Wednesday, May 24, 2006

Previous assault, childbirth, PTSD

I'd like to explore this remarkable connection a bit further. There definitely seems to be a notable association of these phenomena: a history of previous sexual assault, a bad childbirth experience, and PTSD. Here's my question:

Why is there such a ferocious insistence that it was the childbirth experience that caused the PTSD and not the previous sexual assault? Afterall, sexual assault is almost by definition a horrific, frightening, demeaning experience. PTSD is a well known phenomenon after sexual assault. Childhood molestation is equally horrific, frightening and demeaning. It represents a terrible betrayal of a vital trust and often occurs repeatedly over a number of years. Again, PTSD is a well known result after such a trauma.

Yet here we have a group of women who have been sexually assaulted in some way, and they are adamant in their insistence that the assault did not have serious psychological repercussions. They were fine until they had a baby. The psychological issues became apparent then and, therefore, it must have been the doctor's fault.

I'm not sure that I would have even noticed this if even a few people had said "yes, I had a really bad birth experience, but I know my experience was affected by the assault in my past." Yet no one has said that. Instead they have insisted, absolutely insisted, that the original attacker bears no responsibility for their current psychological issues; the doctor bears all the responsibility.

What is going on here? No matter what the doctor did (and while I have a very hard time believing some of the reports, it is certainly possibly that at least some of what is claimed is true), it could not begin to compare to the original assault. I am almost forcibly struck by the level of anger toward the doctors. I can practically feel the hostility through my computer. Yet there is a curious lack of emotion toward the original assailant. The level of anger directed toward the doctor seems startlingly high, and the level of anger toward the assailant seems curiously low.

It feels like there is a psychological need to blame the doctor INSTEAD of the original attacker. Why should that be?

46 Old Comments:

The doctor was at fault in my case, pure and simple. It doesn't matter that I had been assaulted before. The doctor treated me badly, even if I had never been assaulted before I would still have felt the same way about the birth.

But then, I wouldn't expect you to believe that Amy cos you are so hell bent on making the victims of birth trauma and sexual assault feel like shit instead of placing blame at the feet of those who really should know better, who should treat women with the care and respect they deserve.

I shouldn't have to write on my birth plans that I was assaulted, every woman in labour should expect the same level of care. Those caring for her should understand that childbirth is a scary, its intmate, it makes women feel vulnerable etc etc etc etc and the care givers should be sensitive to that.

As a side note, it was written everywhere about my past but a) no one bloody read it, b) no one seemed to particularly care when my real midwife discussed it with them and c) there so many staff in and out through out the whole time that no onereally remembered etc. That is why I am better off with a homebirth, I get the care I deserve, my baby gets the care he/she deserves and after all of it, I get to spend time with my baby, thinking about my baby rather than having to push back flash backs, rather than crying my eyes out...........

Some Obs just don't do their job properly, accept it and get over it.

By Anonymous Anonymous, at 7:49 AM  

Well, my anger isn't at the OB's, mostly because I took myself out of their realm of care. I have ptsd after the nitwits they are passing off as EMT's were so pathetically un prepared for the transfer of my daughter. The birth itself wasn't easy (pain isn't nice, at any time really), but those five-ten minutes afterwards were a horror. My midwives provided the equipment. The emt's provided the ride. The city is still scrambling to explain the obviously substandard of care that was sent. The neo natal neurologist was wrote a beautiful note, saying that she was glad I'd had a homebirth. It was the "best thing for your daughter".
I'm not angry at OB's. I'm angry with the system I get exposed to through my doula work. I'm angry at people who won't listen to women. I'm angry that we HAVE to ask that special treatment be given to women in childbirth if abuse is suspected. We don't always know. Shouldn't doctors/nurses/midwives always have a "continuity of care" for ALL women? Assault, abuse, or childbirth trauma is Trauma period.

By Anonymous Anonymous, at 9:48 AM  

once you have had an experience- and you have controlled your life as best you can to not have this happen to you ever again- and then something huge and out of control like birth that is certainly on the edge as life and death can get- you have people behaving -even for this culture- rudely and roughly and inapproprately and you find yourself once again in the position of being harmed - touched when you don't want it yelled at- intimidated- not listened to- restricted in many ways- I don't see how or why you think that institutions are free from abuse --
being re-injured is as bad as the first insult-

By Anonymous Anonymous, at 10:26 AM  

I would add that in the case of birth you choose a care provider and put trust in that person and then they harm you - different than a rape or childhood abuse you actually picked this person to care for you- and they harm you instead --- really think over how flippantly or condescending medical folk are toward a birth plan you write out
think of routines--- that alone speaks about how you do not provide individualized care and why medical informed consent is the first thing to go out the window in a court case- because our whole society believes that they do not understand what is being done to them and that we place trust in and do what a medical provider says( very paternal/maternal) .
I believe that this level of unequal power is abusive, in and of it's self-we have tried to make informed consent important but it is still winked at- they don't really know what they are doing- and that may be true but it is also true when a patient consents rather than disagrees with the treatment you propose-
do you feel you have a right to treat a patient the way you think best?
how would you define care provider rights? patient rights?

By Anonymous Anonymous, at 11:46 AM  

on checklist
Check the symptoms below that you experience (that may or may not be related to a traumatic event) and make notes as needed:

I experienced or witnessed a traumatic event during which I felt extreme fear, helplessness, or horror.

The event happened on (day/month/year)_______________.

What happened?________________________________________.

1) I have symptoms of reexperiencing or re-living the traumatic event:

Bad dreams or nightmares about the event or something similar
Behaving or feeling as if the event were actually happening all over again (this is known as having flashbacks)
Having a lot of emotional feelings when I am reminded of the event
Having a lot of physical sensations when I am reminded of the event (e.g., my heart races or pounds, I sweat, find it hard to breathe, feel faint, feel like I'm going to lose control)
2) I have symptoms of avoiding reminders of the traumatic event:

Avoiding thoughts, conversations, or feelings that remind me about the event
Avoiding people, places, or activities that remind me of the event
Having difficulty remembering some important part of the event
3) I have noticed that since the event happened:

I have lost interest in, or just don't do, things that used to be important to me
I feel detached from people; I find it hard to trust people
I feel emotionally "numb" and I find it hard to have loving feelings even toward those who are emotionally close to me
I have a hard time falling or staying asleep
I am irritable and have problems with my anger
I have a hard time concentrating
I think I may not live very long and feel there's no point in planning for the future
I am jumpy and get startled easily
I am always "on guard"
4) I experience these medical or emotional problems:

Stomach problems
Intestinal problems
Gynecological problems
Weight gain or loss
Chronic pain (e.g., in my back, neck, pelvic area (in women))
Problems getting to sleep
Problems staying asleep
Skin rashes and other skin problems
Irritability, a quick temper, and other anger problems
Lack of energy, chronic fatigue
Alcoholism and other substance use problems
General anxiety
Anxiety (panic) attacks
Other symptoms such as: ______________________________

By Anonymous Anonymous, at 12:44 PM  

I think you people are misinterpreting Amy. She isn't bent on making anyone feel like shit. She disagrees with you about homebirth based on logical reasons.

She has discovered a correlation. Yelling and getting angry about her exploration of that isn't going to help you or anyone else.

Try to think about statements she has made and her other blog "Treat Me with Respect". If there is anyone who is going to listen to you about experiencing trauma during the birth, whether on its own or because of a previous experience, it is going to be this woman. If she finds a correlation between sexual assault and birth triggering PTSD, then isn't that a good thing? Doesn't it then make it something that could be prevented? Couldn't her research into that area lead to a more sensitive approach to birth on the part of doctors?

Just, stop being angry and think a little, please. Amy is right now 'thinking out loud'. This is a person in a position to do studies and get published and change things. Before you say homebirth is the only alternative, try thinking of the 98% of women who would never consider the choice or don't even know it exists, and the percentage of them that have experienced sexual assault. In my opinion, any research in this area can only lead to improvement.

But, if she is human, she is also angry and hurt at the aggression that has been shown to her. Such tactics do not promote healing for anyone. It certainly does not promote communication.

Communication on this board is how we can make two things happen:

Home birth can become safer.
Hospital birth can become kinder and gentler.

Now tell me: is there anything wrong with these goals?

By Anonymous Amka, at 1:19 PM  


I think there is a reason why the doctor is blamed.

In most cases of molestation, the perpetrator is well known to the victim, very often a family member. Perpetrators work very hard to groom their victims. They encourage trust and dependence.

Also, an unfortunate effect may be that other authority in the victim's life who should provide safe have does not believe the victim and/or handles the situation inappropriately.

A doctor now comes in, and it is their goal to establish trust. A certain amount of dependence on the doctor is expected and needed, even. Even a normal birth is fraught with pain and anxiety. A woman who has undergone molestation may also experience a great deal of discomfort and lack of trust in her own body. She may be in denial as to what kinds of things will occur during the birth.

Even a caring OB or nurse will need to check progress. A woman who isn't trusting her body may not 'help' things along as much, thereby increasing the need for doctor intervention at precisely a time when the woman is in a very high state of discomfort, anxiety, and even experiencing flashbacks. The experience may be heavy with years of being stuck in the denial or anger stages.

The doctor also does not have the luxury of being someone the woman desperately wanted to have a normal relationship with, as would have been the case with a family member. So the woman naturally projects her anger onto the doctor.

By Anonymous Amka, at 2:27 PM  

I am offended this is a blame the person you harm mentality --- read the check list-- I bet women have been coming to you for years telling you they have a good number of things on the list.

it isn't exclusive to OB a hospital is a culture unto it's self- it isn't just nursing homes that are guilty of patient abuse- it is just that in the case of nursing homes it is repeated because it is long term care-- I think that the same behaviors and same kinds of mistreatment go on in the hospital.
If a patient pulls out a tube- then the nurses "show them who is boss and will leave it in longer " by simply not asking or reminding the doc... and other things like that - I know nurses I know doctors I have spent time in the hospital.
Several years ago now a wonderful old doctor I knew retired- and just around the time he retired he was going with a grandchild/or great grandchild to some medical appointments-- after that he gave a lecture in which he basically said don't put up with this -- doctors have to learn to respect their patients and there are other fundamental problems in the system- doctors need to respect the people who work for them- and with them starting with the language they use , the way they think about time and other people's time, respect what your rights are and that they are just advisors--

By Anonymous Anonymous, at 5:18 PM  

"once you have had an experience- and you have controlled your life as best you can to not have this happen to you ever again... you find yourself once again in the position of being harmed... being re-injured is as bad as the first insult-"

While I understand there is definitely a correlation between sexual abuse and birth needs/desires, I also acknowledge that birth trauma/PTSD can (and does) occur independently from any previous abuse (sexual, emotional, or physical).

Speaking about women who have been abused and why the woman is so angry at the doctor... :

Most women have spent a great deal of time in therapy and healing from their sexual abuse in order to function in their lives. Most women have beautiful, wonderful, productive lives despite being hurt so profoundly when they were young (or not so young).

It can take a woman a LONG time to allow someone "in" - into their hearts, their arms, and their loins. Trust and intimacy become repeating themes in their lives... so when a woman finds someone they can open up to, be intimate with enough to marry, it is an enormous milestone.

Letting anyone touch her body can be stressful and the idea of someone touching her "there" can be utterly distressing. Building trust during the pregnancy, a woman tries hard to have the person who will attend her be respectful and kind. The phrase "I trust my doctor" is not taken lightly by these women.

Therefore, when a woman gets into labor and finds herself in bed after specifically working out with the doctor to not have to be in bed (or with an IV or eating only ice chips or having medication "offered" to her a couple of times an hour or having her water broken, etc.), it can be an insult to think they are just a number - just standing orders - when the birth plan had been specifically worked through with the doctor.

Then the doctor, usually not the woman's own that she's had those trust building conversations with, comes in to "deliver" the baby - insists on the woman being in the leg supports that splay her in the most uncomfortable (emotionally and physically) and vulnerable position (after working out with the doctor she wouldn't have to be in that position). S/he proceeds to manipulate the vagina, pulling, pressing, yelling at the woman to push! push! harder! now! is that all you've got? harder! and continuing to put his/her fingers into her vagina watching, watching her progress which, to her, is staring at her genitals... along with everyone else in the room.

I believe that even women who've had an epidural have reactions to the insult of vaginal manipulations during birth. Fingers do NOT need to be in the vagina in order to birth a baby. Women do NOT need to be splayed apart like a piece of meat being dried on a rack.

Add to the situation an episiotomy after SPECIFICALLY telling the doctor to let her tear - a vacuum being applied and re-applied and re-applied again and watching the cup fling her blood and mucous around the room as it plops off the baby's head. Or forceps knowing what injuries can come from them.

When birth happens without more manipulations, the placenta still needs to be born - er, pulled out. Sometimes manual "exploration" occurs without regional anesthesia. Didn't the doctor say he was going to let the cord stop pulsating and let the placenta be born on its own? What happened to that plan?

"Just one more stitch," when a woman tells the doctor five times she can feel the needle and is crying at that point.

This is why women blame the doctor. I hope that helps explain things a bit better.

(All of this is pretty much with NORMAL birth without out-and-out manipulations and coercion or lies about procedures, protocols or circumstances. When those become part of the equation, the pain is amplified tremendously.)

Perhaps in this light, changes might begin to be made. (Doubtful, but hopeful.)

By Blogger Navelgazing Midwife, at 5:42 PM  

(dropped the last note too quickly... meant to finish up with this)

So, despite being sexually abused previously, it is the assault of the doctor at hand that gets the brunt of the anger because s/he is the person doing the assaulting at the moment (or during the moment). I don't see women angry at the doctor that wasn't at the birth, but at the actual perpetrator of the pain and manipulations. If it were displaced, I can see the raised eyebrows of confusion, but this is so blatantly obvious WHY the doctor is the one the women grow to hate and want to see hurt as much as she is. The original perpetrator had his/her time in the therapy room for all those years before. This assault came into her life and begins the cycle of healing all over again.

All of that said, it assumes a belief that women can be traumatized by their birth experiences without ever having been sexually or physically abused. If one doesn't believe that, then it is all moot.

To those of us who know, it is far from moot. It is Truth.

By Blogger Navelgazing Midwife, at 5:55 PM  

I think one important aspect of birth trauma during a normal birth, post sexual abuse or not, is that the woman comes into the situation uncomfortable with her body, especially her sexual organs, in the first place. It is a sad commentary on our society. Either its a sinful, dirty place or it doesn't live up to the obscene perfection that media constantly portrays.

By Anonymous Amka, at 6:47 PM  

I can practically feel the anger emanating from some of these posts. There are very strong emotions here. It is quite remarkable that the lion's share of your anger seems directed toward the doctor despite the fact that the original assault was far worse.

Many of your posts are eloquent testimonials to the way that the original assault shaped your outlook and perceptions. Yet it appears that no one would or could convey to the doctor the previous experience of assault, so the doctor had no way of knowing how you might react.

You seem to have only a vague awareness that your perceptions and reactions are quite different from most other women, because they have been shaped to a large degree by the previous experience of victimization. So, while the doctor's actions may have evoked strong feelings, they would not be construed by an outside observer as being remotely like a rape or an assault.

Again, there is a curious lack of hostility toward the original assailant and an enormous amount of hostility (outsize, in light of what really happened) toward the doctor.

The anger is very, very real, but it seems to me that it comes from the original assault. It may have been unearthed by what happened at the time of birth, but it was not caused by it. The original assault caused the PTSD and the PTSD dramtically impacted the perceptions of what happened in childbirth.

There really seems to be an almost palpable need to lay all the suffering at the feet of the doctor. Why?

You don't seem to appreciate that you are accusing doctors of things that are so heinous that there simply must be independent corroboration for them to be believed. It is virtually impossible for me to believe that not only are doctors committing assault on women in labor, but that the entire hospital structure, nurses, administrators, etc. is in collusion with this. If this were really happening, people would be suing doctors and nurses and hospitals, and nurses would be reporting doctors. That isn't happening.

It seems far more likely that in many cases you are diverting your anger over the original assault to a doctor who did nothing in particular wrong, and who had no idea that you might have been affected by a previous assault.

The bottom line, in my judgment: The doctor is not the person responsible for your PTSD or other psychological difficulties. It may be the original assailant who is at fault, it may be other psychological factors that have not been discussed, but it is NOT the doctor.

By Blogger Amy Tuteur, MD, at 7:32 PM  

birth as done in the hospital is considered normal to you and you are acculturated to it.

Now you deny that I may have a different experience of the very same place?

By Anonymous Anonymous, at 8:07 PM  


Just curious what you think about the theory I proposed in answer to your question?


She is, in fact, saying that the subjective experience is different, but that is not (usually) because the doctor actually assaulted the woman.

By Anonymous Amka, at 8:19 PM  

Ah, but people have *tried* to sue doctors and hospitals! It's really hard to sue for what is considered the standard of care. Until more information is known about birth trauma, it just won't be seen in the courts.

Soon. Very soon.

Just because it is the standard of care doesn't mean it's ethical.

By Blogger Navelgazing Midwife, at 8:45 PM  

Navelgazing midwife:

"Ah, but people have *tried* to sue doctors and hospitals!"

People sue doctors and hospitals all day everyday, and cases with merit go to trial. There are assault cases against all kinds of doctors (especially psychiatrists) and health professionals. Many times these cases result in wins for the accuser and doctors losing their licenses.

I am just not buying this. There is not a giant conspiracy of doctors, nurses and administrators who "prevent" women from reporting inappropriate action. And there is not a giant conspiracy that extends to the legal profession that "prevents" women from suing.

These cases would be treated like any other cases of inappropriate conduct. Of course that means that there would need to be evidence presented, witnesses, etc.

It seems to me that we have two choices here:

we can believe that there is a gigantic conspiracy of doctors, nurses, hospital administrators, and now the legal system that is abusing women and protecting the abusers


we can believe that women who have experience a previous sexual assault are suffering from symptoms of PTSD that cause them to overlay their previous experience on their childbirth experience. While their childbirth experience is very real to them, and the feelings that it invokes are genuine, they are not based on the REALITY of what took place during labor and delivery.

The second explanation seems A LOT more plausible to me, especially since no evidence is provided for the first explanation.

By Blogger Amy Tuteur, MD, at 9:49 PM  


"Just curious what you think about the theory I proposed in answer to your question?"

Yes, I do think that part of the explanation may be that it is much easier to blame a stranger (the doctor) than the original assailant who may be a family member or friend.

By Blogger Amy Tuteur, MD, at 9:52 PM  

so conspiracy no
acculturated into a system yes
if you think that this doesn't trickle down then doctors must be the only immune humans on the planet-- if you weren't exposed to abuse before medical school you are certainly put though it during.----
who is doing this to medical students ? doctors and nurses --- so they are doing this to others but not patients?
West J Med. 1991 Aug;155(2):140-5.

Comment in:
West J Med. 1992 Jan;156(1):88.

Student perceptions of mistreatment and harassment during medical school. A
survey of ten United States schools.

Baldwin DC Jr, Daugherty SR, Eckenfels EJ.

Division of Medical Education Research and Information, American Medical
Association, Chicago, IL 60610.

Senior students at 10 medical schools in the United States responded to a
questionnaire that asked how often, if ever, they perceived themselves being
mistreated or harassed during the course of their medical education. Results
show that perceived mistreatment most often took the form of public humiliation
(86.7%), although someone else taking credit for one's work (53.5%), being
threatened with unfair grades (34.8%), and threatened with physical harm (26.4%)
were also reported. Students also reported high rates of sexual harassment (55%)
and pervasive negative comments about entering a career in medicine (91%).
Residents and attending physicians were cited most frequently as sources of this
mistreatment. With the exception of more reports of sexual harassment from women
students, perceived mistreatment did not differ significantly across variables
such as age, sex, religion, marital status, or having a physician parent. Scores
from the 10 schools also did not vary significantly, although the presence of a
larger percentage of women in the class appeared to increase overall reports of
mistreatment from both sexes.

PMID: 1926843 [PubMed - indexed for MEDLINE]
BMC Med Educ. 2005 Oct 18;5:36.

Mistreatment of university students most common during medical studies.

Rautio A, Sunnari V, Nuutinen M, Laitala M.

Department of Pharmacology and Toxicology, University of Oulu, FIN-90014,

BACKGROUND: This study concerns the occurrence of various forms of mistreatment
by staff and fellow students experienced by students in the Faculty of Medicine
and the other four faculties of the University of Oulu, Finland. METHODS: A
questionnaire with 51 questions on various forms of physical and psychological
mistreatment was distributed to 665 students (451 females) after lectures or
examinations and filled in and returned. The results were analysed by gender and
faculty. The differences between the males and females were assessed
statistically using a test for the equality of two proportions. An exact
two-sided P value was calculated using a mid-P approach to Fisher's exact test
(the null hypothesis being that there is no difference between the two
proportions). RESULTS: About half of the students answering the questionnaire
had experienced some form of mistreatment by staff during their university
studies, most commonly humiliation and contempt (40%), negative or disparaging
remarks (34%), yelling and shouting (23%), sexual harassment and other forms of
gender-based mistreatment (17%) and tasks assigned as punishment (13%). The
students in the Faculty of Medicine reported every form of mistreatment more
commonly than those in the Faculties of Humanities, Education, Science and
Technology. Experiences of mistreatment varied, but clear messages regarding its
patterns were to be found in each faculty. Female students reported more
instances of mistreatment than males and were more disturbed by them.
Professors, lecturers and other staff in particular mistreated female students
more than they mistreated males. About half of the respondents reported some
form of mistreatment by their fellow students. CONCLUSION: Students in the
Faculty of Medicine reported the greatest amount of mistreatment. If a faculty
mistreats its students, its success in the main tasks of universities, research,
teaching and learning, will be threatened. The results challenge university
teachers, especially in faculties of medicine, to evaluate their ability to
create a safe environment conducive to learning.

PMID: 16232310 [PubMed - indexed for MEDLINE]
JAMA. 1994 Apr 6;271(13):1049-51.

Medical student abuse: an international phenomenon.

Uhari M, Kokkonen J, Nuutinen M, Vainionpaa L, Rantala H, Lautala P, Vayrynen M.

Department of Pediatrics, University of Oulu, Finland.

OBJECTIVE--To evaluate the prevalence of physical and psychological mistreatment
of medical students at two medical schools in Finland. STUDY DESIGN AND
SETTING--To enable comparison between Finnish and American students, we used the
American Medical Association's Office of Education Research questionnaire.
RESULTS--Three of every four students surveyed reported experiencing some kind
of mistreatment during their medical education. Students most commonly reported
sexual mistreatment, usually as slurs and sexual discrimination, from
classmates, preclinical teachers, clinical teachers, clinicians, nurses, and
patients. Other forms of verbal abuse, psychological mistreatment, and physical
threats were also reported. CONCLUSIONS--All forms of mistreatment were reported
occurring less frequently than in the United States; still, the level of such
behavior was high. The results suggest the need for more international awareness
and debate regarding the habits and behavior of teaching staff in medical

PMID: 8139064 [PubMed - indexed for MEDLINE]
Isr J Med Sci. 1996 Mar-Apr;32(3-4):229-38.

Student abuse in medical school: a comparison of students' and faculty's

Lebenthal A, Kaiserman I, Lernau O.

Department of Surgery, Hadassah University Hospital, Jerusalem, Israel.

A perceived abuse or mistreatment has been identified in the United States as a
major source of stress for undergraduate medical students. The objective of this
paper is to explore whether medical students in Israel have similar complaints,
and if so, whether medical faculty members are aware of students' perceptions of
mistreatment. Third and fifth year medical students of the 6 year undergraduate
program of the Hebrew University-Hadassah Medical School were asked to respond
to a self-administered questionnaire similar to those used in previous studies
in the USA. An additional questionnaire was developed for faculty members.
Response rates were 75% for students and 39% for faculty members. Analysis of
the responses indicated that similar to the results of American studies, the
number and severity of all forms of perceived incidents of abuse increased from
the third (pre-clinical) to the fifth (clinical) year. Verbal abuse was the most
frequently reported form of mistreatment. The most frequently identified abusers
were nurses, followed by clinical faculty members, and general surgery was
reported as the most abusive clinical department. Students' complaints of denial
of basic privileges were more common than those reported in the USA, while
verbal abuse and physical threats were more frequently reported by American
medical students. Analysis of the responses of faculty members indicated that
clinical faculty, residents and interns were unaware of the extent of these
students' perceptions, while pre-clinical faculty overestimated the extent of
verbal and psychological abuse. We conclude that the perception of abuse or
mistreatment among Israeli medical students is more prevalent than either
students or faculty believe.

PMID: 8606140 [PubMed - indexed for MEDLINE]
Ann Intern Med. 2000 Jun 6;132(11):889-96.

Faculty perceptions of gender discrimination and sexual harassment in academic

Carr PL, Ash AS, Friedman RH, Szalacha L, Barnett RC, Palepu A, Moskowitz MM.

Boston Medical Center, Boston University School of Medicine, Massachusetts
02118, USA.

BACKGROUND: Gender-based discrimination and sexual harassment are common in
medical practice and may be even more prevalent in academic medicine. OBJECTIVE:
To examine the prevalence of gender-based discrimination and sexual harassment
among medical school faculty and the associations of gender-based discrimination
with number of publications, career satisfaction, and perceptions of career
advancement. DESIGN: A self-administered mailed questionnaire of U.S. medical
school faculty that covered a broad range of topics relating to academic life.
SETTING: 24 randomly selected medical schools in the contiguous United States.
PARTICIPANTS: A random sample of 3332 full-time faculty, stratified by
specialty, graduation cohort, and sex. MEASUREMENTS: Prevalence of self-reported
experiences of discrimination and harassment, number of peer-reviewed
publications, career satisfaction, and perception of career advancement.
RESULTS: Female faculty were more than 2.5 times more likely than male faculty
to perceive gender-based discrimination in the academic environment (P < 0.001).
Among women, rates of reported discrimination ranged from 47% for the youngest
faculty to 70% for the oldest faculty. Women who reported experiencing negative
gender bias had similar productivity but lower career satisfaction scores than
did other women (P< 0.001). About half of female faculty but few male faculty
experienced some form of sexual harassment. These experiences were similarly
prevalent across the institutions in the sample and in all regions of the United
States. Female faculty who reported being sexually harassed perceived
gender-specific bias in the academic environment more often than did other women
(80% compared with 61 %) and more often reported experiencing gender bias in
professional advancement (72% compared with 47%). Publications, career
satisfaction, and professional confidence were not affected by sexual
harassment, and self-assessed career advancement was only marginally lower for
female faculty who had experienced sexual harassment (P = 0.06). CONCLUSION:
Despite substantial increases in the number of female faculty, reports of
gender-based discrimination and sexual harassment remain common.

PMID: 10836916 [PubMed - indexed for MEDLINE]

By Anonymous Anonymous, at 10:20 PM  

Ethn Dis. 2005 Autumn;15(4):740-7.

African-American preference for same-race healthcare providers: the role of
healthcare discrimination.

Malat J, van Ryn M.

Department of Sociology, University of Cincinnati, OH 45221, USA.

OBJECTIVE: To determine the extent to which African Americans prefer same-race
clinicians and the extent to which: 1) knowledge of historical mistreatment; 2)
perceptions of current racial inequities in medical treatment; and 3) personal
experiences of discrimination are associated with preference for same-race
healthcare providers among African Americans. DESIGN: Statistical analysis of a
nationally representative telephone survey designed by the Henry J. Kaiser
Family Foundation and conducted by Princeton Survey Research Associates (PSRA).
Bivariate significance is determined by using chi-square tests of association.
Multinominal logistic regression models adjust for age, gender, income,
education, and self-reported health status. RESULTS: Approximately one in five
African Americans states a preference for a same-race healthcare provider.
Neither knowledge of historical mistreatment nor perceptions of current racial
inequities in medical treatment are related to preferred race of healthcare
providers. In contrast, personal experiences of discrimination in health care
are associated with a preference for same-race healthcare providers.
CONCLUSIONS: The results suggest that while knowledge of unfair treatment
historically and perceptions of current racial inequity do not affect
preferences, personal experiences of unfair treatment may have a significant
effect on African-American patients' preferences regarding health care. Findings
suggest that rather than focusing on how historical mistreatment and current
inequities in medical treatment affect individual patients, research should
focus on individual experiences.

PMID: 16259502 [PubMed - indexed for MEDLINE]
Mayo Clin Proc. 2005 Dec;80(12):1613-22.

Medical student distress: causes, consequences, and proposed solutions.

Dyrbye LN, Thomas MR, Shanafelt TD.

Department of Internal Medicine and Division of Primary Care Internal Medicine,
Mayo Clinic College of Medicine, Rochester, Minn 55905, USA.

The goal of medical education is to graduate knowledgeable, skillful, and
professional physicians. The medical school curriculum has been developed to
accomplish these ambitions; however, some aspects of training may have
unintended negative effects on medical students' mental and emotional health
that can undermine these values. Studies suggest that mental health worsens
after students begin medical school and remains poor throughout training. On a
personal level, this distress can contribute to substance abuse, broken
relationships, suicide, and attrition from the profession. On a professional
level, studies suggest that student distress contributes to cynicism and
subsequently may affect students' care of patients, relationship with faculty,
and ultimately the culture of the medical profession. In this article, we review
the manifestations and causes of student distress, its potential adverse
personal and professional consequences, and proposed institutional approaches to
decrease student distress.

PMID: 16342655 [PubMed - indexed for MEDLINE]

By Anonymous Anonymous, at 10:47 PM  

I applaud the poster's finding all those examples of studies done on the abuse of med students and s/he is correct that it absolutely filters down. Even in my early psychology classes we learned that examples of abuse are mimicked - no less so for doctors than parents.

I am guessing that Amy hasn't read any of her fellow colleague's exposes regarding their medical school and residency years and how cruel and inhumane they were taught to be to the patients. One book in particular stands out because he was a noted anthropologist before going to medical school (and becoming a physician) - Melvin Konner, M.D.'s _Becoming a Doctor: A Journey of Initiation in Medical School_.

It's sad that Amy can't believe the stories women share. It speaks volumes of her lack of hearing probably throughout her entire OB career. It's sad she has to find an excuse for her and her colleagues' behavior. It's sad she has to invent an excuse for women's behaviors after their births. Instead of HEARING what women have to say, it is far easier to negate any of their sorrow and pain with the oh-so-typical "they're making it up" or "they're blaming the wrong person." Can I just say how sick and tired we all are of being told it is all in our heads? It is NOT in our heads! It is in our hearts and bodies and spirits - affecting aspects of our lives we never imagined.

Why is it so hard to just believe? Why discount what so many women have to say?

By Blogger Navelgazing Midwife, at 1:02 AM  

Acta Obstet Gynecol Scand. 2006;85(4):435-40.

Fear of childbirth and history of abuse: implications for pregnancy and

Heimstad R, Dahloe R, Laache I, Skogvoll E, Schei B.

Department of Obstetrics and Gynecology, St. Olav's University Hospital,
Trondheim, Norway.

BACKGROUND: The aim of this study was to assess the prevalence of fear of
childbirth, and to find possible associations to selected sociodemographic
factors and important life events. A secondary aim was to explore the
relationship between these factors and pregnancy outcome. METHODS: Questionnaire
booklets were sent to 2680 women at 18 weeks of gestation, of whom 1452 women
(54%) responded. The questionnaire included background factors (marital status,
education, history of abuse, current pregnancy), W-DEQ (measurement of fear of
childbirth), and STAI (measurement of subjective anxiety). Pregnancy outcome
information was recorded. RESULTS: The prevalence of serious fear of childbirth
(W-DEQ > 100) was 5.5%. The W-DEQ and STAI scores were positively correlated (r
= 0.44, p < 0.001). Among the anxious women, a trend towards more frequent
operative vaginal delivery (12.1% versus 6.9%, p = 0.07) was noted, but not for
emergency cesarean section (10.6% versus 7.6%, p = 0.34). Women who reported
being exposed to physical or sexual abuse in childhood had a higher W-DEQ score
(71, SD 31 and 69, SD 27) than did the non-abused (61, SD 23, p < 0.01). Only
half of women sexually or physically abused in childhood (54% and 57%
respectively) had uncomplicated vaginal delivery at term versus 75% among
non-abused (p < 0.001). CONCLUSION: The prevalence of serious fear of childbirth
was 5.5%. Fear of childbirth was not associated with mode of delivery, whereas
sexual or physical abuse in childhood influenced negatively mode of delivery.

PMID: 16612705 [PubMed - indexed for MEDLINE]
Br J Obstet Gynaecol. 1999 Mar;106(3):227-32.

Subsequent obstetric performance related to primary mode of delivery.

Jolly J, Walker J, Bhabra K.

St James's University Hospital, Leeds, UK.

OBJECTIVE: To relate subsequent obstetric performance with primary mode of
delivery. DESIGN: Postal questionnaire survey of women who delivered their first
child five years ago. SETTING: Huddersfield Royal Infirmary. POPULATION: Women
who were delivered of their first baby in 1991: 250 by normal vaginal delivery;
250 by instrumental vaginal delivery; and 250 by caesarean section. MAIN OUTCOME
MEASURES: Answers to fixed choice questions on fear of future childbirth, number
of subsequent children and reasons for no further children. RESULTS: The
response rate was 64%. Overall, 222 (46.6%) women were initially frightened
about future childbirth. According to mode of delivery: 93 (57.1%) after
instrumental vaginal; 79 (47.9%) after caesarean section; and 50 (33.8%) after
normal vaginal delivery. Five years after the primary delivery, 99 women (20.8%)
were still frightened about future childbirth: instrumental vaginal group 41
(25.2%); caesarean section group 43 (26.1%); and normal vaginal group 15
(10.1%). In the group of women who were delivered by caesarean section 13% more
women had not had a second child after five years compared with the normal
vaginal delivery group ((P < 0.03, relative risk 1.46 (1.07-1.99)). In the group
of women who had a vaginal instrumental delivery 6% more had not had a second
child after five years compared with normal vaginal delivery group. Of the women
who had no further children, 30% who had caesarean section and 28% vaginal
instrumental delivery had involuntary infertility. CONCLUSIONS: Caesarean
section or vaginal instrumental delivery leaves many mothers frightened about
future childbirth. Primary caesarean section and to some extent vaginal
instrumental delivery is associated with an increased risk of voluntary and
involuntary infertility.

PMID: 10426641 [PubMed - indexed for MEDLINE]

By Anonymous Anonymous, at 1:11 AM  

I am weeks away from having my second baby. I had my first in hospital, in fact, the hospital that I work in. I am having this baby at home. Why? Because after the birth of my first baby I felt abused and violated. Things were done to me without my consent (in fact, some in direct contradiction of what I said should happen, both in my written birth plan and verbally at the time) and with out explanation of what they were doing and why. At one point, having ignored my request/demand to be left to rest and bullied me into an assisted delivery and put in stirrups, I was catheterised without any word of warning or explanation. To be man-handled, over-powered (physically or psychologically) and brutalised by a group of people is tremendously traumatic, be they medical professionals of rapists. No matter what was really going on these people ignored me when I said "no" and did what they wanted, isn't that what a rapist/abuser does?

I have no past history of sexual assault or abuse, but I was assaulted and abused by the Dr who delivered my baby. It took me over a year to recover physically and emotionally and to be able to resume anything like a normal sex-life with my partner, who witnessed this "joyoues" event and was also traumatised by it. I am still not "over" it yet, I am hoping a calm, natural delivery at home will help me come to terms with what happened to me in hospital.

I don't claim to have PTSD, but I do get flashbacks, and similar problems.

The real point here is not whether the way a Dr treated you when you had a baby triggered PTSD that involves previous sexual abuse/assualt, but that the way some Dr's treat women in labour is basically assualt/abuse. It is pretty immeterial as to whether you have suffered previous abuse etc, no one should be treated the way I was, and so many of these women describe the way they were treated when they had thier babies.

Incidently, there was no medical need for the intervention and assisted delivery I had, it was just quicker and easier for the Dr to do it this way.

By Anonymous Anonymous, at 6:16 AM  

"I have no past history of sexual assault or abuse, but I was assaulted and abused by the Dr who delivered my baby."

I'm sorry, but your interpretation of what happened is not very plausible.

If you were assaulted or abused, you could should report it to the president of the hospital. If you were assaulted or abused, you should report it to your state's board of registration in medicine. If you were assaulted or abused, you should report it to the police.

You don't seem to understand that you are accusing the doctor of a crime and therefore, you need to have proof.

Second, the appropriate response is to pick another doctor or CNM and another hospital. It is not to risk your baby's life at home.

" It took me over a year to recover physically and emotionally"

This tells us nothing about the doctor's responsibility. Perhaps you had postpartum depression. Perhaps you had a pre-existing history of depression or other psychological risk factors.

On the the things I find most remarkable about these stories is the unwillingness to apportion one iota of responsibility for a woman's problems to anybody else except the doctor.

You claim to have had serious psychological problems since the birth of the baby. It is very unlikely that this came out of the nowhere.

Even people who do suffer from PTSD after a traumatic event have pre-existing risk factors such as anxiety and depression that make them more vulnerable than the average person. As part of their recovery, they need to explore and understand those issues. No therapist would agree that someone could ascribe all their difficulties to one experience.

By Blogger Amy Tuteur, MD, at 7:04 AM  

I find the reference to the papers on treatment of medical students to be a perfect example of what I have been talking about: an abuse of language, a desire to shock and draw attention to oneself, and a complete loss of perspective on the reality of what is happening.

I have no trouble believing that senior doctors are mean and nasty to medical students, interns and residents. However, that is a very far cry from saying that senior doctors rape and assault medical students.

If you want to say that your doctor was mean to you; I'd believe that. If you want to say that your doctor is a mean and nasty person; I'd believe that, too.

If you want to tell me that your doctor was so mean and nasty to you that it was like RAPE or ASSAULT, then you are abusing the language. You are trivializing the experiences of women who truly have been raped and assaulted. You are misusing the words in order to shock and draw attention to yourself. You have completely lost perspective on the REALITY of what is happening.

That people would take the time to search out and provide those references tells me two things:

1. you were originally searching for papers about the abuse of patients at the hands of doctors and couldn't find any

2. so, you settled for papers about doctors yelling at medical students as if that was in any way illustrative or equivalent, which it is not.

By Blogger Amy Tuteur, MD, at 7:18 AM  

let me see it is more than words Amy and most students aren't in a physically vulnerable position and so can readily remove themselves and it is not limited to just words---
"Response rates were 75% for students and 39% for faculty members. Analysis of the responses indicated that similar to the results of American studies, the number and severity of all forms of perceived incidents of abuse increased from
the third (pre-clinical) to the fifth (clinical) year. Verbal abuse was the most frequently reported form of mistreatment. The most frequently identified abusers were nurses, followed by clinical faculty members, and general surgery was reported as the most abusive clinical department. Students' complaints of denial of basic privileges were more common than those reported in the USA, while verbal abuse and physical threats were more frequently reported by American medical students"

If they are threatening a woman at the same time as they are treating her physically -- what is that ? how about a episotomy straight up through a woman's clitoris? I know the woman who had this done to her and she spent years in court against this doctor,

maybe it would be appropriate to tell someone and complain, without these studies who have these students been complaining to, and how many of them?
And don't you think that someone should study the behavior of medical and non-medical personnel in the hospital?
we are a group of women who are saying publicly that there is a culture of mistreatment in the hospital- it is like playing dodge ball with sick and vulnerable people

By Anonymous Anonymous, at 10:31 AM  

This also needs to be studied- given the raising rate of C-sections and operative deliveries in the country.

"Only half of women sexually or physically abused in childhood (54% and 57% respectively) had uncomplicated vaginal delivery at term versus 75% among non-abused (p < 0.001). CONCLUSION: The prevalence of serious fear of childbirth was 5.5%. Fear of childbirth was not associated with mode of delivery, whereas sexual or physical abuse in childhood influenced negatively mode of delivery."

Given what we know as midwives this info should probably be in another study-- because we do end up having far less operative deliveries, despite the risk group we care for.

By Anonymous Anonymous, at 10:40 AM  

"how about a episotomy straight up through a woman's clitoris? I know the woman who had this done to her and she spent years in court against this doctor"

I don't believe it.

First of all, an episiotomy goes DOWN not up. So you are basically saying that the doctor decided to mutilate this woman's genitalia and no one seemed to see a problem with that at the time.

Second, if it has been in court, tell me where and I will look it up to see if it really exists.

By Blogger Amy Tuteur, MD, at 11:20 AM  

Look it up

By Anonymous Anonymous, at 12:16 PM  

I believe Montana is the state- I met her in Washington .

By Anonymous Anonymous, at 12:56 PM  

Why is it only abuse if reported? No matter if an event is reported or not, it could be traumatic enough to have a long term effect on a person. What percentage of rapes are actually reported? Are you saying that if a woman doesn't press charges then it couldn't possibly be real, Amy?

You are being a prime example of why women don't press charges when having one of these traumatic events. People would say "so what, the baby is alive." or "I don't believe you" or "there must have been good reasons for the doctor to do what he/she did and you must be misunderstanding the event." After going through something so horrible, the last thing a woman wants to do is try to talk about it and then be treated so horribly for having the experience in the first place. To disclose more private information about yourself and your vulnerabilities just to have them shoved back in your face from a snearing/angry mob of nonbelievers really is hurtful. (hmmm.... isn't this the reason why lots of rape victims don't report the crime?)

I also don't understand why a woman should have to tell her care provider (OB, midwife, whatever) about previous abuse. Shouldn't ALL women be treated with respect during their births?

By Anonymous Anonymous, at 2:29 PM  

"Are you saying that if a woman doesn't press charges then it couldn't possibly be real, Amy?"

No, I'm not saying that at all. However, if NO woman presses charges, if NO nurse reports such behavior, if NO ONE reports such events to a medical board, it suggests to me that it is more likely to be rhetoric than reality.

Furthermore, there are women who report abuse at the hands of doctors, and those doctors are disciplined, but NONE of those women tell stories like these.

"After going through something so horrible, the last thing a woman wants to do is try to talk about it and then be treated so horribly for having the experience in the first place."

But women are talking publicly about this. They are posting about it on their personal websites and they are writing to other people's websites about it. The problem is not that women are not talking about it; it is that they are not talking about it to anyone who would or could demand proof.

This reminds me of the controversy over "recovered" memories of abuse. Many, many innocent people have been accused of heinous crimes when they did not do anything at all. The big difference here, though, is there are always witnesses.

It is simply impossible for me to believe that all the nurses in America are part of a giant conspiracy to protect abusive doctors. Nurses are professionals, and most put the needs of their patients first. I can't imagine that a nurse could witness the kind of stories described and keep silent about it.

"I also don't understand why a woman should have to tell her care provider (OB, midwife, whatever) about previous abuse."

Why? Because the previous experience alters her perceptions. It's not like women don't tell their doctors about these things. I have had patients tell me or tell colleagues and special arrangements were often made in consultation with the patient to make her experience as tolerable as possible.

If you don't tell your doctor that you are needle phobic, how will anyone know before starting an IV. If you don't tell your doctor you are claustrophic, how is she supposed to know that you will have difficulty with an MRI or CAT scan. Doctors are not mind readers.

It is not as though I can't believe that inappropriate and mean things happen. I know they do. That is a far cry from rape and assault, and it is a far cry from a giant conspiracy involving thousands of people who don't care if doctors sexually abuse and assault patients and stay silent to protect them.

By Blogger Amy Tuteur, MD, at 3:33 PM  

It is a culture Amy and nurses are guilty of abuse as well- or at least that is what the medical school studies say-- it really isn't a conspiracy most things aren't conspiracies but that doesn't mean that what goes on is acceptable by modern standards.

probably time for some questionaires similar to the ones the medial students filled out but for patients.

By Anonymous Anonymous, at 7:04 PM  

"It is a culture Amy and nurses are guilty of abuse as well- or at least that is what the medical school studies say"

I didn't see any studies that said nurses were guilty of rape and assault, did you?

By Blogger Amy Tuteur, MD, at 8:38 PM  

time to do some studies- see if there is validity to any of the complaints-- since it has been a fairly recent development to look at how medical students are mistreated and how that may impact their practice and the culture of medicine then it follows the next thing is to look at how it does effect practice- in the word of the patients- look at the language used
"...With the exception of more reports of sexual harassment from women students, perceived mistreatment did not differ significantly across variables such as age, sex, religion, marital status, or having a physician parent. Scores from the 10 schools also did not vary significantly, although the presence of a larger percentage of women in the class appeared to increase overall reports of mistreatment from both sexes."
the words are reports, perceived
what we have been doing is reporting our perceptions-

By Anonymous Anonymous, at 10:10 PM  

"No, I'm not saying that at all. However, if NO woman presses charges, if NO nurse reports such behavior, if NO ONE reports such events to a medical board, it suggests to me that it is more likely to be rhetoric than reality."

These are pretty big ifs, Amy.

If a woman calls about pressing charges after first trying to work things out with the practitioner (Why did you do that? Didn't you hear me say no? Don't you remember my birth plan? Was there a medical problem I was not informed of?), and the prosecutor says, "We can't get juries to buy sexual assault charges if the complaint is not made in the first 48 hours," you would not hear about it.

If the medical board does an investigation and closes the file without action, you would not hear about it.

If the nurse(s) have a mortgage or a kid in college and care about their livelihood, you may not hear about it. They may quietly change jobs.

If the peer review committee hears it, it's privileged, right? And you won't hear about it.

MM, Georgia

By Anonymous Anonymous, at 11:42 AM  

MM, I could believe that some of those things happen some of the time. I cannot believe that those things happen 100% of the time.

By Blogger Amy Tuteur, MD, at 12:30 PM  

Amy Tuteur, MD said...
MM, I could believe that some of those things happen some of the time. I cannot believe that those things happen 100% of the time."

doesn't have to happen to 100% of the people 100% of the time- but what is the % ??
needs to be studied.

By Anonymous Anonymous, at 1:16 PM  

"doesn't have to happen to 100% of the people 100% of the time- but what is the % ??"

We were discussing why there have been no public complaints by women who believe that they were assaulted in labor. MM offered different ways in which those public claims might be supressed.

My response was that it may be possible to supress some of the claims some of the time, but it would not be possible to supress all the claims.

A labrynthine explanation is being constructed to support the assertion that women are assaulted and raped in labor. Well, it really happens, but no one reports it. The nurses refuse to acknowledge it. The hospital administrators refuse to pursue it. The legal system refuses to pursue it. The complaints are made but they are suppressed, etc.

A far more plausible explanation is that the women who are proclaiming assault on their websites and other people's websites are describing events that didn't really happen the way that they are describing them.

By Blogger Amy Tuteur, MD, at 3:26 PM  

I just hate how much this whole debate sounds like, no means no when you are massively drunk on a date but if you are in high labor and say no, you can be penetrated on someone else's idea of what is good, by any method of force or coercion or just by ignoring the no and proceeding, and the fact that the doctor/nurse/midwife/assistant felt justified at the time in ignoring the no, means that the woman is somehow aberrant in experiencing assault. The practitioner is an authority figure and the woman's family is often as afraid of birth and worshipful of medical figures as ... well we know this is how our society tends to view things.

For her own good. Desensitized by the nature of the work, I'm not surprised that this happens. But it's not the women who go to them trustingly who need to be fixed. It's the people who violate that trust -- trust that at a minimum, the woman is still a human being with the right to refuse consent!

Strong language is helpful to make the point, I believe.

It could justifiably be said that I would benefit from a lay right now. If someone decides to screw me and I say no, are they justified in proceeding on their version of for my own good? Will you argue that I must have been previously sexually assaulted when I have flashbacks of the rape? What if I'm just fingerfucked against my will. Now is it OK? It was for my own good! (Did I [have a healthy baby][have an orgasm]?)

What if I say no to my husband? And he proceeds? Like a practitioner can argue that s/he could do what she did because she was hired to do a job, can my husband argue that I married him and that's part of THAT job? I believe most jurisdictions now hold husbands accoutable for rapes that occur when the wife says no. Y'know why? We're not property. We're not husband's property, doctor/midwife property, fetal property, societal property.

If a woman says Get your fingers out of my vagina -- there's not a damn thing wrong with her version of reality when she subsequently recalls a sexual assault by providers who went ahead without consent. If a woman says Don't cut me, and the doc cuts, s/he's the lowest form of pond scum unless there was REALLY a dying baby who did not have five seconds for his mom's consent to be obtained with more information and consultation.

I'm sure the provider remembers doing his or her job, possibly as trained, possibly as s/he thought was best. That's what needs to be retrained. Not the gentle human spirit and heart.


By Anonymous Anonymous, at 4:27 PM  

So women were beaten by husbands for years in our history, and that has been slow, slow , slow in changing- we even have laws but how successful are we at changing abuse? How long has it been and how long did it take to change restraining policies in hospitals and why did they change? because it is considered a form of holding someone against their will-- before this changed how many patients do you think filed charges? how long did it take--you can read the old very old birth stories of women who gave birth when scopolamine was used or talk to them and the horror they had and how they would be restrained and even when they did not want the drug they were given it ( was it a conspiracy then?)-- you would think that this was not acceptable today- and we are saying that there are things being done to this day that are not acceptable - and some women do experience violence on the order of rape- -----------------------
how long did it take to catch up to this guy? was he alone in the operating room everytime he did this?

January 27, 2000
How Doctor Got Work After Carving Into Patient

When Dr. Allan Zarkin came looking for work, Merle Hoffman could not have been happier. She and the doctor had worked together off and on for many years in her clinic, Choices Women's Medical Center in Queens. Moreover, her medical director had just left, so she happily handed the title over to Dr. Zarkin on Nov. 1.

What she said she did not know was that the doctor had been dismissed just weeks before from Beth Israel Medical Center for what may be the most bizarre incident in the history of the hospital.

Dr. Zarkin is accused of carving his initials into the stomach of a patient on whom he had just performed a Caesarean section, a charge he does not deny. The patient, Dr. Liana Gedz, is suing the hospital, the doctor and his former medical practice for $5.5 million, charging that the incident has left her physically and emotionally scarred. Dr. Zarkin has since had his medical license temporarily suspended pending a final investigation, and he is also the subject of an inquiry by the Manhattan district attorney's office.

The fact that Dr. Zarkin was able to practice medicine -- and by some accounts with further bad results -- after the incident at Beth Israel underscores that even within a system like New York's, which is known nationally for its oversight of doctors, the smallest bureaucratic missteps, combined with peculiarities in the law, can keep even egregiously bad doctors in practice.

For its part, Beth Israel did much by the book. The hospital dismissed Dr. Zarkin almost immediately after the incident and reported the dismissal to the state in a timely manner.

But the hospital did not detail in its note to the state what exactly Dr. Zarkin had done, which, state officials say, accounts for a four-month lapse between the incident and his license suspension. Further, the hospital sent a letter to Ms. Hoffman, his new supervisor at Choices, informing her that he was no longer admitting patients there, and that she should contact them with any questions about Dr. Zarkin. It did not mention the incident.

Ms. Hoffman, who trusted Dr. Zarkin, did not check with Beth Israel or Dr. Zarkin's former partners about why he had parted ways with them, she said. But not checking his credentials is a violation of state law, and her clinic, which provides abortions and other women's health services, is now being investigated by the State Department of Health.

For its part, the state moved quickly to get Dr. Zarkin out of medicine when it finally learned the details of what happened at Beth Israel in September. But the Department of Health had already received at least two complaints from patients about the doctor, one well over a year old. Further, under state law, officials at the agency would not have been permitted to tell Ms. Hoffman anything about Dr. Zarkin's history or the fact he was being investigated until his license was officially suspended, which was not the case when he returned to work at the clinic.

The events surrounding Dr. Zarkin are the sort that draw fire from health care policy experts who cite recent data showing that medical error is among the leading causes of accidental deaths in America.

''It is this type of breakdown in oversight combined with a kind of lackluster commitment on behalf of facilities that leads to unnecessary injuries and deaths,'' said Blair Horner, the legislative director for the New York Public Interest Research Group. Mr. Horner's group is among many pushing for a law that would make extensive information about doctors available to New York residents.

Unlike many doctors whose licenses are ultimately suspended, Dr. Zarkin had a clinical history that suggested anything but imminent disaster. Although obstetrics and gynecology is a speciality that draws a disproportionate number of malpractice suits among even its finest doctors, his record was nearly spotless. Further, the practice where he was a partner, New York Gyn/Ob Associates in the Murray Hill section of Manhattan, was well respected at the hospital and by its peers.

''He was an excellent physician,'' said one senior doctor, who spoke on the condition of anonymity. ''He got along very well with his patients and was a good citizen.''

Dr. Zarkin did stand out. Among the blue shirt and white jacket set, he wore high-fashion suits and loud ties, and was known for his garrulous, joking nature.

''When he was around, you would know it,'' one doctor said. Another added: ''He was larger than life. Personality-wise, he was a little nutty, but in terms of medical judgment, no one questioned him.''

In recent years, however, it was apparent that not all patients were happy. The Department of Health has said it is looking into two other patient complaints against Dr. Zarkin. Although a spokeswoman would not elaborate on the complaints, a woman who contacted The New York Times said she visited Dr. Zarkin in the mid-1990's for routine gynecological exams. The patient, who insisted that her name not be used, said that Dr. Zarkin made increasingly lewd remarks to her over three years, leading her to file a complaint with the state.

Besides making crass sex jokes, she said, Dr. Zarkin commented that she was ''beautiful'' and his ''favorite patient.'' She filed a complaint with the Department of Health, she said, when the doctor told her he was taking Viagra three times per day and masturbating in the shower.

A Health Department spokeswoman, Kristine Smith, said that the department had taken a sexual harassment complaint against Dr. Zarkin seriously and investigated it. She added that in those types of cases, the department tended to prefer to build a case against a doctor showing a pattern of abuses, and was moving toward that goal before Sept. 7, when Dr. Gedz had her C-section at Beth Israel.

By all accounts, Dr. Gedz, a dentist, and Dr. Zarkin had developed a fond friendship while he was caring for her during her pregnancy. He had even been a guest at a summer home she and her husband owned.

The accounts of what happened during the delivery are sketchy -- the hospital will not provide full details, citing the lawsuit, and Dr. Gedz refused repeated requests for an interview. But after he completed the surgery, Dr. Zarkin apparently sliced his initials in Dr. Gedz's stomach, something she discovered in the recovery room. (The hospital says that staff members who were in the operating room immediately told their supervisors.)

Dr. Zarkin's lawyers say that the incident was a manifestation of Pick's disease, an Alzheimer-like degeneration of the frontal lobe of the brain. ''Our legal response to the lawsuit was that what was done was not a willful or intentional act,'' said Dr. Zarkin's lawyer, Kenneth J. Platzer, who added that he could not comment on other complaints against his client.

Beth Israel executives said they were horrified. After a brief investigation, they suspended his right to work at the hospital, and he resigned on Sept. 17 rather than face dismissal and the hearing process. The hospital wrote to the state saying that he would no longer practice medicine there, citing ''gross misconduct.'' He was also dismissed by the partners at his Murray Hill practice.

But the state did not move as quickly. Investigations take a certain amount of time, Ms. Smith said. The agency has the right to keep a doctor from practicing while he or she awaits due process, which it would have done if it had been given the details of why Dr. Zarkin left Beth Israel, she said. ''It is fair to say that had we known the specific circumstances that produced the allegations from Beth Israel, we would have moved much more quickly to stop his practice of medicine,'' she said.

Furthermore, Ms. Smith said, the hospital did not file an additional report with the agency's bureau of hospitals, which is mandatory when there is an incident that adversely affects a patient, and is something she said the hospital might be penalized for.

Jim Mandler, a Beth Israel spokesman, said: ''We felt that the language 'gross misconduct' would automatically precipitate a thorough investigation with which we had every intention of cooperating with fully.''

On Jan. 7, once the department did learn the circumstances, it temporarily suspended Dr. Zarkin's license, four months after the doctor carved his initials into his patient's stomach.

Dr. Zarkin did not share any of these details with Ms. Hoffman at the Queens clinic when he came looking for a job, she said. Dr. Zarkin had worked for her part time between 1983 and 1991, and she was very pleased with his work. ''He always presented himself as a physician who cared deeply about patients,'' she said.

Things started to look strange when she got a letter in late December from an insurance company that said it would not be renewing Dr. Zarkin's malpractice insurance. Soon after, an oblique letter from Beth Israel arrived in the mail, suggesting that if she had any questions about the doctor, she should call the department chairman, which she did not do.

By some accounts, Dr. Zarkin's care at Choices was not all it should have been. A complaint filed with the State Health Department by Dr. Enayat Hakim Elahi, the medical director who preceded Dr. Zarkin at the clinic, relates a November incident in which Dr. Zarkin botched a complicated gynecological surgery.

Dr. Elahi, who has filed many complaints to the state about conditions at Choices, says that he did not see the incident; he heard of it through his former colleagues there. The incident was confirmed through interviews with other clinic employees who agreed with Dr. Elahi's assessment. Ms. Hoffman denied the assertions that poor care was given at her clinic, and said that Dr. Elahi had a grudge against her.

On Dec. 28, Ms. Hoffman, who reads all the mail that comes to the clinic as a safety precaution, said she opened a letter to Dr. Zarkin from Dr. Gedz's lawyers informing him of the lawsuit.

''I saw he was being sued for $5.5 million for carving A Z on someone's stomach,'' she said in an interview. ''I felt shock and amazement when I read it. I called him into my office and I asked him, 'Did you do these things?' and he said, 'Yes,' and I asked him why and how this could have happened and he said he thought he did such a beautiful job, he thought he should sign it.''

She dismissed him that day. ''I felt profoundly betrayed,'' Ms. Hoffman said. ''Obviously if he had told me he would never have been hired.''

By Anonymous Anonymous, at 9:19 PM  

Also how many years were medical schools doing exams on knocked out female patients before the whistle was blown and that stopped?

By Anonymous Anonymous, at 9:48 PM  

Posting a story about a mentally ill doctor who was immediately dismissed from his job is NOT going to convince anyone that there are numerous OBs going around assaulting and raping patients in the presence of other people.

Quite the opposite; this man was reported immediately and dismissed immediately.

By Blogger Amy Tuteur, MD, at 10:24 PM  

amy re-read the story he had 3 complaints against him one from a year before....

By Anonymous Anonymous, at 10:44 AM  

"ut the Department of Health had already received at least two complaints from patients about the doctor, one well over a year old. Further, under state law, officials at the agency would not have been permitted to tell Ms. Hoffman anything about Dr. Zarkin's history or the fact he was being investigated until his license was officially suspended, which was not the case when he returned to work at the clinic."

By Anonymous Anonymous, at 10:47 AM  

That's right. This guy was mentally ill and people complained about it. The administrators took all the action that was available to them under the law of their state.

This does nothing to bolster your claim than MANY women are victims of assault and abuse in labor and no one is reporting it.

By Blogger Amy Tuteur, MD, at 2:34 PM  

and so if you want to keep maintaining an idea that women are fabricating mistreatment- I cannot change your view
If there are any take home messages it is complain- complain complain
to know who to complain to multiple copies of a letter to hospital administration, the care provider themselves- state board of quality assurance- or nursing board or medical board.... you may or may not hear back but it is possible that multiple complaints will be heard-
I know that suing medical care providers are one of the ways - paying them back for mistreatment but in the long run they are still out there doing the same thing to others--

By Anonymous Anonymous, at 7:37 PM