenomenon occurring in almost all the areas where Sowa Rigpa is practiced: in Tibetan areas of the PRC, the Tibetan exile community, Bhutan, Ladakh, Nepal Himalayas, as well as in Buryatia, Kalmykia and Mongolia. The extent of this increase is difficult to pinpoint, but as an indication Byams-pa ’Phrin-las in 2000 reported that 42 per cent of all Mentsikhang staff in Lhasa were women,46 and in 2007, the director of the Tibetan Medical College in Lhasa told us that 50 per cent of the approximately 300 college students were women that year. Tashi Tsering provides the names of all female students at the Dharamsala Men-Tsee-Khang between 1969 and 2001, who ranged between five and ten per batch. We were told that, currently, more than half of the students are female (See Figure 2).47
So far, we know little about how these increasing numbers of female amchi and female students have come about, or the challenges and opportunities this growth has fostered for the practitioners and their patients.48 Mona Schrempf, in her article in this volume, found both gender and ethnicity to be crucial to the building of the essential trust within doctor-patient relations particular to reproductive medicine in Amdo. This indicates a need for further studies of gendered practices in other medical fields. A significant increase in female practitioners is also found in the neighbouring medicines of Ayurveda and TCM.49 Cameron’s study of female practitioners of Ayurveda in Nepal shows the correlation of what she calls the ‘feminisation of Ayurveda’ and the marginalisation of Ayurvedic practitioners in the public health care system, suggesting not a causal relation, but at least parallel processes. In some Tibetan areas of the PRC, we see similar processes of marginalisation of Sowa Rigpa in the rural areas, at least within the governmental rural health care system, occurring at the same time as the ongoing increase in the number of female doctors trained in both government and private schools. The ways in which the presence of more female doctors has been reconfiguring Tibetan medicine, if at all, remain to be explored. Taking the lead from Cameron,50 we believe that further studies of female healers in professional non-western medical traditions will be a fruitful addition to existing anthropological studies of midwives, mothers and spiritual healers, and the significant ‘production of health by women’.51
Related to the question of female practitioners is the matter of female authorship of medical texts. As the monasteries were the traditional nucleus of textual production in all science fields, it appears that all writers of Tibetan medical works were men, and often monks. At the same time, medical authorship was not solely tied to monastic contexts and to the more expensive and elaborate printing culture. In fact many medical texts and medical notes were written and copied by hand, providing a potential opening for female authorship beyond the male monastic sphere. As a large proportion of these manuscripts were destroyed during the Cultural Revolution, and many have not been copied widely, we still know little about these traditions.52 However, we should be cautious to presuppose that authorship in manuscript traditions was equally dominated by men as in the printed text cultures. Looking for gender in both printed text and manuscript traditions, we might be surprised by the presence of women, perhaps not as authors, but as sources of knowledge.
We found one of these ‘surprises’ in Khenrab Norbu’s text Mirror of the Moon: Methods for Giving Birth Helpful to All.53 The roots for the knowledge conveyed in this text are attributed to the Medicine Buddha and the Four Tantras, but are also referred to as what we could broadly call ‘wise women’s knowledge’. The origin of knowledge about certain aspects of childbirth, such as kneeling on all fours on a bed, is here named as ‘the good idea of women who have experienced childbirth’, and more generally the text and its direct instructions for pregnant women (sbrum ma) are said to have been inspired by the complications that the ‘young aristocratic woman’ (lcam chung) Namgyal Drolkar from Shelkar experienced during the birth of twins at the end of her first pregnancy.54
More Tibetological work is required in order to provide a fuller overview of the gendered nature of Tibetan medical text production and practice. In other formalised Asian medicines and particularly in Chinese medicine, the genre of case stories has proved to be a rich source for scholars to study differential treatment of male and female patients.55 Our endeavours to provide a ‘herstory’56 of Tibetan medical history is certainly disadvantaged by the absence of this genre, especially until the twentieth century. In more recent times, case records and case histories in Tibetan medicine do exist, and these too have proven to be reliable sources of information about differential treatment.57
With the recent increase of female doctors, it will be especially interesting to follow new developments in the writings and practices of ‘women’s medicine’. This is a field that has, as we will discuss below, always been one of the branches of medicine but which has had little practical relevance among male doctors. As in the case of Khandro Yangga, there seems to have been an expectation of female doctors specialising in women’s medicine. One could therefore expect that an increase in the number of female doctors might lead to a growth in female authorship in general, and the production of medical literature on women’s diseases and treatment in particular.
While before the mid-twentieth century Tibetan medicine may have been an exceptional field in terms of fostering female expertise in comparison with other Tibetan cultural institutions, we still know very little about female and male doctors’ lives and work. Existing biographies of women usually show that female doctors received their medical education due to unusual circumstances, such as the lack of a male offspring in their families, close kinship ties with male doctors, or because they were simply out of the ordinary religious practitioners or nuns.
In the introduction to their volume on women in Tibet, Gyatso and Havnevik suggest that outstanding women in Tibetan societies were related to great men. This is clearly the case in many of the known stories of female doctors, but also often simply used as a method of identifying these women, in lists such as: ‘Tashi Paldon...niece of Terchen Barwe Dorje; Rinzin Wangmo, daughter of Dru Jamyang Drakpa..., Phurbu Dolma, the daughter of the great physician of Derge Gonchen monastery’.58 We want to question these forms of relatedness by pointing more broadly to social hierarchies, naming practices, and access to knowledge in traditional Tibetan societies. With hereditary rank being so fundamental to social position and possibilities,59 many of these female doctors belonged to the upper social strata, which would indicate a relationship to other well-known men. Moreover, due to the limited use of family names in Tibetan communities, a person is often described with reference to their place of origin and social connections. Therefore, in the description of female doctors, what is more crucial: their relationship to a particular man, or their belonging to a certain high ranked family? Might there be a tendency to highlight the relationship of outstanding women to their male relatives in our own descriptions only, when perhaps these relations were not as important in their gaining access to knowledge and realising their potential? How, then, should we represent the social belonging of these female practitioners? We suggest adopting a broader social perspective on the background of outstanding women, which might bring forth a more nuanced picture of kinship relations, social status and access to knowledge. We have found that various amchi are continuing their mother’s ‘medical house’ (sman grong), that is they practice medicine, transmit the medical text and manuscript collections and instruments. The break in the patrilineage is inconsequential, as the immaterial wealth—i.e. medical knowledge and practice etc.—continues, and at times also the medical house’s material wealth.
Even with the increase of female students and doctors very few women publish in the field of medicine. If they do so, ‘women’s diseases’, childbirth and children’s medicine are the usual domains. Although medical texts were and still are usually written by male authors, this volume also shows that the knowledge on which they based their writings may indeed have come from Tibetan women.
Women in Tibetan societies: ambiguity and lower birth
Turning now to the second part, we look at the limited presence of women in the Tibetan medical field through the broader perspective of the position of women in Tibetan societies, and describe the medical and religious ways of understanding the female body. Historically, access to education and formalised knowledge was limited for Tibetan women, with the exception of a very few high ranked members of the aristocracy,60 and possibly certain nuns. This is also reflected in the low numbers of known female medical practitioners. As already discussed, medical training in nunneries or membership of a ‘medical house’ tended to be the main trajectories open to women who wanted to pursue a medical line of work, however it seems that before the twentieth century very few did. This can be explained sociologically in the expected roles for men and women, but should also be seen in relation to fundamental evaluation of the female body and mind, i.e. of the female rebirth. These perceptions are grounded in both medicine and religion.
Early Western sources depicted Tibetan women as outgoing, actively participating in public life and showing little shyness compared to women in India and Nepal.61 These reports were often based on contact with women of the aristocracy, who also in their autobiographies presented themselves in a similar way.62 Starting in the beginning of 1980s, however, critical sociological studies of the roles of women in Tibetan societies presented a more refined picture, pointing to general subordination, and especially a negative evaluation of the female rebirth.63 In our ethnographic studies in rural and urban Central Tibet, we have found very similar shared assumptions of female rebirth as being inferior. In conversations with female interlocutors, we often got the impression that women felt sorry for themselves for being born into a female body, pointing to what were for them obvious disadvantages of being a woman, such as a weaker body, childbirth, more sickness, and also an emotional mind. This interconnectedness of suffering and the female body itself is also alluded to in the autobiographies of female religious experts, such as the Dolpo nun Orgyen Chökyi (O-rgyan Chos-skyid)64 and the Golog treasure revealer Sera Khandro (Se-ra mKa’-’gro).65 Moreover, as Schrempf shows in this volume, in patriarchal Amdo, girls are less valued than boys and viewed as a burden to their families.
When trying to explain why women experience a harder life than men, the Tibetan language itself is very often used as evidence. Indeed, the most common word for woman (as well as wife) itself, skye dman translates as ‘low birth’,66 a point made explicit by many of our Tibetan interlocutors. We have spoken with women in Lhasa who have explicitly said they avoid using the word skyes dman and have asked their husbands and family to abandon that term, replacing it for instance with ‘Aji’ (A ce), meaning both wife and woman. We were also told it is a term consciously avoided by the Dalai Lama. Similarly, as Janet Gyatso has shown,67 another word commonly used for woman is bud med (the politically correct feminist term for a woman). However this term is easily interchangeable with bu med, meaning ‘not boy’. In addition to these etymological points, there are numerous Tibetan proverbs describing women as being born into a lower rebirth, and therefore subordinate to men.68 One well-known saying reported also by Gutschow is that women are seven lifetimes behind men, and following on from this that women must accumulate the merit of seven additional lifetimes before they can be reborn as men.69 However, one way of compensating for the low merit leading to a female rebirth is, as reported by Schrempf, by giving birth to a son.70
Tibetans clearly connect gender models and negative evaluation of female rebirth to Buddhism. If we look at Buddhism, we see an ambiguity distributed across the different historical phases, from early Buddhism up to the different schools of Tibetan Buddhism active today.71 Sponberg described how early Buddhist literature on women featured a range of co-existing attitudes towards them, from expressing a liberation path open to all, to outright misogyny, portraying women as weaker human beings and, in some cases, as ‘active agents of distraction and ruin’.72 In the sixth or seventh century, however, an additional attitude emerged within the Mahayana tradition that involved a ‘dramatic revalorization of the feminine...[as well as] a re-evaluation of all those qualities and expectations culturally ascribed to male and female’.73 The feminine and the masculine were then perceived to be—at least in some contexts—dialectically and mutually complementary on the path to enlightenment. Such a dialectic perspective is most clearly expressed in later Tibetan Buddhism and manifests in the quintessential pair of ‘wisdom’ (feminine) and ‘skilful means’, or ‘method’ (masculine); where the latter refers to compassion in action. The assertion that enlightenment cannot be reached without the conjoining of wisdom and compassion, like the two wings needed for the bird to fly, is a most basic religious knowledge to Tibetans today. This mutual dependency has also been discursively mobilised in an attempt to achieve a better position for women.74 Gyatso has summed up the ambiguity of gender models and attitudes towards women as a continuous ‘misogyny of Buddhist traditions, on the one hand, and the deification of a female principle in Buddhism, on the other’.75 The growing body of literature on women and Tibetan Buddhism, i.e. female practitioners for the most part, indicates that the deification of the feminine principle has not, however, had a liberating effect on the social position of women—lay or ordained.76
The female body in Tibetan medical literature and medical illustrations
How then is the ambiguity of Buddhist attitudes towards women reflected in the medical literature and its illustrations? Are there elements of both misogyny and deification of the female principle in Tibetan medicine? In what ways do the intertwined nature of Buddhism and Sowa Rigpa manifest in the perceptions and descriptions of the female body?
Wind and desire
As Mingji Cuomu’s article in this volume illustrates, classical Tibetan medicine is closely related to Tibetan Buddhist philosophy. This is also evident in the descriptions of the sexual differentiation of male and female bodies.77 The Four Tantras mention several reasons for the birth of a male or female child; among them, the day of conception and the relative amount of the mother’s or father’s reproductive substance.78 It also states that even though any body (male or female) arises from the nyes pa gsum (the three humours: wind, bile, phlegm), the ’byung ba bzhi (the four elements: earth, water, fire, wind), and the powers of previous karma and desire, a female body is the result of ‘less merit’.79 This assertion is often uncritically repeated in the classical commentarial literature on the Four Tantras, and as Janet Gyatso’s and Rae Dachille-Hey’s articles in this volume show, it is made even more explicit in the medical paintings. Only more recently are such patriarchal definitions less often repeated, as we will discuss towards the end.
Even if not outright misogynistic, Tibetan medical texts such as the Four Tantras clearly describe the female body in terms of its difference from the normative male body, and as a body of extra suffering: ‘since she is of lower birth, the female (bud med) body has extra (illnesses)’.80 These are the oft-cited additional 32 ‘particular’ (gtso bo) women’s disorders (mo nad), discussed in Chapters 74 and 75 of the third volume of the Four Tantras.81 A further eight disorders, although called ‘common’ (phal pa’i nad) but in fact associated with pregnancy and obstetric complications, are discussed in Chapter 76 of the same volume.82
These chapters provide substantial information on the causes (rgyu rkyen), classification (dbye ba), symptoms (rtags) and cure (bcos thabs) of women’s diseases (mo nad), and have been copied and discussed in existing commentarial literature, even though its authors were scholarly men, usually monks.83 In the medical paintings from the seventeenth century, however, the causes and types of diseases described in these chapters on mo nad are not depicted, as discussed by Gyatso in this volume. Instead more widely held negative ideas about women are reproduced by linking them—repeatedly and in visually effective ways—to the three poisons.84 In other places in the medical illustrations, women are not only connected to the three poisons, but often appear in relation to discussions of the wind humour and its root cause of desire, represented by the colour blue. In her article in this volume, Dachille-Hey’s article shows how, in the parts of Chapters 2–5 on wind, bile and phlegm disorders (’dus nad), a strong connection is made between desire, wind (rlung) and women. This point can be seen in relation to Adams and Dovchin’s argument that the moral and religious foundations of Tibetan medicine come forth strongly in the diagnosis and treatment of female disorders. They also hold wind to occupy a special position in terms of female disorders, and show how the qualities associated with it—emotions and desire, often grasping for sexual satisfaction—are regarded as harmful for women’s health.85 Although, as Gyatso points out, it is difficult to identify with certainty male and female figures in the medical illustrations it does appear that female forms make a more frequent appearance in the section on wind disorders, as compared to the sections on bile and phlegm disorders.
While Chapters 42 and 43 of the third volume of the Four Tantras feature a relatively equal discussion of disorders common to the male and female genitalia, the last two chapters on fertility/virility (ro tsa)86 again clearly feature a structural subordination of women within the text: male sexuality and fertility are subjects of the primary (gtso bo) topic, and female reproductive function is but an auxiliary (yan lag) matter.87
As we can see, almost all of the disorders of women specifically mentioned in the Four Tantras are in one way or another related to women’s reproductive or sexual functions and roles. Thus the female body, whenever it does become a topic of medical interest, is largely viewed as a ‘reproductive body’ and, often a ‘body of wind and desire’.
The exceptional female body
Based on her in-depth study in this volume of the seventeenth century illustrations to the Blue Beryl, Gyatso analyses how the Tibetan medical body is represented as a default male body, especially in its anatomical and physiological depictions.88 At the same time, the female body becomes characterised by ‘extras’ (lhag)—the extra amounts of flesh and fluids, or the extra number of orifices.89 Following Gyatso, we argue that disease and diagnosis in the Four Tantras are also explained above all in terms of a male body. For example, even when the Four Tantras state that the twelve organ pulses of a patient need to be taken differently for women and for men, the exemplary patient is male. How the organ pulses of a female patient should be read deserves no further explanation there. Rather, as a reason the tip of the female heart being tilted towards the right, and vice-versa with men, is stated.90 Although this anatomical distinction has aroused scholarly interest later, it is not mentioned in the respective places on the anatomical and physiological paintings. In the anatomical paintings, Gyatso argues, both androcentric gender bias and gender parity are present in a more obvious and stronger way than in the Four Tantras and the commentaries.
How, then does this reality of the ‘default’ male body in Tibetan medical literature and visual culture, and of women’s ‘extra’ suffering due to the pronounced ‘inferiority’ of the body, relate to our earlier exploration of the sociology of medical practitioners and authors? This default male body norm was established by male monastic medical writers and usually male medical lineage holders and, given the historical and cultural context in which they worked, the topic of women and ‘women’s diseases’ would have been unlikely to bring prestige and respect. More probably, it would instead have raised suspicions. With women being reduced largely to their reproductive and sexual roles this may not be surprising.
Female medical deities
Having established more fully how misogynistic and patriarchal structures influenced Tibetan medical ideas of the female body, we ask, in contrast, has there been anywhere in the medical writings and in visual depictions, a deification of women? While all scholars and practitioners of medicine, as well as patients and lay Buddhists, are well aware of the blue beryl-coloured Medicine Buddha, or Sangye Mengyi-la (Sangs-rgyas sMan-gyi Lha),91 female medical deities have been given a less prominent role, although they are mentioned occasionally in the medical literature and iconography. The most prominent female medical deity is commonly referred to as ‘Mengyi Lhamo’ (Sman-gyi Lha-mo), Dutsi Lhamo (bDud-rtsi Lha-mo) or Yidro Lhamo (Yid-’phrog Lha-mo). In the legendary biography of the 8th century figure Yuthog ‘the Elder’ (whose 12th name-sake Yuthog ‘the Younger’ is known to be the author of the Four Tantras), his ancestry is traced back on his mother’s side to a human incarnation of Dutsi Lhamo, the inn-keeper’s daughter, (Kyepa) Yidro Lhamo (Yid-’phrog Lha-mo), who is cast as a beautiful and charming woman with supernatural powers. Yidro Lhamo is described as taking on a particularly important role in the spread and propagation of medical plants and trees in India, Khotan, China, Nepal and Tibet, and is reported to have offered the panacea arura to the Buddha in India.92
Mengyi Lhamo’s strong connection with the plants used in Tibetan medicine probably earned her the iconographic depiction as a female deity holding an Arura Chebula plant in her hand (see Figures 3 and 4).93
She is still revered for the propagation and protection of medical plants, and for her blessings to enhance the potency of plant medicines, by contemporary medical practitioners we spoke to in Central Tibet and in exile.94 As the Medicine Buddha presides over a group of eight Medicine Buddhas, so does Mengyi Lhamo preside over a group of eight Medicine Goddesses. We have yet to find iconographic depictions of this group of Medicine Goddesses. Although Dutsi Lhamo’s wrathful form, Dorje Phagmo, is seen as the female tantric consort of the wrathful emanation of the Medicine Buddha, Tamdrin,95 this union of (medical) ‘wisdom’ and ‘skilful means’ seems rarely visually represented. Moreover, Mengyi Lhamo and her group of eight Medicine Goddesses play a less pivotal role in prayers and as a main resource for healing powers for doctors, patients or Buddhist practitioners.
To conclude, Tibetan medical literature and its illustrations portray the male body as the default human, while largely casting women as exceptions and in relation to their reproductive roles and sexuality at the same time. While misogynistic attitudes prevail in the medical literature, hence posing a continuation of some of Buddhism’s legacy, the deification of women or the ‘female principle’ is not as pronounced in medicine as it is in Vajrayāna Buddhism. In comparison with the main Tibetan medical deity, the blue beryl-coloured Medicine Buddha, or Sangye Mengyi-la, female medical deities such as Mengyi Lhamo and the group of eight Medicine Goddesses are mentioned much less frequently in the texts. As Jenny Bright also points out in her translation of Tsultrim Gyatso’s work in this volume, religious practices to invoke deities such as the Medicine Goddess of Bright Light (sNam-kyi Lha-mo ‘Od-chang-ma) are recommended to help a woman gain more merit. However, this group of deities takes equally marginal positions in iconographic depictions, as well as in medical and lay practitioners’ and patients’ prayers. The presence of female divinities, as in Tibetan Buddhism, has proven to have only limited effect on the opportunities open to female doctors (and patients).
Tibetan medicine and reproductive health
Building on our recognition of the common association of women and Tibetan medicine through sexuality and reproduction, in this third part we turn to a prominent issue in studies of health and medicine in Tibetan communities, namely reproductive health.96 Several of the articles in this volume, i.e. Schrempf, Bright, and Cuomu, focus on issues related to women’s reproductive capacities, and their social and medical understandings. As seen above, women’s diseases, as well as gestation and childbirth, are inherent parts of Tibetan medical theory. However, in practice amchi have remained only marginal in events such as childbirth. Furthermore, Tibetan communities are among the few in the world without a traditional institution of birth attendants or midwives, leaving women’s reproductive experiences particularly vulnerable. How can we explain the relatively low presence of Tibetan medicine in the field of reproductive health?
Childbirth and Tibetan medicine
To date, only those chapters in the Four Tantras relating to paediatrics have been translated into French and German,97 but the chapters on gynaecology await translation into European languages other than Russian.98 While there are few translations of the classical gynaecological texts, Bright’s article on menstruation in this issue presents the first translation of contemporary Tibetan studies of the subject. Reproductive health has primarily been analysed through contemporary ethnographies, and increasingly so since the 1990s. This new emphasis on reproductive health must be seen in relation to the worryingly high maternal mortality ratios that were reported for the Tibetan areas of the PRC in the 1990s, and led to a number of both research and applied health initiatives attempting to improve the situation.99 The total maternal mortality rates for these Tibetan areas are not available, however reports from some regions in the Tibet Autonomous Region (TAR) show figures as high as 400–500 deaths per 100,000, ranking it among the highest in the world.100 These numbers are also significantly higher than those found in both adjacent countries (Nepal: 290/100,000) and other areas of the PRC (45/100,000 (on average)).101 There are many reasons for this situation in the TAR, lack of access to adequate health services and cultural preferences for home births being two important factors. In Shigatse prefecture for instance, NGOs have reported that in the beginning of 2000, as many as 90 per cent of women delivered at home, 94 per cent doing so without any trained birth assistants, which made them vulnerable to potentially lethal problems, including post-partum haemorrhage, eclampsia (toxaemia of pregnancy), and obstructed labour.102 Mapping cultural practices of childbirth has therefore been an important contribution made by anthropologists involved in both research and health programmes in Tibet.
Tibetan childbirth practices have been described in different types of publications, including clinical studies,103 socio-cultural analyses,104 as well as in popular writings.105 These studies have shown that, although outside the sphere of Tibetan medical professionals, Tibetan women perform a variety of practices to enhance the chances of a safe delivery. Adams et al. describe how these relate to five key categories: ‘fear of attack by spirits/demons and negative health effects of meeting strangers; fear of and taboos against pollution/defilement (grib); injunctions to silence and secrecy; various beliefs about diet and behaviour; various social and economic obstacles to receiving hospital care’.106 To tackle these challenges, women utilise a number of methods, including religious and dietary practices. As mentioned, amchi are also approached for specific Tibetan medicines associated with aiding and speeding up delivery.107 Although amchi provide these pills for expectant mothers, amchi themselves are seldom present during the labour. Even in urban areas, most Tibetan women give birth at home, with the help of female relatives or their husband. Despite state efforts to promote use of birthing facilities in the county (biomedical) hospitals, the results seem to have been limited so far.108
Despite the vast knowledge of embryology, including gestation and childbirth, in Tibetan medical expertise, this knowledge has only marginally benefitted women in vulnerable health situations. One of the reasons for this,109 is found in Frances Garrett’s work on embryology in Tibetan literature. Garrett asserts that the description of embryology, or what is often called ‘the formation of the body’ (grub pa lus) has two forms and purposes in Tibetan medical and Buddhist writings: first, to address and educate doctors and religious practitioners about the nature of conception, foetal growth, pregnancy and birth; and second, to use embryology as a case to discuss the inherent morality of the Buddhist path.110 Further, she points out that in the literature describing the growth of the embryo, the female body disappears from the text, signifying that the main focus is not on women’s health, but rather on the nature of human rebirth within a Buddhist philosophical framework. In their contributions to this volume, Cuomu and Bright posit another possible reason for the scarcity of works on women’s medicine and childbirth in the Tibetan medical literature, namely the centrality of monasteries to medical knowledge production and practice. Cuomu adds Tibetan women’s shyness in talking about health problems relating to the ‘secret parts’ of their bodies might be an additional causal factor.
Modernising reproductive health
Despite the peripheral position of gynaecology and paediatrics to Tibetan medicine, attempts by the Tibetan government and central medical experts in Lhasa were made at the beginning of the twentieth century to develop a children’s health care programme (byis pa nyer spyod). In this volume, Stacey Van Vleet describes the endeavour of the thirteenth Dalai Lama to implement a plan based on the manual On Childcare: Treasure of the Heart Benefitting Beings (byis pa nyer spyod ’gro phan snying nor), written by his personal physician, Jampa Tupwang (Byams-pa Thub-dbang). The programme comprised three main elements: the distribution of eight compounded medicines to parents of newborns, advice for rituals and care during the first year, and the efforts to calculate the natal astrology chart for all newborns. Notwithstanding contact with biomedicine in his various periods in exile, the Dalai Lama and his physician chose to base the childcare programme entirely within the formal structures of Tibetan medicine. This proved an early progressive attempt to develop Sowa Rigpa into a medical apparatus available for all social backgrounds within his own reign. However, the Dalai Lama’s programme was discontinued in the 1920s, due to the turbulent political situation of the time.
In more recent history, political turmoil, caused by the Chinese invasion, has again left Tibetan medicine and its practitioners on the margins in relation to one of the most controversial reproductive health issues in contemporary Tibet, namely birth control. Amidst claims that it was a part of a policy of ‘genocide’ of the Tibetan people on the one hand, and to aid Tibetans to transform themselves into modern families on the other,111 state birth control has proved one of the most difficult issues to research in Tibet. A decade ago, Goldstein et al. published findings from the TAR showing no coercive implementation of birth control in their particular area of study.112 As Schrempf notes in her article in this volume, there seem to be vast discrepancies not only in attempts to control reproduction in Tibetan areas of the PRC, but also in the ways in which women have been subject to birth control and contraceptive use. In this first study mapping women’s experiences of family planning policies Schrempf shows that Tibetan women in Amdo endured forced sterilisation and abortion campaigns throughout the 1980s and 1990s, and that the surgeries carried out on them during these years have left the women describing feelings of pain, loss of strength, and an increasing social pressure in these male-dominated communities.113 Changes are happening in this field; Schrempf notes that younger women in the urban centres are more comfortable with the use of contraception, and often embrace the idea promoted by birth control campaigns that such measures allow the modern family to exist beyond a subsistence economy.114
Given the state’s explicit involvement in women’s reproductive health, in which ways do Tibetan medicine and the State-promoted biomedicine integrate? And who are the Tibetan participants and voices in this new field of integrated women’s medicine? Birth control technology used in Tibet comes exclusively from biomedicine, and includes IUDs, abortion, and tubal litigation. Not surprisingly, Sowa Rigpa, through its long-standing emphasis on the connections between fertility and virility, has traditionally focused on enhancing fertility, rather than controlling it.115 Fertility control today therefore represents a medical field completely dominated by biomedicine, when compared to the pattern in general reproductive health, which is characterised by integration of biomedicine and Tibetan medicine. This integration involves, however, biomedicalisation. In her extensive scholarship on contemporary practices of Tibetan medicine, Vincanne Adams has discussed the various ways in which Tibetan medicine, including women’s medicine, is undergoing processes of modernisation and scientification through which biomedical technology and understanding come to form a central part of Tibetan medical practices.116 These powerful, state-initiated modernisation processes are clearly part of the reason why Tibetan medicine is marginal to current reproductive health practices, as through these, traditional medical knowledge is placed lower in the hierarchy of ‘science’ and thus at the periphery of decision making.117 At the same time, similar processes of biomedicalisation are seen at the Men-Tsee-Khang in Dharamsala, outside of the Chinese state’s modernisation project. This leads to the question of the power of ‘science’ and commercialization in more general terms—beyond the reach of a particular state. Despite the fundamental differences of the political context of Tibetan medicine in India and the Prc, there are also some pronounced similarities in the processes of transformation, particularly seen in its incorporation of biomedically-defined anatomy and technology.118
Women’s (reproductive) health has been one way of discussing the subject of Tibetan modernities. Schrempf has argued elsewhere that family planning, for instance, is a field in which Tibetan women struggle to find a ‘Tibetan figuration of modernity in which...[they] must negotiate their own subjectivity in relation to the greater forces of socio-cultural, economic and political transformations in China’.119 Chertow has also pointed to the role of Tibetan women in the Chinese project of modernising Tibet through state-sanctioned health projects, suggesting that through these projects, Tibetan women are constructed as a ‘newly gendered, classed and racialised subject-citizen’ within the Chinese state.120 From the Chinese government’s side too, the efforts to improve maternal and child health through the establishment of biomedical clinics and hospitals are indeed promoted as part of the modernisation of the Tibetan society. However, as Van Vleet’s article in this volume shows, public health was not foreign to the Tibetan government in Lhasa before the Chinese invasion. She argues that the childcare programme launched in 1916 was one of many campaigns to educate women about childbirth and care, taking place not only in Tibet and neighbouring countries, but globally, initiated by both colonial rule and nation states. These campaigns were formed within discourses that linked public health care with ideas of ‘benevolent rule, state sovereignty and civil society’.121 The Tibetan childcare programme was designed to educate parents, not only mothers, independent of social standing. As a political project, the programme aimed to ‘cultivate a sense of Tibetan subjecthood’122 in relation to the delineated territorial nation state, which, Van Vleet points out, happened well before the thirteenth Dalai Lama had initiated his better known reforms of the tax system, the army, the postal system and more. It seems that also in the beginning of the previous century women’s and children’s health represented a rationalisation of the Tibetan bureaucracy, and as such it ‘was an early, important, and perhaps more politic priority’.123
Contemporary medical writing and gender models
While Tibetan modernisation of medicine was firmly grounded in the idea of Sowa Rigpa as the ‘definitive methods of analysis’, as Van Vleet also found from the beginning of the twentieth century, the Chinese state’s modernisation of health and medicine is conducted along biomedical lines. Although also expressed by practitioners as a process involving ‘loss’ of traditional knowledge, and particularly religious elements of medicine, Adams argues that biomedicine is also used by Tibetan doctors as a source of ‘scientific legitimization’ of Tibetan medicine in its institutional form.124 Likewise, in her study of contemporary medical literature, Bright describes hybrid accounts of menstruation (or ‘monthly mark’, zla mtshan) in which Tibetan medical concepts of digestion and formation of the ‘red element’ (khams dmar), and biomedical concepts of hormones are intertwined in unorthodox ways so that hormones provide an explanatory model for digestion and menstruation. In line with Adams, she argues that integration with biomedicine is used to ‘substantiate and bolster the validity of Tibetan medical claims’, 125 rather than to dispute Tibetan medical theories. Underlying these arguments is the notion of agency and participation of Tibetan actors in the medical field, a point we find important to underline here.126
In which ways do cultural and religious perceptions of gender translate into these contemporary writings of a hybrid women’s medicine? Has the integration of biomedicine influenced traditional notions of the inferior female body found in medical and religious theories? The texts on menstruation analysed by Bright provide an indication that gender perceptions from the foundational texts, such as the Four Tantras, are maintained in contemporary writing. Just as people today writing about hormones, i.e. biomedical entities, do not contest Tibetan theories of digestion and the formation of menstruation, we can see similar processes of integration with other religious ideas of conception, including karmic explanations of female rebirth. Continuities in gender perception can also be found in these contemporary texts in the area of connections between women’s disorders and sexuality. In most of these male-authored texts on gynaecology, sexual advice for men is also included.127 Bright explains this continuity of gender perceptions through the characteristic form of text production employed. In this, the writer structures his or her texts as commentaries on the authoritative texts, and hence does not challenge fundamental theories and concepts.
At the same time, contemporary authors express sympathy towards women. This is seen for example in the avoidance of the infamous line, ‘by having less merit [one] obtains the female body’.128 In one of his books on women’s disorders, which has been analyzed by Adams,129 Palden Trinley, a doctor at Lhasa Mentsikhang, writes at great length about gender discrimination of what he calls the ‘feudal system’, i.e. pre-1950 Tibetan society, explaining it in social and cultural rather than medical terms. In fact, most of the writers examined by Bright explain women’s low social status in Tibet in ways that go beyond medicine and religion. Explanations of the fundamental differences of the female and male body in terms of low merit are not prominent in contemporary medical literature, and Bright argues that in an integrated women’s medicine of today sex differences are regarded as ‘innate “chemical-like” features of the body’,130 much in the same ways as hormones have been sexed in biomedical theories.
Despite the increased volume of female medical expertise, it seems that authorship of medical texts remains predominately male. So far, it would appear that today’s women practitioners produce few medical texts themselves. One important exception is Mingji Cuomu, who is represented with an article in this volume. Educated as a Tibetan medical doctor in Lhasa and later in Public Health and Medical Anthropology in England and Germany, she represents an exceptional and new kind of female medical practitioner, combining clinical work, research and medical writing. Conducting research on broad topics such as public health, clinical trials and knowledge transmission in Tibetan medicine,131 her focus in Tibetan language publications has nevertheless been on gynaecology and obstetrics.132 Beyond confirming gender stereotypes in Tibetan medicine, the pattern of increasing numbers of female doctors publishing primarily on reproductive health indicates a future development whereby Tibetan medicine is more strongly incorporated within maternal and child healthcare.
Beyond this special issue’s concerns with women as Sowa Rigpa practitioners and with Tibetan medical views of the female body as such, the scholarship represented within this volume also aims to disturb the usual perspectives in studies of Tibetan medicine featuring largely male authors, practitioners and patients. It reveals how human bodies and minds in Sowa Rigpa have largely been defined based on a normative and default male body and mind, a state of affairs that has been articulated and illustrated (with few exceptions) through men.
Compared to other domains of Tibetan social and cultural life, Tibetan medicine may have been an area with more room for female manoeuvre and performance beyond normative gender roles. Nevertheless, we question women’s exceptional status as a social group, in the sense that we would argue for a constant negotiation and adjustment of ideals, through human or other agency, whether these ideals are outlined in texts or propagated in the context of social and moral orderings and disciplines. Hence the co-existence of seeming paradoxes should not be surprising, such as finding a woman doctor, with nuns and monks as her disciples, purifying mercury for locally produced precious pills in a rural Tibetan nunnery, yet at the same time noting that the Lhasa Mentsikhang does not allow any females, whether human or animal, near the one and a half month-long mercury purification at its production site outside of the city. Despite social constraints, structural limitations and cultural perceptions of the female rebirth as a disadvantage, there are accounts of women with great accomplishments and influence throughout Tibetan history.133 In medicine there are well-known female doctors such as Khandro Yangga and Lady Doctor Lobsang Dolma, but also less well-represented women amchi, who nevertheless at times were holders of prestigious medical houses.
In addition to the well-known Tibetan category of medical lineages (sman gyi rgyud), we have pointed to the fact that some of these are also referred to as ‘medical houses’ (sman grong). Importantly we suggest that an emphasis on ‘medical houses’, as a new analytical perspective on the transmission of Tibetan medical knowledge, might be a fruitful way to account for women and understand better how they, whether lay or ordained, in different places, have learnt and practised medicine.
In terms of the female body in mainstream Tibetan medical literature and visual culture, leaving the vast extant manuscript and non-elite visual culture aside for the time being, the articles in this volume present the female body as represented and perceived predominantly as a ‘body reproductive’, a ‘body/mind of desire’, and a ‘body of extras’.
As anthropologists, feminists and women, both having studied and lived in Tibet and having worked with exiled Tibetans for a number of years, we are curious to learn and to see what is changing in Tibetan medical notions of humanity, gendered discourses, personal experiences and broader healing and cultural practices of women and men. These are timely considerations, not least because almost half of the medical student population at most Tibetan medical institution—in large Chinese state colleges, exile institutions and in small private schools—is female. What will be the implications of this for the proclaimed notion of the inferiority of the female body in medicine and religion? Or, what will be the implications for the doctor-patient encounters in rural and urban Tibetan communities? What forces foster new ideas in this domain and in which ways will they be articulated?
It is only in recent decades that we can find published Tibetan medical texts by female authors, one of which is represented in this volume. We have discovered that these women do not reproduce the oft-held negative ideas about women (nor do some of their male contemporaries), yet they do tend to publish in the fields of mo nad, pregnancy and child birth.134 That female amchis’ expertise seems more comfortably cast in this domain was, as we have seen, already an issue for Khandro Yangga, chosen to head the newly established department for women and children’s health at the Mentsikhang in 1962. Could it be that the domain of women’s diseases, pregnancy and childbirth has been a field of medical expertise of Tibetan women all along, but existed outside of what has been defined as ‘medical’ in Tibetan medicine or biomedicine? How will the boundaries within Sowa Rigpa and other knowledge systems be redrawn, redefined and crossed with more women entering professional medical work, where traditional medicine is also beginning to take a more central position than in the past? And how will this take place in dialogue and in discussion with biomedical ideas and its global assemblages of biopower, science and technologies? By bringing these articles together, it has been our aim to start engaging with these questions.
These contestations of traditional gender roles and the creation of new subjectivities, within and outside of medicine, are taking place at interesting times. The use of the term ‘low birth’ skye dman for ‘woman’ is self-consciously debunked by many urban Tibetan women in favour of bud med or a ce. While the oppositional unity of ‘wisdom’ and ‘method’ may be used as a liberating force for religious women, it remains to be seen how feminist literature is navigating its path across and between the Communist Party and other lines. Almost twenty years have passed since Samuel wrote that ‘Tibetanists have generally ignored the issues raised by feminist thought’.135 We hope that scholars of Tibetan studies and the anthropology of Tibet alike will be more attuned to listen to and represent women’s voices, and that the disciplines will not need to be critiqued, again, for its lack of subaltern movements and engagement with gender studies.
We would like to thank the Nansenfoundation and the Norwegian Research Council for their project grant made available to Hofer and Fjeld, without which this joint writing and editing project would not have been possible. Equally, heartfelt thanks to the Section for Medical Anthropology and Medical History, Institute for Health and Society for facilitating Theresia Hofer’s stay as a guest researcher. Many thanks also to our reviewers, as well as our colleagues who closely read and commented on the introduction, in particular Barbara Gerke and Sienna Craig. We gratefully acknowledge support from the Trace Foundation for funding conference travel of Tibetan participants to the panel in Bhutan and for covering the costs of translation of Cuomu’s article included here, as well as the Austrian Ministry of Education and Research and the Norwegian Research Council for funding conference travel. Finally, we wish to thank our copy editors Liz Hudson, Ruth Biddes and Thea Vidnes, and translator Katia Holmes for their excellent work and collaboration.
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and Nor-bu Chos-’phel bKra-shis Tshe-ring , Mnga’ ris smad yul skyid grong rgya dgu’i lo rgyus dang brel ba’i skyid grong grwa khang dkar ba’i sman pa mkhas grags can blo bzang sgrol ma’i nang mi’i lo rgyus nor bu’i me long. (‘A Brief Account of the Famous Tibetan Lady Doctor Lobsang Dolma Khangkar (1935–1989) and her Family, Including Historical Materials on Kyirong, South West Tibet’). 2008 Dharamsala: Amnye Machen Institute.
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(alias Dra-kya ma-ni), Byis pa btsa’ thabs kun phan zla ba’i me long zhes bya ba. (‘Mirror of the Moon: Methods for Giving Birth Helpful to All.’) mKhyen-rab Nor-bu Lhasa Mentsikhang, (On Folio 8a it is stated that the text was written on an auspicious date in the ‘year of Mars’ ( n.d. mig dmar lo), however we are not sure which year this may correspond to).
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In the following, we rely largely on data from Central Tibet, where the authors have carried out most of their research, but also take into account works on other regions where Sowa Rigpa is practiced.
Samuel 2008, p. 253.
Cf. McKay 2007. Similarly, there has been an emphasis in Mongolia to refer to Sowa Rigpa as ‘Mongolian medicine’ (ITTM 2002), or in Bhutan as ‘traditional Bhutanese medicine’ (McKay and Wangchuk 2005). In contrast in India, the name Sowa Rigpa has been promoted by the Central Council of Tibetan Medicine in the context of its (now successful) lobbying to include Tibetan medicine as an ‘Indian system of medicine’ under India’s state administration for traditional medicines AYUSH (Kloos 2011).
Adams 2001a, Janes 1995.
Janes 1995, Adams 2001b, Hofer 2011a, Saxer 2010.
Craig (forthcoming), Kloos 2010, Prost 2008.
Adams and Craig 2008.
Cf. Adams, Craig and Schrempf 2010.
For a more detailed discussion of terminology, see Hofer (in press).
Cf. Taube 1981, Hofer 2007 and in press, Schrempf 2007.
Bolsokhoyeva 2007, Meyer 1995, pp. 116–120, Gerl and Aschoff 2005, TIN 2004.
Gyatso and Buffetrille 1987, Gerl and Aschoff 2005.
The standardised translation of rgyud bzhi is Four Tantras. However, as tantra here should not be understood as the esoteric Buddhist scriptures of Vajrayana Buddhism as such, some authors, such as Janet Gyatso and Jenny Bright in this volume, choose to use Four Treatises, as rgyud also translates simply as text in general.
Cf. Garrett 2009.
For example, Hofer found that the largest Gelugpa Monastery in Ngamring (Ngam ring Chos sde dgon), with approximately 400 monks living there before 1959, did not have a resident doctor in the 1940s and 1950s, but rather depended on ritual healing, prayers or lay medical doctors who came to treat the monks with Tibetan medicine.
For instance, MacDonald proclaimed that “every doctor in Tibet is a Lama” (MacDonald 1929). Hofer has argued elsewhere that British colonial representations of Tibetan medicine as primarily a domain of Tibetan Buddhism, were attempts to establish British superiority and ‘science’ over indigenous ‘belief’, Hofer 2011b.
Tashi Tsering 2005.
Hofer 2011a, pp. 86–7.
On this school and medical activities at Tashilunpo, see Hofer 2011a.
There is one notable exception, namely Pelshung Tibetan medicine school, which operated near Shigatse from 1999 to 2006 and did not train any female amchi, as its director considered it a deviation from Tibetan medical tradition.
Diemberger 1993, Garrett 2008, Levine 1981.
Tashi Tsering 2005.
On the latter see Hofer 2011a, pp. 90–92.
For instance Amchi Ku Dawa’s wife in Chu’og District, Ngamring County. How she studied medicine is still unknown to us.
In Derge area, we were told by Thubten Phuntsog about Purpa Drolma (Phur-pa sGrol-ma) who was taught by her father and alongside her brother called Tsering Dorje (Tshe-ring rDo-rje). Her father was usually referred to as ‘Dramang Lhaje’, after Dramang Monastery that he was affiliated with, but his full name was Jamyang Sangpo (’Jam-dbyangs bZang-po). Personal communication, Hofer with Thubten Phuntsog, Beijing, 2007.
Lévi-Strauss 1987, 1991, Carsten and Hugh-Jones 1995, Hsu 1998, Fjeld 2007.
Lévi-Strauss 1987, p. 174.
See Schrempf, this volume, and Makley 2007.
Sa-skya sMan-grong and lHun-sdings sMan-grong. Cf. Hofer 2007 and in press.
Byams’-pa ‘Phrin-las 2000, pp. 458–463, bKra-shis Tshe-ring 1994, Khangkar 1998, Hofer 2011b, Josayma and Dhondup 1990, Tashi Tsering 2005, Nor-bu Chos-’phel and bKra-shis Tshe-ring 2008.
Tashi Tsering describes her father, Dingpon Tsering Wangdu, as the holder of three unbroken lineages: ‘a lineage of lding-dpon (ruling family of one of the territorial nine sections of Kyirong); a lineage of grong-sngags or dbon-po (lay tantric practitioner); a lineage of sman-pa (‘doctors’)’ 2005, p. 177. See also Aufschnaiter’s diary entry on Lobsang Dolma’s father, ‘Traba Angdi’, reprinted in Brauen 2002, pp. 42–3.
Cf. Kloos 2008.
Cf. Khangkar and Lamothe 1997.
She is co-author of Brown, Farwell and Nyerongsha 1997.
The reason often given for higher prevalence of nuns as amchi was that they were usually more literate than lay women, and literacy was an undisputed requirement for the study of Sowa Rigpa.
Cf. Hofer 2011a, p. 86.
Da-wa Ri-bdag 2003 and fieldnotes 2007, Hofer.
Chiu Gonpa Tekchoeling, Nyemo County. Personal Communication, Dawa Norbu, Lhasa, 2007.
Personal communication with Thubten Phuntsog, Beijing, 2007.
Gyatso and Havnevik 1995, p. 13.
This is seen for instance in Byams-pa ’Phrin-las collection of 155 biographies of famous Tibetan doctors, of which only one is a woman (Khandro Yangga), Byams-pa ’Phrin-las 2000.
Byams-pa ’Phrin-las 2000, p. 463.
Personal communication with Stephan Kloos.
Hofer’s forthcoming post-doctoral fellowship at the University of Oslo will tackle this topic through her project: ‘Women Doctors in Tibetan Medicine and the Modernisation of Health Care’.
Cameron 2010, Mei Zhan 2009.
Cameron 2010, pp. 46–7.
Inhorn 2006, pp. 358–9.
A large number of manuscripts, which have been collected from all over Tibet after the Cultural Revolution, are now held at the Mentsikhang’s library in Lhasa. See sMan-rtsis-khang 2006.
Byis pa btsa’ thabs kun phan zla ba’i me long zhes bya ba bzhugs so.
Hofer 2011c for a translation and critical discussion of the text.
Cf. Furth 1999, 2007, Farquhar 1991.
Tashi Tsering 2005, p. 173.
Goldstein 1971, 1989, Fjeld 2005, 2008.
Fjeld 2005, Yuthok 1990, Taring 1970.
See for instance Bell 1924:129ff, see also Acharya and Bennet 1981.
Taring 1970, and other works by Yuthok 1990 and Sakya and Emery 1990.
After strong pressure from Tibetan women’s organisations in India, the exile government in Dharamsala has now suggested a new spelling for ‘woman’, ‘kyeme’, where kye is still spelled skye (birth) but where me is spelled sman meaning medicine (instead of dman for ‘low’), thus giving ‘kyeme’ a new etymological meaning, ‘birth medicine’ (Namgyal Tsomo, personal communication with Fjeld). Rumour has it that it was a Western ordained Tibetan Buddhist nun in Dharamsala who initiated this rewriting. We have not, as yet, been able to confirm this.
‘If one wants a teacher, one makes a son a monk, and if one wants a servant, one makes a daughter a nun’, Lopez 1998, p. 211.
Gutschow 2004, p. 16. She points out that there is a rather dubious logic to such a system, for if it always takes seven more rebirths, how can a woman ever be reborn as a man?
Schrempf, this volume.
These differing textual attitudes could perhaps been seen to reflect the point often made by more recent gender theorists about the multiplicity of gender discourses in most communities, cf. Moore 1994, Howell 1996.
Sponberg 1992, p. 19.
Sponberg 1992, p. 25.
Palden Trinley, in Adams 2001a.
Gyatso 2003, p. 89.
Havnevik 1989, 1999, Gyatso 1989, 1999, 2003, Diemberger 2007, Makley 2005, Gutschow 2004, Schaeffer 2004, Jacoby 2007.
Cf. Garrett 2008 and Young 2011.
Clark 1995, pp. 48–9.
‘Bso nams dman pas za ma mo lus thob’, g.Yu-thog 1984, p. 393. On the term za ma mo, see Gyatso 2003.
g.Yu-thog 1984, p. 393.
The 32 particular disorders in the Four Tantras (g.Yu-thog 1984, p. 393) are subdivided into five uterine disorders, sixteen ‘channel disorders’ (rtsa nad, subdivided into khrag tshabs and rlung tshabs), nine uterine tumours (skran nad), and two kinds of (’srin bu’i nad) or ‘micro-worm’ disorders (today commonly translated as ‘infections’).
These are ailments associated with pregnancy (mtshan ma’i nad), abortion and protracted labour (bu ma phyin pa), haemorrhaging (khrag ma chod pa), post-natal ailments (nad gzhug las pa), ‘post-natal infections’ (dug dab), g.Yu-thog 1984, p. 400.
E.g. in Desi Sangye Gyatso’s Blue Beryl, Sangs-rgyas rGya-mtsho 2005, pp. 1090–1109.
It is a general pattern that the rich content of the Third Tantra is left out from the Blue Beryl illustrations. While for other chapters they present at least causes and types of diseases in a brief manner, by contrast the chapters of mo nad are left out all together.
Adams and Dovchin 2001, p. 440.
Chapter 91 and 92, cf. Gyatso 2008.
Gyatso 2008, p. 83.
Cf. Young 2011: 209.
More women are found in the later paintings of the set, where however, they are, according to Gyatso, still shown almost always in gender-specific roles and never taken to illuminate a gender-neutral condition.
Rechung 1973, p. 94.
Second medical thanka, top row, sixth figure from the left.
Personal communications, 2006, 2011.
Cf. Clifford 1984, pp. 50–51.
Adams 2001a, 2005, 2007, Adams et al. 2005a, Adams and Dovchin 2001, Chertow 2007, 2008, Craig 2009, Garrett 2008, Gutchow 2011, Hancart-Petitet and Pordié in press, Schrempf 2008.
Filliozat 1937, Jäger 1999.
ONE Heart, Terma foundation, Burnett Institute, among others. Several of the anthropologists active in Tibetan medicine studies were involved in these initiatives, among them, Vincanne Adams, Sienna Craig, Mingji Cuomu, Jennifer Chertow and Theresia Hofer. These international NGO-initiatives were, however, partly or fully closed down following the 2008 uprising in Tibet.
Adams et al. 2005a, TIN 2002.
Craig 2009 p. 150.
TIN 2002, p. 67.
Adams et al. 2005a, Adams et al. 2005b, Miller et al. 2007.
Crook and Osmaston 1994, Rozario and Samuel 2002, Vorndran 1999, Ortner 1973, Childs 2004, Craig 2009.
Brown et al. 1997, Sangay 1984.
Adams et al. 2005a, p. 826.
The following medicines were commonly used by amchi in Tsang, to help during birth or in complicated deliveries: zhi bye 6 and zhi bye 11 to ease childbirth and the delivery of the placenta, gur gum 8 to stop excessive bleeding in childbirth, and zhi bye 6 and chi nar 6, to stop vomiting during pregnancy and childbirth.
In a recent study from Rebgong in Amdo (Qinghai province) sNying-dkhar-rgyal argues that following the implementation of the New Cooperative Medical Scheme in 2003, through which patients are secured reimbursement of significant portions of hospitalization costs, birth practices are changing towards more use of the county hospital (sNying-dkhar-rgyal 2011).
See also Craig 2009, p. 153
Garrett 2008, see also Craig 2009.
Tibetan Women Association 1995, see discussion in Schrempf, this volume.
Their sites of study were rural areas of Shigatse and Lhasa Municipality Prefectures, Goldstein et al. 2002, Goldstein and Beall 1991.
Schrempf, this volume. Cf. Mueggler 2001 for descriptions of loss and pain following birth control campaigns among Lòlop’ò (officially classified as Yi) in Southwestern China.
See also Childs et al. 2005.
Gyatso 2008. See for instance Fjeld 2009 on the use of Tibetan medicine for fertility enhancing purposes in contemporary Lhasa.
Adams 2001a, 2001b, 2002, Adams et al. 2005a, Adams and Dovchin 2001, Adams and Li 2008.
See also Janes 1995.
Schrempf 2008, p. 121.
Chertow 2008, p. 151.
Van Vleet, this volume.
Van Vleet, this volume.
Van Vleet, this volume.
Bright, this volume.
Similarly, Makley in her recent work on the Ethnic Park in Beijing, argues that Tibetan participants in the park are not just passive receivers of state cultural policies, they have proved to be capable of diverting ‘meaning and values along alternative lines, even as they cope with the often crushing weight of shifting state and market pressures’ Makley 2010, p. 129.
dPal-bzang rGya-mtsho 2010, p. 33, quoted in Bright, this volume.
Bright, this volume.
Adams 2001, pp. 226–227. Palden Trinley (also spelled Palden Thinley) is also the author of one of the texts analyzed by Bright.
Bright, this volume.
See Craig, forthcoming.
sMin-skyid mTsho-mo 2009, Byams-pa sGrol-dkar et al. 2004.
See Diemberger 2007, Havnevik 1999, Jacoby 2007, Schaeffer 2004, as well as Uebach 2005.
dPal-ldan ‘Phrin-las 1996, Lha-mo sKyid 2007, sMin-skyid mTsho-mo 2009.
Samuel 1994, p. 696.