Monday, May 22, 2006

Birth trauma, how should we talk about it and how should we interpret it?

The debate about homebirth is still going on over at NHS Doctor. As inevitably happens, a homebirth advocate equates the experience of hospital birth as "like a rape". Here is the response I posted to that comment:

"I find that comment extremely offensive. It trivializes the trauma of women who actually have been victims of rape. It is grotesque to compare being disappointed in your birth experience to the reality of physical and sexual violence."
I was surprised to get several private e-mails about my comment, some of which tried to explain to me why hospital birth can indeed be like rape.

I certainly stand by my original comment, but I want to amplify it. There are two specific issues that concern me, the irresponsible use of language, and the association of these feelings with previous sexual assault.

I do not deny that birth could be traumatic, but I feel very strongly that we need to be more sensitive and aware in our use of language.

We live in a culture where shock is used to market products and where shock is used to make oneself noticed. I fear that that has contributed to a degradation of the way we use language that should be reserved for certain specific instances. For example, many groups blithely complain that this or that act is "like a lynching". No, unless someone was lynched, the use of that term is grotesque. In this country a real lynching was often about hanging innocent black men from trees in the middle of the night, just to express a vitriolic form of racism. It demeans the suffering of so many black men and boys to use the term "lynching" in a rhetorical way.

Similarly, rape has a certain specific connotation. If someone wants to say that the way their doctor treated them felt like an assault, fine. However, to describe it as a rape or like a rape, in my judgment, is to appropriate the term for its shock effect. It is demeaning to women who have been victimized by this specific type of violence.

Second, I have begun to look into the apparently close association of birth trauma with previous sexual assault. It is an association which has been suggested to me primarily by women who consider themselves victims of birth trauma. In their minds, the sequence of events seems to be childhood history of sexual assault, birth trauma, PTSD brought on by the events of the birth. People have simply assumed that the doctor's treatment was equivalent in some way to the original assault.

This not really consistent with the way post traumatic stress syndrome is known to occur in others. I would like to suggest that the sequence is more like this: childhood history of sexual assault, PTSD aggravated by the sexual connotations of reproduction and birth, birth trauma as a manifestation of PTSD from previous events.

In other words, birth trauma does not cause PTSD. Rather PTSD leads these women to experience birth like their previous sexual assault, even though an outside observer, even a homebirth advocate, would not find the doctors behavior objectionable.

I am reminded of a friend who was a victim of incest by her father over many years. As an adult, she needed to have an ultrasound, and in that situation a vaginal ultrasound would typically have been recommended. She was honest with her doctor, however, and told the doctor that she could not tolerate anything in her vagina because it brought back her original experiences. The doctor and the radiologist made special arrangements to do a slow and detailed abdominal ultrasound rather than subject her to the vaginal ultrasound which would have been quicker and easier (for them).

If my friend had not been brave enough to confide in the doctor, she might have undergone a very traumatic vaginal ultrasound. She would have experienced it as reminding her of the original assault. That does not mean however, that the technician would have been unkind or unprofessional or brutal. Her subjective experience would have been transformed by her memories.

Incest, particularly, is a difficult crime to reconcile psychologically. The assault may have been committed at the hands of a beloved parent and it is hard to hold two such contradictory views in one mind. The effects never end. How much easier, then, to psychologically off-load the original assault onto the head of the doctor, a stranger. Perhaps women who have been victimized in the past blame the doctor as a way of redirecting their original anger in a more psychologically tolerable direction. In their minds, they are no longer suffering from PTSD because of assault by a beloved relative; all of a sudden, they are suffering PTSD because the doctor, a stranger, violated them.

When a former soldier with PTSD reacts violently to those around him in a shopping mall parking lot, believing himself to still be under gun fire, no one actually thinks that the people in the parking lot were shooting at him. Similarly, when a woman with PTSD reacts strongly to a doctor, believing herself to still be in the deeply abhorrent state of being victimized by sexual assault, we should be extremely wary about concluding that the doctor was actually assaulting her or treating her badly.

I want to be very clear in what I am saying:

1. Victims of childhood sexual assault may develop PTSD.

2. PTSD may lead women to experience events in childbirth in a way that is not consistent with what is actually happening. There is nothing traumatic going on at the time of birth (similar to the soldier who believes himself to be under gunfire in the parking lot when there is none).

3. The doctor has done nothing to precipitate PTSD (just like the people in the parking lot of done nothing to even remotely suggest that they are shooting at the former soldier).

4. The reaction of the woman to the birth tells us about her, and her psychological state. It tells us nothing about the doctor's behavior.

5. The appropriate response is psychological counselling which explores the original assault and its current psychological manifestations. It is inappropriate to conclude that the woman was treated poorly during labor and delivery.

This sequence is consistent with what we know about PTSD and what we know about the effects of childhood assault.

45 Old Comments:

Amy wrote:
"When a former soldier with PTSD reacts violently to those around him in a shopping mall parking lot, believing himself to still be under gun fire, no one actually thinks that the people in the parking lot were shooting at him. Similarly, when a woman with PTSD reacts strongly to a doctor, believing herself to still be in the deeply abhorrent state of being victimized by sexual assault, we should be extremely wary about concluding that the doctor was actually assaulting her or treating her badly."

Sounds good...except...nobody in that parking lot has a gun, and certainly nobody is shooting. There's not even a power dynamic at play there. Everybody's just walking around peacefully.

In a birth trauma scenario, you have a woman who's naked or partially dressed - at the very least, her genitals are exposed.

She's in a physically compromised position - often flat on her back, legs open; almost always on a bed with others standing physically higher than her.

There's a major power dynamic in the doctor/patient relationship. Most doctors don't take unfair advantage of that power imbalance, but some do.

Often, some or all of the medical personnel are complete strangers, or the woman has met them only perfunctorily before.

The woman may be in pain, is likely in major stress, and is certainly experiencing one of the most life-changing days of her life. For medical personnel, it's just another day at work and they feel fine.

The woman may be coerced or forced into medical procedures against her will, including penetration of her vagina. (And yes, "we have to do this or your baby could die" is language of coercion. Is the baby really going to be in mortal peril if that vaginal exam or Pitocin IV isn't done right this minute?)

Medical personnel may use wording that is similar to that used by a woman's original abuser. "Just relax, hon - it'll all be over quickly."

Combine some or all of those factors with a woman who has an abuse history, and you have a disaster waiting to happen.

Imagine if I had a life-threatening allergy to peanuts, and you can eat them with no problems. You invite me over for tea and serve cookies with peanut butter mixed into the batter. There's nothing else on the table, and you don't tell me the ingredients. I eat them and go into anaphylactic shock. Would you sit back and say "What's the big deal - she's making a drama out of nothing - I just served the same thing to another friend yesterday, and she was fine!"

Unless you have experienced birth trauma yourself, please do not presume to accuse women of overreacting.

By Blogger Anne, at 10:13 AM  

Anne, there's no accusation of overreaction. You are missing Dr Amy's point.

The question is not whether the reaction is appropriate. It surely is: ANY emotional feeling is very difficult to label as "inappropriate"

The question is merely to whom the "blame" for that reaction is apportioned.

In the legal world, we have a hypothetical "normal person". The idea is that if you do something which would not bother a "normal" person--like, for example, saying "hello"--and they are harmed by it due to their own condition, it's not YOUR fault they are harmed.


In your cookie analogy: Well, you might not say "nothing's wrong". Nobody HERE is saying that those women don't FEEL what they feel.

But if I didn't know you had a peanut allergy, you'd be wrong to accuse me of "assaulting" you with a cookie. And the women are wrong to accuse the doctors of "raping" them.

Dr. Amy is making a similar point. If a woman is harboring severe emotional distress, which she has not disclosed to her doctor, and which makes her likely to react in "abnormal" emotional manners, she is an unusual patient.

Unless the doctor knows, or should know, about her problem, how can you accuse them of "rape" when the real fault lies with the person who CAUSED the woman to feel like that in the first place?

By Blogger sailorman, at 11:33 AM  

I used to think that the author of the book "Birth Without Violence" (which I hadn't read) was going a little overboard by using the word violence. Then I was at a birth where the behavior of the staff was nothing less than violence.

The use of "rape" in that circumstance is consistant with at least one of the meanings of the word. And as Anne has pointed out, many instances of cargiver-controlled birth are, in fact, analogous to sexual assault. And the phrase "like a rape" is appropriate.

Saying something is "like" something else only draws a parallel - the person is not in fact saying it *is* that something else.

I have to conclude that Dr.Amy has not actually had one of these birth experiences in which she was stripped of her control, her dignity and her clothing; had people forcing her to do things by threats or scare-tactics, had her private parts unnecessarily cut, and had her baby traumatically pulled from her body. Maybe she's never had a nurse tell her to stop making noise or she'd drug her. Or a doctor do a vaginal exam without even asking or warning her.

As a childbirth educator I have heard so many horrible stories. As a doula, I've seen them first-hand. I'd definately have to stand by the person or people who used the phrase in the first place. Childbirth can indeed be "like a rape."

By Anonymous Christine, at 3:10 PM  

Christine, you are very right. Apparently Dr. Amy has no firsthand experience in anything homebirth related yet she preaches about it and then tells other midwives that they couldn't have attended hospital births (or had one) and therefore they know nothing.

I actually feel a little sorry for you, Dr. Amy. You have obviously never experienced a truly loving, natural and amazing birth where you and your baby were of utmost importance, where you were in control, and where you were treated as if you were doing something absolutely amazing - which should be the case. I have never met a woman who has had a hospital birth where she was "delivered" and then had a homebirth or birth center birth where she birthed her baby and then said she preferred the former. There is something that you get - as well as one's baby and family - from birthing your child in a setting in which you feel most comfortable and you are in control of what goes on and where you bond with your child in an indescribable way that cannot be matched in a hospital.

I support hospital birth for women who need it. But I support it in hospitals where obstetricians follow a similar model of care as midwives and where they respect the mother and understand that this is HER child and HER birth. It is so unfortunate that this is extremely rare. There are far too many obstetricians and nurses that see their "patient" as just another woman adding to the population and who see this woman as unable to understand her body, unable to know when to push, unable to know when to nurse the baby, unable to know when to rest. This irreprable damage to a woman's ego, heart and the crucial bond between her and her child. I also support homebirth and birth center birth for women who need it. In my 21 years of homebirth experience I have found that for some women a homebirth carries less risk than birthing in a hospital when they cannot find an obstetrician and team that will support her in what she wishes to achieve with her birth.

I just wish that all women had the chance to experience a birth in a setting that she would feel most comfortable in and therefore in which mother and baby would be healthiest in all aspects, physically, emotionally and spiritually.

By Anonymous Anonymous, at 3:41 PM  

"I actually feel a little sorry for you, Dr. Amy. You have obviously never experienced a truly loving, natural and amazing birth where you and your baby were of utmost importance, where you were in control, and where you were treated as if you were doing something absolutely amazing"

Now how could you possibly know whether this is or is not true? Since you cannot know whether or not it is true you are simply making it up as you are going along. Since you are willing to make up information about ME as you are going along, how can you expect to be taken seriously when you are commenting on anything?

You should read my post below about the alternate world of the homebirth advocate. You are certainly illustrating it.

Furthermore, I notice that while everyone is flinging personal insults, I have not seen anyone address the substance of the post. Isn't my description of birth trauma as a RESULT of PTSD rather than a CAUSE of PTSD more consistent with everything we know about PTSD?

By Blogger Amy Tuteur, MD, at 4:27 PM  

"I actually feel a little sorry for you, Dr. Amy. You have obviously never experienced a truly loving, natural and amazing birth where you and your baby were of utmost importance, where you were in control, and where you were treated as if you were doing something absolutely amazing"

Now how could you possibly know whether this is or is not true? Since you cannot know whether or not it is true you are simply making it up as you are going along. Since you are willing to make up information about ME as you are going along, how can you expect to be taken seriously when you are commenting on anything?

You should read my post below about the alternate world of the homebirth advocate. You are certainly illustrating it.


Thank you for proving my point. Just as you don't want me telling you that your experience was not a wonderful and safe experience for you, I don't want you suggesting that I put my child in danger by not birthing in a hospital. For you, hospital birth IS better for you because that is where you feel most comfortable. In addition, you are respected and trusted more by fellow obstetricians than the average mother with no training in obstetrics would be. But, for women like me, a homebirth is better as long as the pregnancy remains low-risk.

By Anonymous Anonymous, at 4:58 PM  

"Just as you don't want me telling you that your experience was not a wonderful and safe experience for you, I don't want you suggesting that I put my child in danger by not birthing in a hospital."

One thing has nothing to do with the other. My experience is my EXPERIENCE. Your decision to risk the life of your child is based on FACT. The fact is that in every study done on the subject, hospital birth is safer.

It is extremely important for people to be able to tell the difference between what is perception, and what is fact. You have every right to make your decisions based on personal beliefs, but don't be confused into thinking that because YOU believe it, that makes it true.

By Blogger Amy Tuteur, MD, at 5:06 PM  

From m-w.com:

Main Entry: 3rape
Function: noun
1 : an act or instance of robbing or despoiling or carrying away a person by force
2 : unlawful sexual activity and usually sexual intercourse carried out forcibly or under threat of injury against the will usually of a female or with a person who is beneath a certain age or incapable of valid consent -- compare SEXUAL ASSAULT, STATUTORY RAPE
3 : an outrageous violation


It's obvious as a collective society we have chosen to redefine rape as sexual assault only.

I do not deny that birth could be traumatic, but I feel very strongly that we need to be more sensitive and aware in our use of language.

Unless you have lived the experience of the woman who describes her birth as a rape, you have no business being anything less than sensitive and aware of her language. When I hear assault as a better choice of word, it conjures the image of a woman who was either beat down or unable to continue fighting back. I don't see either of those words having a place in the world of childbirth, but it is not up to us, the caregivers to decide how a woman feels about her life experience.

In other words, birth trauma does not cause PTSD.

CMAJ:

"Post-traumatic stress disorder after childbirth: the phenomenon of traumatic birth

J. L. Reynolds

CHILDBIRTH CAN BE A VERY PAINFUL EXPERIENCE, often associated with feelings of being out of control. It should not, therefore, be surprising that childbirth may be traumatic for some women. Most women recover quickly post partum; others appear to have a more difficult time. The author asserts that post-traumatic stress disorder (PTSD) may occur after childbirth. He calls this variant of PTSD a "traumatic birth experience." There is very little literature on this topic. The evidence available is from case series, qualitative research and studies of women seeking elective cesarean section for psychologic reasons. Elective cesarean section exemplifies the avoidance behaviour typical of PTSD. There are many ways that health care professionals, including physicians, obstetric nurses, midwives, psychologists, psychiatrists and social workers, can address this phenomenon. These include taking a careful history to determine whether a woman has experienced trauma that could place her at risk for a traumatic birth experience; providing excellent pain control during childbirth and careful postpartum care that includes understanding the woman's birth experience; and ruling out postpartum depression. Much more research is needed in this area. "

(I think it's interesting that Brooke Shields, who according to her book and magazine articles states she had a long labor resulting in a late cesarean, tough recovery and near-suicidal postpartum depression. She elected a cesarean with baby number two which no doubt minimized her anxiety and potential for trauma should the same events repeat, and amazingly is depression free.)

Also your definition is a little different than the American definition found on mentalhealth.com. Dr. Long suggests that PTSD can be triggered by a traumatic event.

I love this one and it seems appropriate for you: Birth trauma lies in the eye of the beholder. Mothers perceived that their traumatic births often were viewed as routine by clinicians.

By Anonymous MetroMidwife, at 7:27 PM  

Metromidwife:

"Unless you have lived the experience of the woman who describes her birth as a rape, you have no business being anything less than sensitive and aware of her language."

Sensitivity does not mean accepting everything that the patient says as true. I do not deny that the patient believes what she say. The former soldier with PTSD who believes that people are shooting at him tells us what he BELIEVES about what is happening. That does not make it true.

The woman who interprets her birth experience as rape BELIEVES that she is being assualted. That does not make it true, either.

I think that the key point here is that so many of these women are, by their own admission, victims of previous sexual assault. Molestation and sexual assault are KNOWN causes of PTSD.

The such women go on to have a completely separate experience, the birth of a child. They BELIEVE that they are being assaulted during the birth. It is this belief that is the MANIFESTATION of PTSD. The birth did not cause the PTSD, the original assault caused it.

I would no more believe that an assault took place than I would believe that the people in the parking lot were shooting at the former soldier. PTSD causes people to experience things that are not based in reality. That is a key element of PTSD.

When a woman experiences a birth as a rape, she is manifesting PTSD from her original experience. No one is assaulting her; she IMAGINING it. That's what happens in PTSD. People imagine things that are not really happening. They superimpose previous experiences on current reality.

These women are psychologically fragile and they need mental health treatment. The last thing they need is people validating the illusion that the rape is taking place now. They need the psychological help that will let them recognize that they are reliving what happened BEFORE.

I have not seen a shred of scientific evidence that birth trauma causes PTSD. I think it is a made up diagnosis to avoid doing the exceptionally difficult psychological work of dealing with the original assault.

I also believe that the willingness of the homebirth movement to promote this fake diagnosis further reduces its already low credibility.

Essentially, women who are direct entry midwives are now making themselves into direct entry psychiatrists and that is wrong.

By Blogger Amy Tuteur, MD, at 8:25 PM  

Essentially, women who are direct entry midwives are now making themselves into direct entry psychiatrists and that is wrong.

I'm sorry. Have you changed specialities since starting this blog? Your original post and subsequent replies to this thread indicate you are holding yourself out as a psychiatrist.

By Anonymous MetroMidwife, at 8:58 PM  

I had no previous sexual trauma before the unessesary c-section of my first daughter. But I had significant PTSD after that horific experience. I felt VERY degraded, powerless and abused.

The medical model of childbirth is what's grotesque. There is absolutely NO reason for a healthy woman to give birth in a hospital.
Woman need to edjucate themselves and reclaim their *BIRTH RIGHT*.
Hospitals are for emergencies.
"Birth is an emergence not an emergency"

By Anonymous Anonymous, at 9:28 PM  

From the definition of PTSD in the DSM IV:

"The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event or recurrent distressing dreams during which the event is replayed. In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment. Intense psychological distress or physiological reactivity often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g. anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for a woman who was raped in an elevator)."

This is strikingly similar to the descriptions women here have provided of their experience of childbirth.

-recurrent, intrusive recollections

-dissociative states ... during which components of the event are relived and the person behaves as though experiencing the event at that moment

-Intense psychological distress ... often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event

All of which strongly supports the idea that the assaults which women claim to have experienced during childbirth were manifestations of pre-existing PTSD, and have no basis in what actually happened during the birth.

By Blogger Amy Tuteur, MD, at 10:32 PM  

I've been physically assaulted by an ex boyfriend.

I've experience mild molestation followed by not so mild sexual harassment when school authorities handled the situation incredibly poorly. I was too damn stubborn to get my parents involved.

I've had four hospital births, one attended by a very grouchy and IMHO, somewhat irresponsible nurse. None of these births came close to the previous two experiences.

In all this debate, the thing that bothers me is that many of the homebirth advocates seem to forget that doctors got into this business because they want to help people. They do it using science. Science is the logical study of nature.

By Anonymous Anonymous, at 11:10 PM  

One thing has nothing to do with the other. My experience is my EXPERIENCE. Your decision to risk the life of your child is based on FACT. The fact is that in every study done on the subject, hospital birth is safer.

It is extremely important for people to be able to tell the difference between what is perception, and what is fact. You have every right to make your decisions based on personal beliefs, but don't be confused into thinking that because YOU believe it, that makes it true.


I never put my child in danger. If I put my child in danger because I gave birth with a C.N.M. who has birthed three children of her own and has had over forty years of experience in childbirth (in and out of hospitals) as an attendant and a hospital 5 minutes down the street, then I can say that you put your child in danger because you gave birth in a hospital where they have very little trust in birth and the mother and often overprescribe unnecessary interventions that can lead to things like a cesarean and all it's inherent risks, can compromise breastfeeding and bonding, and so on.

Birth is not a tragedy just waiting to happen, it is a wonderful event unfolding before one's eyes. The way you look at it can determine the outcome of it and the future of everyone involved.

By Anonymous Anonymous, at 11:18 PM  

"I have not seen anyone address the substance of the post."

Amy - come on! Part of your post directly addressed the language we use and its appropriateness.

You have got to recognize that women do get PTSD from traumatic childbirth. If that is the only major trauma she has, how can you arbitrarily blame her PTSD on something else?

The FACT is that women are assaulted in childbirth. How dare you decide that what they went through is not valid or that they can't choose the language they feel appropriate to the situation? You are demeaning women who have been victimized by their birth experience by accusing them of using language simply for the shock value, to get attention.

By Anonymous Christine, at 11:46 PM  

This is anonymous 11:10

I looked at all of my births as natural events. As I experienced them, I thought back to the trillions of women who had done it before me and I felt empowered by that. I also knew that millions of women and more of their babies had died in that same, natural process.

There were things I would have rathered not occured. A homebirth would have been a very nice experience. But I was not willing to risk my babies so that I could have a very nice experience.

I know that birth is usually a process that works out wonderfully when left to progress as it will. All of my children delivered normally. I'm blessed to have easy births. But doing it at the hospital was my insurance plan. Every birth was different, and you never know what will happen.

This isn't living in fear, this is living in reality. Expecting the best, but preparing for the worst.

By Anonymous Anonymous, at 11:51 PM  

Christine:

"The FACT is that women are assaulted in childbirth. How dare you decide that what they went through is not valid or that they can't choose the language they feel appropriate to the situation? You are demeaning women who have been victimized by their birth experience by accusing them of using language simply for the shock value, to get attention."

You know, you just can't hurl vicious accusations around against other people (obstetricians) and expect that no one is going to call you on it.

1. These women are making specific and horrific charges against other people. Once you accuse other people of crimes, people rightfully expect you to be able to prove it.

2. No one who witnessed the events (nurses and other hospital personnel) can corroborate what the patients believe they saw.

3. I am not doubting the claim of PTSD. I am doubting the original cause.

4. An unusually high proportion have been sexually molested prior to their childbirth experience.

5. Their personal descriptions of their birth experiences matches the description of a PTSD response very closely, suggesting that these experiences ARE PTSD responses and not real experiences.

6. Feelings deserve to be validated. That does not mean that they are based on events that actually happened.

7. If the phenomenon of PTSD due to childbirth were real, we would see it among women of all ethnic groups and all philosophical persuasions. Instead, it appears to be restricted to homebirth advocates.

8. If the phenomenon of post childbirth PTSD were real, we could expect to see it after other serious gynecologic procedures (hysterectomy, D&C, etc.), but we don't.

By Blogger Amy Tuteur, MD, at 7:11 AM  

One thing has nothing to do with the other. My experience is my EXPERIENCE. Your decision to risk the life of your child is based on FACT. The fact is that in every study done on the subject, hospital birth is safer.

Oh Dear Amy. Please be honest. Please list your references. THIS IS CATEGORICALLY UNTRUE. For low risk pregnancies attended by a certified midwife Home and birth centre birth is as safe for the baby and safer for a woman than hospital birth. Let's look at the Cochrane Database, let's bring out the evidence.
I think re the term rape and PTSD you don't get it either. I am a survivor of rape and I am a mother of 6. Yes some proceedures could of triggered flashbacks etc. What many women have revealed however is that the power and control enforced by modern obstetrics felt like rape. These women have not experienced rape in the conventional sense but they have felt that the way they were treated felt like rape. Sexual Assault is about power, and so is much of modern obstetrics and it certainly is not based on evidence!)

By Anonymous Anonymous, at 8:20 AM  

7. If the phenomenon of PTSD due to childbirth were real, we would see it among women of all ethnic groups and all philosophical persuasions. Instead, it appears to be restricted to homebirth advocates.

I doubt it is restricted to home birth advocates, but since you are happy to speak on behalf of all doctors we can be confident that women other groups are also being brushed off at their claims.

What happened at the end of your career that you now result to insult women. nurses (the smart ones of the past could be doctors but today's nurse is the last in her class), health care administrators, and ER doctors online?

By Anonymous MetroMidwife, at 8:52 AM  

I could imagine PTSD occuring in an instance where a healthy woman is expecting a normal birth outcome and things go terribly wrong so that she ends up with something like a crash ceasarean and a baby that gets off to a rough start.

By Anonymous Amka, at 9:17 AM  

Metromidwife:

"What happened at the end of your career that you now result to insult women."

Now that's a bit ironic, isn't it? A group of women claim to have been effectively "raped" by their obstetricians and they think they're the ones being insulted when people ask for proof?

By Blogger Amy Tuteur, MD, at 9:28 AM  

Now that's a bit ironic, isn't it? A group of women claim to have been effectively "raped" by their obstetricians and they think they're the ones being insulted when people ask for proof?

Not so much ironic as well documented in your posts around the blogosphere. Perhaps if you want "proof" of PTSD you should go troll their message boards, not you own.

By Anonymous MetroMidwife, at 9:47 AM  

Ok, so since there weren't witnessess, then it didn't happen, Amy? I guess there are a vast majority of crimes out there now that we can't prosocute.... good to know that there has to be someone to watch the event and validate it for it to be real.

I would dare to bet that there are women in ALL backgrounds who do experience birth rape. It isn't about a sexual event, it is about power.... just as conventional rape is.

Maybe you never treated a woman in the horrible ways that some others have, but that doesn't mean that there aren't care providers out there who haven't. I have even heard of homebirth midwives who have caused PTSD, it isn't just OB/GYNs (although, I believe more common in the hospital overall). I have heard of doctors who have ripped apart vaginas with their bare hands because the woman refused an episiotomy.... guess that doc is practicing good medicine? Or doesn't it more sound like a power struggle? He was going to teach that woman a lesson about telling him how to do his job. Now, no matter if that woman had previous trauma or not, wouldn't that event be enough in itself to cause PTSD? I certainly think so! Does it sound rapish to me? Absolutely! No, there wasn't a penis going into the vagina, but it certainly was an outrageous violation.

By Anonymous Anonymous, at 10:12 AM  

That is an interesting story, anonymous 10:12. I would like to hear the entire context of it, though. I seriously doubt the doctor was being vindictive. More likely, he was trying to save the baby who was stuck. Or, perhaps, he didn't do it at all, but the woman tore.

We can't really know. We weren't there. All we are hearing is the woman's side of the story.

By Anonymous Amka, at 10:28 AM  

I have BEEN there when a woman was assaulted during childbirth. I have seen it happen. It's not a vicious accusation when it is TRUE. Are you actually saying that this does not happen? If it has happened and continues to happen, who are you to make a judgement as to whether a person's claim of PTSD linked to a traumatic birth is valid?

"An unusually high proportion have been sexually molested prior to their childbirth experience."

Do you have proof of this? If it's true, it's still only most, not all. So tell me, the women who have no history of trauma who develop PTSD after a traumatic birth - what would you say the cause of their PTSD is?


"If the phenomenon of PTSD due to childbirth were real, we would see it among women of all ethnic groups and all philosophical persuasions. Instead, it appears to be restricted to homebirth advocates."

Again, where's your proof? And, are you sure the sequence of events doesn't go: traumatic childbirth, PTSD, then a person becomming a home birth advocate? The woman who had the traumatic birth I described above was not a home birth advocate until AFTER her birth trauma. Just walking into a hospital is intensely stressful for her. She has no history of sexual assault.

"If the phenomenon of post childbirth PTSD were real, we could expect to see it after other serious gynecologic procedures (hysterectomy, D&C, etc.), but we don't."

What is the correlation between childbirth and hysterectomy or D&C? Nothing is like childbirth. And I've never seen doctors treat their patients so condescendingly and with more power play than I have during hosptial births. With those procedures, you are fixing a problem. Normal birth is not a problem. It is not an illness. It's not an accident waiting to happen.

I have seen doctors using vague and sensational language, scare tactics, outright lies, and, yes, brutality to get their "patients" to do what they wanted. Recently, I had a friend who was going to attempt a VBAC in the hospital Starting from a month before her due date, her doctor started trying to scare her into a repeat c-section. Not by telling her the valid risks of VBAC but by lying to her about her condition and what effect it would have on her attempts at VBAC. In the end, the doctor told her at her 40 week appt. that he wasn't going to let her try for a VBAC after telling her the entire pregnancy she could. This same woman was told an outright lie by a nurse concerning a medication they wanted to give her.

Maybe you don't treat your patients this way. Maybe you were never treated this way during your own birth(s). But that doesn't make your experience fact, as you are so quick to point out. My point is that I have seen traumatic birth lead to incredible depression in some cases and, yes, PTSD in others. If I know of at least one case, then it can't be impossible.

...unless you'd like to call me a liar.

For the record, both of my births were hospital births, the second being a general anesthesia c-section. It was necessary and I am eternally grateful for the technology we have or neither of my kids would be here. My births belonged in hospitals, most do not.

By Anonymous Christine, at 12:48 PM  

My God. This is truly over the top. If you are going to post crap like this, you really should have some proof.

By Anonymous Joanna, at 1:05 PM  

"A group of women claim to have been effectively "raped" by their obstetricians..."

This goes back to the language thing. How many of these women say they were raped in the sexual assault? Because the term "like a rape" is an analogy. Saying "my birth was a rape" is a metaphor. Describing this experience in those terms is not inappropriate and I would say most of those women are not actually saying their doctors committed some sexual act with/to them against their will.

By Anonymous Christine, at 1:06 PM  

I was referring to the following snippet:

I have even heard of homebirth midwives who have caused PTSD, it isn't just OB/GYNs (although, I believe more common in the hospital overall). I have heard of doctors who have ripped apart vaginas with their bare hands because the woman refused an episiotomy.... guess that doc is practicing good medicine? Or doesn't it more sound like a power struggle? He was going to teach that woman a lesson about telling him how to do his job

By Anonymous Joanna, at 1:06 PM  

on OBGynLinx today was a article on PTSD and cervial cancer. you might want to check it out!

If cervical cancer can cause PTSD why is it a stretch to say it can happen during birth?

http://tinyurl.com/kbepg

By Anonymous DoulaGal, at 1:34 PM  

christine said,

"lying to her about her condition and what effect it would have on her attempts at VBAC. In the end, the doctor told her at her 40 week appt. that he wasn't going to let her try for a VBAC after telling her the entire pregnancy she could."

It looks to me like there was a change in her condition that made the risks of trying a VBAC outweigh the benefits of a trial of labor. How do you know he was lying about her condition? Why would he string her along before, only to make a patient upset and irate at the end?

It seems to me that if he was lying to get his way, then it would indicate a lazy kind of doctor. Why would he bother setting up a situation, then, where the woman would become angry and upset at him for misleading her? That doesn't quite add up.

I'm not discounting anyone's experience, but I think it is better to consider more factors. Consider what can fix the problem rather than throwing the baby out with the bathwater.

For instance, the power plays and condescending behavior may be because there has not been sufficient education on how to communicate with a woman who is delirious with pain. But even if that is present, it may be that because she is not responding coherently, the healthcare professionals start to control the situation more. They have to speak to her with more authority to get a response. This is percieved as a power play.

I'm going to stand here and say that I was highly emotional and not as intellectually competent as I usually am towards the end of my pregnancies. During active labor, my brain is on autopilot. I am barely coherent. I am not ashamed of this.

I'm not saying there aren't jerks who are doctors. I'm not saying assaults don't happen. I'm saying I feel like this is the exception rather than the rule. Most of the women I talk to love their OB.

By Anonymous Amka, at 2:45 PM  

Joanna-
I do have proof, it is my own experience that my husband also witnessed. I know of at least 1 other patient of this doctor and he did the same thing to her.

By Anonymous Anonymous, at 3:59 PM  

"It looks to me like there was a change in her condition that made the risks of trying a VBAC outweigh the benefits of a trial of labor. How do you know he was lying about her condition?"

Her condition didn't change. If a doctor says, "your blood pressure is higher than safe limits" but it isn't, that's a lie. If he says that she has "too much" protein in her urine when really there is only trace amounts, that's a lie.

Why would he do it? Money and convenience. This practice is known to convince people to schedule their labor or c-sections simply for the convenience of the doctor. Had I known she was going there, I would have recommended somewhere else.

"For instance, the power plays and condescending behavior may be because there has not been sufficient education on how to communicate with a woman who is delirious with pain. But even if that is present, it may be that because she is not responding coherently, the healthcare professionals start to control the situation more. They have to speak to her with more authority to get a response. This is percieved as a power play."

This can be true. However, the situations I have witnessed have involved women who were fully capable of discussing a situation and responding well to a doctor. In fact, many times, it is the fact that the woman or her partner are questioning the doctor's advice (as in, trying to get information to give an INFORMED consent) that brings about the increase in power play.

The "violent" birth I witnessed followed on the heals of a labor in which the midwife (CNM at a hospital) lied to the woman about her baby's condition to try to convince her to have a c-section. She told her that the baby's base line heart rate had dropped from 130s when she came in to 110s. Now, she may not have been focused on the heart rate monitor, but her husband and I were. That statement was completely untrue. The baby's baseline heart rate was in the 130s the entire time. Was her violent birth the result of her unwillingness to "cooperate" or was it the fear-based medicine the CNM was practicing? I don't know. But I know that the power play was real and began the moment she got there.

The only "problem" with this woman's birth was that the baby was posterior when she started to push and thus it took her a little longer to push him out. The internal monitor proved that he was never in danger. Why were they trying to scare her into a c-section? Who knows...

By Anonymous Christine, at 4:47 PM  

Using emotionally charged words like "rape" in this particular society and culture to describe a situation in which no one is being sexually assaulted or in a situation in which the woman has the ability and right to say "no" (in spite of these claims of evil nurses who are threatening you with drugging - puhleeze - like a hospital is going to risk THAT lawsuit!) is downright irresponsible and only further confirms my suspicions that the homebirthing crowd has an agenda to push first and foremost.

If you believe you have indeed been sexually assaulted during a birth, then file charges. If you believe a doctor has acted in a medically inappropriate manner, file a complaint, or sue him or her.

But concocting these over the top fantasies of evil doctors ripping women open with their bare hands or threatening women with violence or drugging or forcing women to have babies on their schedule is utter nonsense.

Do you all live in the backwaters of Arkansas, or something? If you are seeing an OB and you think he sucks, CHANGE YOUR OB! Duh! If you think he sucks and you don't change, well, that's your fault, honey. Anyone that dumb really shouldn't be procreating, anyway.

Jaysus, but just reading this thread makes me hear Duelling Banjos in the background...

By Anonymous Anonymous, at 6:23 PM  

"If you are seeing an OB and you think he sucks, CHANGE YOUR OB! Duh!"

Yeah, I did that. That is why I homebirth now. I don't understand why others get their undies in a bunch over where I choose to birth my kids though. I am out there to support those who also make the same choice that I do, but I have no hidden agenda to convince all women to birth at home. I have no agenda to run all OBs out of business or anything like that. I don't understand why there is anger directed at me and my experience. Why does my personal experience make you angry at me?

By Anonymous Anonymous, at 8:38 PM  

I would like to refer Amy and others to the work of Sheila Kitzinger when discussing whether birth trauma can cause PTSD. She is a social anthropologist, childbirth educator, woman's advocate, author, speaker--and has been working in this arena since the 1960s.

Over the years, she increasingly heard from more and more women about their intense, longstanding, and debilitating distress following their childbirths. She has worked to establish networks in which women can receive counsel and support if they are experiencing PTSD following birth.

Kitzinger is one of the strong voices equating birth violation and rape. She came to this conclusion when one of her daughters became a rape counselor. Her daughter would bring stories home that included the words that victims of rape would use in describing the event and their feelings following their brutalization. Kitzinger heard the same words and feelings from women following traumatic birth as she heard from her daughter's accounts of women following rape.

Having heard Kitzinger speak about this issue several times over the years, I know that she strongly believes that traumatic birth can indeed cause PTSD. As a midwife, I can tell you that I and my friends have also come to believe this. We have come to know women who did not have histories of sexual assault who reported feeling victimized, brutalized, humiliated, sexually injured and assaulted during the course of labor and birth. Yes, this is about abuse of power, but it is a misused power that wounds women in their sexual selves.

These terrible stories come from birth in all settings and will all care providers. They are not the province of only one style of us. It is my impression that hospital births will more often create situations in which women feel violated, probably because of the power differential between doctors/nurses and patients and because of the potential harm from machinery and medications that are designed to force and overwhelm pathological situations. But I know of women who have felt violated by their birth center births, and by their home births.

We all must devote ourselves to honesty, sensitivity, communication, respect, cooperation, tenderness--the list goes on--when we are tending to this most vulnerable time in a woman's life. And I think we need to recognize that women can go into PTSD because of traumatic births. What any one woman will define as traumatic might be miles different from anyone else's. We need to believe her if she tells us she's hurting and that it was because of how her birth was handled.

As far as whether doctors changed their stories about things like allowing VBAC based on changing medical conditions or because they just didn't really want to do it when down to the wire--I know of a couple of doctors who have done that to women at the last minute when there was no change in their conditions. I'm not sure they would define it quite that way, and they certainly have the defense of ACOG guidelines and community standard of care. But it's not easy for someone to pick up and go to another doctor when she's full term pregnant. Those whom I've spoken with about such situations feel coerced and emotionally blackmailed.

And I personally know of a woman who specifically said to the doctor who was in charge of her birth that she didn't want an episiotomy. The doctor, with scissors in hand which he waved in her face, said to her "don't you tell me how to practice medicine." He then cut an episioproctotomy. According to the midwife who was there, it was an unnecessary episiotomy. This particular doctor just liked doing them. It wasn't possible for the mother to go to another doctor at that moment.

Again, I'm not saying this is the sole province of doctors and hospitals. You'll hear stories about midwives, birth centers, and home in which women end up seriously unhappy about their care. I do urge people to take the stories as possible and even likely, rather than act like it couldn't have happened or that the women involved are nut cases.

We all have a lot to learn!

By Blogger Karen, at 8:41 PM  

I do have proof, it is my own experience that my husband also witnessed. I know of at least 1 other patient of this doctor and he did the same thing to her.

3:59 PM

I don't believe you. Were charges filed? Who witnessed this second woman being torn apart with bare hands?
Frankly, this is the kind of crap that made me move away from homebirth advocacy.

By Anonymous Joanna, at 9:41 PM  

'If you believe you have indeed been sexually assaulted during a birth, then file charges. If you believe a doctor has acted in a medically inappropriate manner, file a complaint, or sue him or her.'

I filed a complaint, I was told not to take it any further because nothing would happen. I was too ill to even think about taking it further anyway, I had a chronic infection, was in chronic pain, had a newborn to look after and had to try and deal with my PTSD on top of that. I made my complaint and walked away. Now when it is too late, I wish I had had the strength to do more.

'But concocting these over the top fantasies of evil doctors ripping women open with their bare hands or threatening women with violence or drugging or forcing women to have babies on their schedule is utter nonsense.'

They aren't over the top, they are true.

'Do you all live in the backwaters of Arkansas, or something? If you are seeing an OB and you think he sucks, CHANGE YOUR OB! Duh! If you think he sucks and you don't change, well, that's your fault, honey. Anyone that dumb really shouldn't be procreating, anyway.'

We have to put up with whatever Ob is available at the time of birth, we don't get to ask. Maybe before you make such statements you should actualy check about whether changing Obs is possibility for all women. Unfortunutely it isn't. You could have had the nicest Ob throughout the pregnancy and the end up with twat for the birth and there is nowt you can do.

Hence my decision to have a homebirth with midwives I knew and trusted. I didn't see an B at all during my last pregnancy, it wasn't necessary.

By Blogger Heartwrench, at 2:45 AM  

All I can say is you get what you pay for. If socialized medicine and HMOs mean you have to suffer at the hands of all those evil hoardes of raping doctors and B-movie nurses, then that sucks for you.

You might want to start paying for your own health care, though...just a thought.

The statute of limitations on medical malpractice and/or sexual assault is not so limited as to make it impossible to file complaints, charges or lawsuits outside of a week or two after the birth.

For someone who advocates birth as just another body process like sneezing, this I was soooooo sick afterwards and soooooo incapable of rational thought that I couldn't do anything about this evil, evil, evil brutalizing doctor just makes me believe you less.

An unfortunate birth experience is not equivalent to rape. Insinuating that it is does a terrible disservice to women who really have been raped and have had the courage to stand up and accuse their rapist in a court of law even when they were TRULY traumatized and when they were fighting a system that doesn't want to believe them in the first place.

It's like comparing people to Hitler or situations to Naxi Germany. Once you do it, you lose. Compare something that isn't even close to rape to rape, and you lose. Period.

I'm not angry because of someone's supposed experience. I'm angry because this ridiculous, graphic-novel villain caricature you're trying to make every OB/GYN out there to be is nothing but a vicious, dirty lie that hurts good people and denigrates the choices and experiences of good women.

If you were raped, call a cop. If your doctor was incompetent, call a lawyer. But don't spread scare stories and lies just so your side can win some points.

Frankly, you're the most self-obsessed, ignorant bunch of women I've ever come across. All you talk about is youyouyou and your precious birthing experiences, as if the baby isn't even real or isn't even a human being worthy of its needs being met until it sees the light of day.

Get raped and then compare your less-than-Hallmark "experience" to rape. Until you're raped, shut the hell up. You don't know what you're talking about.

And if you want to talk about "birth trauma", as if it means, oh, my nurse was meeeaaaaan to me, then listen to the stories of the women who had their babies taken away from them before they could even see or hold them because they were dirty whores and deserved to be punished for the crime of having gotten pregnant out of wedlock. That's birth trauma. Birth trauma is not being told you couldn't play your favorite CD during the birth.

By Anonymous Anonymous, at 6:50 AM  

Anonymous - I don't know what has made you such a nasty person but I have a feeling you have been hurt in your life and I'm sorry for that.

But step down, take a breath and read what you have written. Venomous is an understatement and your vitriolic words lend you no credit whatsoever. You consider people stupid for not changing doctors or not paying for their own insurance. Have you ever lived in an area where there are no other choices? Had insurance where there was no other choices? Not been able to afford any other insurance?

Do you know for sure that women aren't filing complaints? Do you understand that some women are so traumatized that they can't file complaints (like many other instances of assault)?

How can you be so nasty about something you have never experienced. No one is talking about a nurse not letting them play their cd. If you havn't been there, how can you say what they went through?

Your comments stem from the height of ignorance. I hope that you don't treat the people close to you in your life the way you are very willing to treat people you have never met.

Amy - I would hope that you wouldn't allow people to come on here and tell others to "shut the hell up" without speaking about its appropriateness. Hopefully, as adults, we can have a discussion without getting nasty.

By Anonymous Christine, at 9:52 AM  

In my post about my own trauma, I did state that it WASN'T only OB/GYNs. That experience of mine was with an OB, but in no way did I say that ALL OBs were doing such things. I also stated that birth rape can happen with ANY care provider. I did not share it in order to frighten women away from OBs.... I could care less who you choose to care for you during your pregnancy and birth! The reason I shared it was to show how I believed that PTSD could come straight from the birth alone and not be dependent on a previous incident. If a woman experiences something that traumatic during the birth of a child, I believe it is certainly enough to cause PTSD.

I honestly can't understand why sharing this was enough to make people so angry at me! If you don't believe me, that is fine (I really don't care), whether I filed a complaint or not really has nothing at all to do with if the situation could cause PTSD though, right? And that was the topic at hand, correct?

By Anonymous Anonymous, at 10:03 AM  

Seriously, Amy, aren't you going to delete that anon 6:50 comment? That's over the top.

By Blogger Jamie, at 10:25 AM  

Christine, Anonymous, I am guessing, was just simply fed up. This is not a support board per se, but a debate board. At any rate, she is simply sharing her frustration. Her feelings are as valid as anyone else's on the board.
Just because someone feels something strongly, does not mean that her feelings are actually correct, or appropriate, or a valid basis for extrapolating general principles.

By Anonymous Joanna, at 10:29 AM  

For your info anon 650, I have been raped and suffered birth trauma. I filed a complaint. Thats all I felt capable of doing at that time. It was more than I did after being raped and held in a caravan for 12 hours.

I live in the UK, I trust the NHS Obs to do their jobs, I don't get the luxury of choosing which Ob I get. I had never met the guy before. There were 2 Obs on that night and the other one, the one I wanted was busy with someone else.

I thought it was gonna be ok because he was doing his job, he was supposed to be looking out for me and the baby, but he messed up and he did it on purpose because I refused an episiotomy.

Now you can believe what you like, but I know what happened, my DH knows what happened and so do the gynaes who had to look after me afterwould after he butchered my nether regions.

By Anonymous Anonymous, at 12:35 PM  

Joanna - I also believe that everyone's feelings are valid. My problem is in the way people choose to express those feelings. The nastiness and personal attacks just aren't necessary. If they are allowed here, it's not somewhere I want to be...

By Anonymous Christine, at 1:51 PM  

well since medicine hasn't deemed it important enough to study it must not be true.
in fact if there is little or no studies or evidence then things just can't be true-- I am not sure drinking water has ever been studied - or atleast not studied in a way that shows if it is healthier than drinking diet soda...

By Anonymous Anonymous, at 7:01 PM