Bedside Manners

For this month’s column, I spoke with Patricia A. Adler, Professor of Sociology at the University of Colorado, Boulder. She and her husband Peter Adler, Professor of Sociology at the University of Denver, co-authored a new book that offers an ethnographic perspective on a controversial health topic. The Tender Cut: Inside the Hidden World of Self-Injury (NYU Press) invites readers to go beyond predominant medical and psychological perspectives by offering a nuanced analysis of self-injury as a sociological phenomenon.

Their book is the culmination of 135 in-depth, life-history interviews conducted over ten years with self-injurers from across the world, as well as analysis of tens of thousands of emails and Internet messages. Their participants were engaging in self-injury, the intentional non-suicidal harm of one’s own body, including but not limited to include cutting, branding, burning, branding, and scratching. 

AN: In your book, you describe a broad range of motivations for self-injury. Can you explain the most typical reasons?

PA: Most of the people we interviewed saw it as a way to cope, to function when they were facing tough times. Many started in their teens when they were trying to cope with negative life circumstances.

AN: Did you find that sex and gender made a difference – did the self-injury types or reasons differ between men and women?

PA: Yes, men and women differed in the ways that they self-injured and their motivations. Men were injuring their bodies because of feelings of rage and anger and were more likely to use dull or rusted instruments to make bigger injuries on parts of their body that would be easily visible. If a man did small self-injuries and tried to hide them, then other guys would be likely to ridicule him. Women were more likely to use sharp, small blades on parts of their body that they could easily conceal because society judges women’s bodies, and they wanted to be able to hide it. They tended to self-injure because of negative feelings about themselves.

AN: It’s fascinating that sex and gender factors into others’ reactions to the self-injurers: that those who acted in ways that matched their gender norms – who were seen as being appropriately masculine or feminine – received less ridicule. Do you think mental health and medical practitioners understand self-injury as a gendered phenomenon?

PA: I think that mental health practitioners probably regard self-injury as they do eating disorders, as a generally female behavior. They may see a guy here and there, but I doubt that any practitioner sees enough to recognize this pattern. And some of the books I’ve read from the clinic people who do see larger numbers have presented cases of men who injure in ‘feminine’ ways. So I don’t think they’re attuned to this gendered pattern.

AN: Most media coverage of self-injury approaches it as a psychological problem, often as a physically dangerous type of addiction. Can you explain the sociological perspective you present on self-injury?

PA: It is common for self-injurers to be told that they have a mental disorder and that it is an addictive practice. We looked at a range of people who self-injure and found that their motivations did not necessarily reflect mental illness. A lot of regular teenagers and adults who were structurally disadvantaged were using it to find relief. Then there are those who have severe mental disorders before they start self-injuring. Some of the people we interviewed were mentally ill, but our research suggests that many of them are not. We intentionally chose the word “tender” in the book’s title because cutting may be a coping mechanism that makes some people feel empowered with a sense of control over their pain. The self-injury gave some people relief from emotional pain that they needed to get through challenging times. Our book is nonjudgmental, providing a “voice” for the experiences of a broad population of self-injurers: comprising people who have genuine mental disorders, as well as those who just have temporary situational life troubles, and everything in between.

AN: From the medical and psychological perspectives, a key focus in on how to help self-injurers stop “dangerous” behaviors. So, what did you learn about the ways and reasons why self-injurers stop?

PA: Many self-injurers stop when they are able to escape from the circumstance that caused them to initially start. So, transitioning from high school to college can be a time when young people stop. For others, it takes getting a good job, finding a partner who will not tolerate it, or becoming a parent and not wanting their children to see them self-injuring.

AN: In other published interviews, you’ve made the somewhat controversial point that not every self-injurer will need to invest in professional medical and mental health treatment in order to quit. What are some of the other ways that those you interviewed found to be helpful when they decided they wanted to stop self-injuring?

PA: Solutions from the medical-psychological community include everything from specialized clinics, which can be very expensive, to outpatient therapy, and drugs. Those who found therapy to be effective were those whose therapists addressed the reasons the person began self-injuring in the first place, rather than those who focused on self-injuring as the problem to be treated. Most of the people who self-injure are not trying to self-destruct; they’re trying to self-soothe. And, we also found many turning to free online support groups to connect with people like themselves who had either stopped self-injuring or could give advice on how to better manage the negative aspects of self-injury. In addition, some people just stopped on their own or with the encouragement and support of friends.

AN: As experts on deviant subcultures, would you say that the Internet has helped to create communities of self-injurers?

PA: Yes, the Internet has helped to build a kind of self-help community for self-injurers. Peer support groups have emerged organically, and people are sharing their experiences with each other in cyber-communities. These online relationships help them manage stress so that they function better in their daily lives.

AN: What role do you think the media played in transforming self-injury into a sociological phenomenon?

PA: It was initially shocking but not necessarily more shocking that the many other ways the people try to relieve their pain. The stories often showed that self-injury was not a suicide attempt and wasn’t necessarily because the person had serious psychological problems. Once the media started to cover self-injury stories of celebrities, then it became more acceptable because young people could relate to these people. Now, it’s so common in high schools that teens are more willing to disclose their self-injuries to their friends, and their friends often see it as “that thing that people do” if they’re unhappy, as a temporary coping mechanism. We see this behavior as highly “socially contagious”—the media, along with word of mouth, has contributed to its spread.

In The Tender Cut, we describe how media coverage of celebrities who self-injured, the accessibility of the Internet, and shifts in cultural norms made it possible for loner deviants to join Internet self-injury subcultures. These subcultures represent a range of levels of acceptance of self-injury and often help people to realize that their behaviors do not necessarily mean that they are mentally ill or bad people. This helps them manage the stigma of society judging people negatively for relieving emotional pain by inflicting physical pain on themselves. Our longitudinal data shows that many who began self-injuring as teenagers eventually outgrow it and lead functional lives.

Is the legality of abortion in the U.S. a moot point if too few ob-gyns are willing to perform the medical procedures?  A recent post on FREAKONOMICS inspired me to find out more about a new article in the journal Obstetrics & Gynecology titled “Abortion Provision Among Practicing Obstetrician-Gynecologists.”

This group of researchers mailed surveys to practicing ob-gyns and reported on the data from 1,800 who responded. The article’s main findings are as follows: “Among practicing ob-gyns, 97% encountered patients seeking abortions, whereas 14% performed them.” Their analysis of the data revealed that male physicians were less likely to provide abortions than female physicians. Age was also a factor, with younger physicians being more likely to provide abortions.

The new article’s abstract states, “…physicians with high religious motivation were less likely to provide abortions.” I wonder if the large numbers of ob-gyns who do not provide abortions speaks to moral judgments that this medical procedure is a sin. So, the legality of abortion may be rendered pointless by physicians who may be making decisions based on religious doctrine? Access to abortion remains limited by the willingness of physicians to provide abortion services, particularly in rural communities and in the South and Midwest.” Does a woman’s geographic location doom her to restrictions on her ability to obtain a medical procedure that is protected by law?

During my study of women and men living with genital herpes and HPV/genital warts infections, I coined the term moral surveillance practitioner to describe the doctor-patient interaction style of health care providers who conveyed a sense of disapproval, judgment, condemnation, and even disgust to their patients who had sought their sexual health services.  In the case of STDs, these practitioners tended to blame their patients for having contracted a medically incurable infection because of their own “bad” and sinful sexual behaviors.

It would be interesting to see if a companion study to the newly published one, perhaps a qualitative interview study, would reveal a more nuanced understanding of the attitudes and values that ob-gyns hold about their female patients who seek abortion services.  With women’s physical and/or mental health often hanging in the balance of the ability to receive a legal abortion, we deserve to know more about the large number of ob-gyns whose moral opinion may be taking precedence over their ethical obligation to, in the words of the Hippocratic Oath, “First, do no harm”…in this case, to do no harm to their female patients who may be harmed by not having a medically safe, legal abortion.

__________

Note: If you’re curious about physicians’ insights and experiences in providing (or not providing) abortion care, then check out two recent books: Carole Joffe’s Dispatches from the Abortion Wars: The Costs of Fanaticism to Doctors, Patients, and the Rest of Us and Lori Freedman’s Willing and Unable: Doctors Constraints in Abortion Care. And, for more of the latest research on reproductive health care and policy, explore the work of UC San Francisco’s reproductive health think tank ANSIRH.

Okay, I’ll admit it – ever the STD researcher, I was tempted to focus on the recent NYT article, “A Vaccine May Shield Boys Too.”* Instead, I dedicate this month’s column to a recent news item that has not attracted a lot of attention: the FDA issued an advisory warning against the use of mesh implants that are routinely used for surgical repairs of pelvic floor damage.  Warning: This post contains medically accurate language which some readers might find disturbing. (It also contains new medical findings that all readers should find disturbing!)

First, it’s important to know what the pelvic floor is and what functions it serves: in addition to this image from 1918’s Gray’s Anatomy, check out a newer medical illustration included in a recent LA Times article.  This muscular structure has the demanding job of supporting the uterus, bladder, urethra, the walls of the vaginal canal and rectum. In other words, it’s pretty darn important.  Without functional pelvic floor muscles, women can experience urinary incontinence, fecal incontinence, and uncomfortable/painful sexual intercourse.  (Not to mention, it’s more than a little disconcerting to have to manually push your prolapsed organs back into place.)

Surgical repairs of this type of damage are often done to correct prolapses of the uterus and surrounding organs which, to put it bluntly, can feel “as if something is falling out of your vagina.”  The problem is that the mesh devices used in many of these surgeries may be harming the sexual and reproductive health of many of the tens of thousands of women who have surgery each year for prolapse.

You might be wondering, how many women are at risk for pelvic organ prolapse?  Cigna say the top risk factors are full-term pregnancies (which stretch the pelvic floor), the strain of childbirth, and having a hysterectomy (surgical removal of the uterus).  On a recent episode of his TV show, Dr. Oz shared the estimate “almost 50% of women will experience some form or prolapse in their lifetime.”

Thousands of women opt for prolapse surgery every year, and many of these surgeries have involved the use of mesh implant devices to support torn/damaged pelvic floor tissue.  As noted in a July 14^th LA Times article, “The advisory was issued after an increase in reported complications involving the device.”  This article also describes complications as including “pain and urinary problems,” as well as, “erosion, when the skin breaks and the device protrudes, and contraction of the mesh that leads to vaginal shrinkage.”  Back in 2008, the FDA’s Public Health Notification and Additional Patient Information documents cited 1,000+ reports of these kinds of serious complications but considered them to be rare.  Fast forward to 2011 when these serious complications “have jumped fivefold,” no longer rare.

So, how does this impact a woman’s sex life?  The FDA notes, “Both mesh erosion and mesh contraction may lead to severe pelvic pain, painful sexual intercourse or an inability to engage in sexual intercourse.”  And, male partners of these women are also at risk: “men may experience irritation and pain to the penis during sexual intercourse when the mesh is exposed in mesh erosion.” 

With the FDA deciding to not remove the mesh implants from the market, did they do enough to protect patients?  Some experts say, “No.”  Dr. Diana Zuckerman of the National Research Center for Women & Families points out that these mesh implants have been used, “despite no clinical trials, no testing on humans to see if they’re actually safe and effective.”  It is time to advocate strongly for research and development of pelvic floor surgical repair techniques which do not involve the use of synthetic mesh implants.

__________

*This article sheds very little new light on a topic I wrote about over a year ago forMs. Magazine and blogged about back in 2009 – Gardasil is not simply the ‘cervical cancer’ vaccine its initial branding advertised; it also offers several potential health benefits for boys and men. 

In honor of April being STD Awareness Month, I devote this month’s column to a topic that remains near and dear to my heart (and my cervix): HPV, human papillomavirus.  So, it’s a great time to get yourself tested at your local STD testing location, or send an e-card to a loved one who could use a friendly reminder:

This month might have inspired some of you to consider vaccines that offer some protection against HPV: like Gardasil or Cervarix.*  However, don’t get too excited about Gardasil if you happen to be 27 years old (or older) and live in the U.S.  Earlier this month, the FDA decided against expanded the vaccine’s label use for ‘older’ women:

…the Limitations of Use and Effectiveness for GARDASIL was updated to state that GARDASIL has not been demonstrated to prevent HPV-related CIN 2/3 or worse in women older than 26 years of age.

However, as of Tuesday, ‘older’ Canadian women now have more options than their U.S. counterparts:

Merck announced that Health Canada has extended the indication of GARDASIL^® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Recombinant Vaccine] in women up to the age of 45. Merck’s HPV vaccine is now approved for girls and women nine through 45 years of age for the prevention of cervical cancer, vulvar and vaginal cancers, precancerous lesions and genital warts caused by the Human Papillomavirus (HPV) types 6, 11, 16, 18.

So, what’s the deal?  According to a Canadian women’s health expert, this is a good decision:

Whatever the reason, there’s a tendency for women to remain at risk of acquiring new HPV infections as they get older. Whether they are changing their social status or not, women should talk to their doctors about the HPV protection provided by the quadrivalent vaccine,” said Dr. Alex Ferenczy, Professor of Pathology and Obstetrics & Gynecology at McGill University.

If I’m correct in inferring that Dr. Ferenczy’s use of the phrase “social status” refers to a woman’s sexual partner/sexual relationship status, then are we to assume that U.S. women between the ages of 27 and 45 are in more stable sexual relationships than their Canadian counterparts?  I’ve yet to read a study that would support this conclusion.

So, as a U.S. woman who happens to be in this age group, I feel it only right to encourage my peers to ask their doctor about Gardasil, especially if they’re “changing their social status.”

For the boys and men out there, remember that the FDA approved Gardasil in October 2009 for protection against two types of HPV which cause genital warts in males ages 9-26.  Then, last December, the FDA approved of GARDASIL for the prevention of anal cancers caused by two different types of HPV in females and males 9-26 years old. 

However, once again, there appears to be possible age-discrimination: men over 26 years old, consider whether Gardasil might offer health benefits for you.

*Note to readers: I respect that many will decide that a vaccine is not right/healthy/safe for themselves or for their family members.  I highlighted the recent news about Gardasil because I believe that everyone deserves access to vaccine updates.  I’ll conclude by quoting myself:

I don’t know if the pro- and anti-vaccine folks will ever see eye to eye, but there’s absolutely nothing to lose and everything to gain by being pro-HPV-education.

Yesterday marked the one-year anniversary of President Obama signing the Affordable Care Act.  I encourage everyone to become familiar with what the Act has already accomplished, as well as the plans through 2015 (see an interactive timeline online).

Today, I dedicate this month’s column to reflecting on one of the new consumer protections that is scheduled to become effective January 1, 2014, No Discrimination Due to Pre-Existing Conditions or Gender:

Before the Affordable Care Act became law, insurance companies selling individual policies could deny coverage to women due to pre-existing conditions, such as cancer and having been pregnant. 

A WhiteHouse.Gov fact-sheet describes the ways in which, “The Affordable Care Act Gives Womem Greater Control Over Their Own Health Care.”  When I first read it, even as a feminist medical sociologist familiar with health care inequities, a few lines jumped out at me:

Right now, a healthy 22-year-old woman can be charged premiums 150 percent higher than a 22-year-old man.

Less than half of women have the option of obtaining health insurance through a job.

Today, maternity benefits are often not provided in health plans in the individual insurance market.

I appreciate the many positive effects this law has on women, men and children, but I find myself asking: why did the Affordable Care Act not include this provision — to eliminate discrimination to due to gender — among its original 2010 provisions?  A comparable provision was effective as of September 23, 2010 for children:

…health plans that cover children can no longer exclude, limit or deny coverage to your child under age 19 solely based on a health problem or disability that your child developed before you applied for coverage.

Now, don’t get me wrong, I’m all for protecting children’s rights to receiving coverage.  As a mom, I understand the instinct to want to protect one’s child before one’s self.  However, it feels like the policy-makers did not take into account the body of research on the direct correlations between maternal health and child health.  To put it simply, an unhealthy mom is not good for the health of her child — whether or not her child has excellent or poor health care coverage.

For example, a 2005 article in the journal PEDIATRICS documents research findings that,

“Maternal depressive symptoms in early infancy contribute to unfavorable patterns of health care seeking for children.” 

Another 2005 article examined the psychological and physical health of adult caregives of children with cerebral palsy and found that:

The psychological and physical health of caregivers, who in this study were primarily mothers, was strongly influenced by child behavior and caregiving demands…These data support clinical pathways that require biopsychosocial frameworks that are family centered, not simply technical and short-term rehabilitation interventions that are focused primarily on the child.

It’s easy to imagine the ways in which a child’s health might suffer if her/his primary caretaker has poor mental and physical health.  And, solely providing health care to the child did not necessarily improve the health outcomes of the caregiving moms.

One more example along the lines of the effects of maternal depression is the case of pediatric asthma.  A 2007 article in the Journal of Health Economics reports a study which shows:

…treatment of mother’s depression improves management of child’s asthma, resulting in a reduction in asthma costs in the 6-month period following diagnosis of $798 per asthmatic child whose mother is treated for depression.

Our health care system will likely save more money once we end insurance company discrimination on the basis of sex/gender.  Now, I recognize that not all women are mothers, but the overwhelming majority of mothers are women.  So, if the gendered division of labors in most families remains such that moms are primarily in charge of maintaing and protecting the health of their children, then wouldn’t we want these caregivers to have access to affordable, quality health care before 2014? 

That said, I am grateful that this law passed and hope that we will continue to work on ways to strengthen coverage for all Americans.

I have said it before about sexually transmitted diseases and HPV vaccines, and now I will say it again about brain trauma and football — men’s health is a feminist issue. 

Back in 2007, a NYT article covered “Wives United by Husbands’ Post-N.F.L. Trauma” whose activism motivated the NFL creating the “88 Plan” to provide dementia benefits.  Then, in 2008, a LA Times op-ed proclaimed, “The NFL’s in denial about depression.”  This week, the NYT article “A Suicide, a Last Request, a Family’s Questions” added yet another tragedy to the growing number of media stories about the physically and psychologically devastating consequences for NFL players. 

As I read it, I found myself flashing back to when I was an undergrad and first read sociologist Michael Messner‘s academic article, “When bodies are weapons: Masculinity and violence in Sport.” What does it mean for boys and men — and for all of us — when   not only normalize but also reward boys and men for using their bodies as weapons?

Check out the abstract (bold font added for emphasis):

This paper utilizes a feminist theoretical framework to explore the contemporary social meanings of sports violence. Two levels of meaning are explored: first, the broad, socio-cultural and ideological meanings of sports violence as mediated spectacle; second, the meanings which male athletes themselves construct. On the social/ideological level, the analysis draws on an emergent critical/feminist literature which theoretically and historically situates sports violence as a practice which helps to construct hegemonic masculinity. And drawing on my own in-depth interviews with male former athletes, a feminist theory of gender identity is utilized to examine the meanings which athletes themselves construct around their own participation in violent sports. Finally, the links between these two levels of analysis are tentatively explored: how does the athlete’s construction of meaning surrounding his participation in violent sports connect with the larger social construction of masculinities and men’s power relations with women?

Mainstream U.S. society continues to validate a very narrow construction of socially acceptable masculinity.  When I teach the Sexuality and Society course at CLU, I ask my undergrad students to tell me the traits of an “ideal” man.  Each time, a new group of students generate basically the same list which includes being heterosexual, tall, muscular/physically strong, and a “protector.”  With this clear and consistent construction of masculine bodies, it’s not a surprise that the NFL continues to attract players who are willing to sacrifice their health and fans who enjoy the spectacle. 

The lure of the N.F.L. — the glory of hyper-masculinity — masks the still unmeasurable damage that these players (and their families) endure.  Their sacrifices allow ‘armchair athletes’ to vicariously revel in battles on the gridiron.  These warriors, ill-protected by sports gear masquerading as armor, are paying steep prices for embodying unrealistic and unhealthy ideals of what it means to be a man in the U.S.  

As research studies work to document the ways in which this sport consistently results in life-changing injuries (and sometimes life-ending conditions), we owe it to boys and men to challenge the status quo.  But, how can we hope to do this if, as one political science blogger suggested, “Americans have begun to construe access to football spectating as a social right“?

I’m collaborating on a study of traumatic childbearing experiences, so I’ve been thinking a lot about the types of injuries that can occur as a result of pregnancies, labors, and different types of deliveries.  My research partner forwarded me a recent blog post on a board-certified urogynecologist’s website titled “Cesarean on Demand Does Not Eliminate Risk of Prolapse.”  This post highlights the findings of a 2009 research article published in the International Urogynecology Journal. In this research, three groups of women were studied: “vaginal delivery with sphincter tear (n = 106), vaginal delivery without sphincter tear (n = 108), and cesarean without labor (n = 39).” [The numbers reflect how many women were in each of the three groups.]

Now, I’m no urogynecologist, but I found it hard to believe that c-sections “on demand” (a.k.a. without labor) would not at least reduce the risk of pelvic floor damage, including pelvic organ prolapse (pelvic organs “slipping out of place” when the supportive muscles and ligaments are weakened or torn).  Prolapse can greatly impact the health and quality of life: for example, women with prolapse may suffer one or both types of incontinence and/or painful sexual intercourse.

I recognize that many medical practitioners, authors and laypeople have come to believe we have too high a rate of c-sections here in the U.S.  Research studies, such as the one celebrated in the recent blog post, call into question whether there are any health benefits of c-sections without labor.  As a medical sociologist who teaches research methods, I consider it to be of utmost importance to discuss research findings with the highest degree of accuracy.  No study is perfect: no study is without bias and no study is without limitations.  So, I read the complete research article to find out if it truly supported the blog author’s contention that these researchers “found NO DIFFERENCE in moderate prolapse between the three groups.” 

I was struck by significant methodological flaws and limitations which, while acknowledged by the authors of the original article, were glossed over or flat out ignored by the author of the blog post.  I found myself asking several questions:

Question #1: how healthy were the women before this childbearing experience?  No one knows: the researchers admit, “our findings cannot be attributed with certainty to delivery method, since some women may have developed prolapse before delivery or pregnancy and prolapse was not assessed prior to delivery in this population.” 

Question #2: who were the women who participated in this study?  The women for this study were recruited from prior studies performed through the Pelvic Floor Disorders Network, specifically from the follow-up study to their CAPS Study (which focused on “fecal and urinary incontinence after childbirth”).  How can we rule out a self-selection bias of those women who said “yes” when they were recruited to this initial study?  Could it be certain women who had C-sections, perhaps those feeling some pelvic/vaginal discomfort immediately following delivery were more likely to say “yes” because they saw value in being interviewed about incontinence?

Question #3: did the researchers recruit enough women for each of the three groups to be able to answer their main question?  No.  The authors wrap up their article by noting that “further research would be required to determine whether cesarean delivery before labor reduces the incidence of pelvic organ prolapse.”  So, this research doesn’t actually determine anything about what they claim as their primary research question.  Why not?  The short answer is that they never got enough women to participate.  The authors claim that they would have needed 132 women per group in order to test the statistical significance of the difference in rates of stage II prolapse between those women who had C-sections without labor and those women who had vaginal deliveries.  While they got reasonably close to their sample size goal of 132 for the two vaginal delivery groups (106 and 108), they only got 39 women to participate in the C-section group.  Is this acceptable?  Statistical significance is key to evaluating any study because it means that the results are “probably true (not due to chance).”  The researchers finally own up to the likely irrelevance of their study towards the end of the published journal article: “Furthermore, our sample size was not sufficiently large to exclude a significant difference between groups.”  In plain language: they didn’t study enough women to know whether or not there are not real differences between the health outcomes for women who have c-sections without labor and those experience other types of labor and delivery.

Question #4: can the researchers say anything definitive that might help improve women’s health?  Hmmm.  The only factor they definitively connect with less pelvic floor damage is lower birth weight: I’m betting that it won’t surprise many to find out that smaller babies causes less damage.  But, what are we supposed to do with this finding? 

The author of that recent blog post dares to call it a “beautifully executed study,” and that’s why I had to wrote this post: to help those of us who are not medical researchers better understand what we should value and what we should question when it comes to research studies that can impact women’s health.

This month’s guest column* by Christine H. Morton, PhD, a research sociologist at the California Maternal Quality Care Collaborative, draws on her research and publications on women’s reproductive experiences and maternity care advocacy roles, including the doula and childbirth educator. She is the founder of ReproNetwork.org, an online listserv for social scientists studying reproduction.

The ever-evolving history of the childbirth reform movement has new developments, which need to be incorporated into the older story which documents the shift from home to hospital birth; and the paradigm clash of midwifery and medical models of birth reflecting holistic and technocratic values, respectively. We need to incorporate the story of the doula, which I argue, is one of many efforts to bridge the divide – to provide, as Robbie Davis-Floyd has called it, humanistic care in birth, which is what most women desire.

History is happening now. In addition to the emergence of the doula in the past thirty years, more recently, we see efforts underway in maternal health policy (Childbirth Connections’ Transforming Maternity Care), among physician and nursing professionals (most especially around maternal quality measures, and maternity quality improvement) and resurgence among, for lack of a better word, ‘consumers’ or childbearing women, who seek greater access to vaginal birth after cesarean (VBAC). What are the goals of each stakeholder; how do they intersect and overlap, and come into conflict with one another? This is a big story, and we need to tell it!

I take a small slice of this larger historical backdrop to consider the interconnected history of childbirth educators and doulas, which will be the subject of my research presentation at the Lamaze-ICEA Mega Conference in Milwaukee.

To back up a bit, when I embarked on my sociological investigation of the doula role, I was interested in many aspects of this innovative approach to childbirth advocacy and support. What strategies and mechanisms enabled women with no medical training to insert themselves at the site where medical care is delivered to a patient in a hospital, and enact their self-defined role? Why did women become doulas and what did the work mean for those who were able to sustain a regular practice over time? How were doulas utilizing and leveraging the corpus of evidence based research which suggested their impact was as great, if not greater, than that of the physician, the culture of the obstetric unit, or the labor and delivery nurse? Where did doulas come from? What, in the history of childbirth reform, or childbirth education, or labor/delivery nursing, could help me understand how doulas emerged at this point in time in U.S. history?

Later, after learning that there were limited histories of childbirth education (by non-childbirth educators), and little research on the history of obstetric nursing, I had to take a step back and consider these factors as well. Why was the work and perspectives of women who support other women during childbirth an overlooked piece of historical research? Why did histories of women’s health reform efforts largely exclude childbirth reform? Why had there been no history of the women who were involved in childbirth education; in labor and delivery nursing; in the mainstream arena of birth care in the US? So as not to be accused of ignoring the scholarship that does exist in this area, I acknowledge my debt to Margot Edwards and Mary Waldorf; to Judith Walzer Leavitt, to Barbara Katz Rothman, Robbie Davis-Floyd, Margarete Sandelowski, Deborah Sullivan and Rose Weitz, Judith Rooks and Richard and Dorothy Wertz (I can make my full bibliography available to those interested). I have been inspired by these histories, but they focused less on the women (childbirth educators) who were making history and more on the larger cultural shifts in beliefs about medicine, technology, women’s bodies and reproduction.

When childbirth education per se was a topic of inquiry, the research focus tended to be on the primary sources of the male physician champions – Grantly Dick-Read, whose work informed the natural birth movement, and Ferdinand Lamaze (and his US counterparts – Thank you Dr. Lamaze author Marjorie Karmel and Elisabeth Bing) who formulated a method for accomplishing unmedicated, awake and aware childbirth. However, most of this scholarship makes unsubstantiated generalizations about what particular childbirth educators (of various philosophies /organizations) believed, and how they taught. There is surprisingly little in the way of empirical research – few scholars interviewed childbirth educators or conducted systematic observation of their classes over time.

So after completing my dissertation on the emergence of the doula role, I had the great opportunity to continue with my research interest through a research grant from Lamaze International to conduct an ethnographic investigation of childbirth education, with my colleague, medical anthropologist Clarissa Hsu. We talked to educators, observed their classes and analyzed our data.

We found that educators who were actively practicing doulas drew heavily on their direct labor support experiences as authoritative resources for stories and examples that supplemented the material they taught. Actively practicing doulas also included more curricular content on early labor than educators without such experience. Having real births to draw upon provided doula-educators a different type of credibility and authority than educators without such current labor support experience. These educators relied on other mechanisms to establish their authority, such as knowledge of the latest research on birth and use of more authoritarian teaching styles.

We found that the intersection of doula practice and childbirth education has significantly affected how childbirth preparation classes are taught, and this new infusion of practice and ideology is worth exploring. I encourage you to explore this with us, and welcome your thoughts.

*Note: this column was originally posted on the Science & Sensibility blog.

For this month’s column, I had the pleasure of emailing with Chris Bobel, Ph.D. about her new book which deftly tackles a taboo topic.

——————————————-

You explore new feminist activism that focuses on menstruation. Historically, how have feminists viewed menstruation, and why menstrual activism now?

The issue of menstruation has not been a top feminist priority, though, since at least the 1970s, a few bold feminists have recknoned with socio-cultural and political dimensions of the menstrual cycle. I argue that the menstrual taboo–which impacts us all, even feminists–often puts the issue off-limits. In mainstream culture, the only menstrual discourse that gets any play is making fun of women with PMS. I studied menstrual activists who want to widen and complicate the conversation. Menstrual activism is part of an enduring project of loosening the social control of women’s bodies, moving women’s bodies from object to subject status–something absolutely foundational to addressing a range of feminist issues, from human trafficking to eating disorders to sexual assault.

What do you think of Kotex’s new ad campaign “Break the Cycle,” which lampoons traditional menstrual product ads?

The new campaign could be a game change, but I’m doubtful. First, the campaign only works as long as the menstrual taboo persists; otherwise, their frank talk doesn’t stand out, does it? While I can join in the joke of the industry poking fun at itself–and I love the message of “no more shame”–in the end, it’s the same, just repackaged.

Second, I resent this campaign for exploiting shame to sell product for nearly a centuray and then exploiting THEIR overdue pronouncement–“enough with the euphemisms, and get over it”–to sell product.

Also, you’ve got to wonder if not only Kotex but their whole industry is now pulling out all the stops to try to hold onto its market share as menstrual suppression drugs–like Seasonique and Lybrel–are gaining interest.

So, what do you think of pharmaceutical industry arguments that support these menstrual suppressants?

Their quasi-feminist arguments co-opt feminism to push drugs. Big Pharma is marketing suppression as a ‘lifestyle choice’, but what most don’t realize is that “menstrual suppression” is actually cycle-stopping contraception that does not only reduce or eliminate menstrual bleeding but also suppresses the complex hormonal interplay of the menstrual cycle. We don’t yet have adequate data to really show if this is a safe long-term practice for otherwise healthy women. Check out this position statement.

Furthermore, ad campaigns represent the menstrual cycle as abnormal, obsolete, and even unhealthy. These messages underscore that women’s natural functions are defective, dysfunctional and need medical intervention. This can lead to negative body image, especially in young women. How is this feminist? ‘Choice’ without good, fact-based information based on thorough medical studies isn’t real choice, and a campaign that exploits women’s negative attitudes about their bodies isn’t feminist either.

Your work uses menstrual activism as an analytical lens through which to view continuity and change in the women’s movement, from what some call the “second wave” of feminism through the “third wave.” So, given that the ‘wave’ distinctions are not without controversy among feminists, what do you see as setting third wave feminism apart? Is it truly unique, or is it merely a label that recognizes the next generation?

There’s a lot of continuity between the waves–mostsly in the tactical sense. Today’s feminist blogs are yesterday’s zines, which reflect earlier mimeographed manifestos; radical cheerleading recalls street theater and public protests, like early second-wavers at the 1969 Miss America pageant. Second-wavers practiced what third-wavers call DIY (Do It Yourself) healthcare when they modeled pelvic self exams. But, most third-wavers depart from most (but not all) second-wavers by troubling the gender binary. For example, the radical wing of menstrual activism movements reers to “menstruators”, instead of assuming that everyone who menstruates gender-identifies as a woman.

Tell me more about that!

Most assume that a female-bodied person, with breasts and a vulva, is a woman, and usually that’s true. We also assume that menstruation is a near-universal experience for women. Radical menstruation activists question these assumptions. Menstruation is not and has never been EVERY woman’s experience. Women don’t menstruate for lots of reasons, and they don’t menstruate their whole lives. Also, some transmen and intersex people DO menstruate. So, equating menstruation with womanhood is problematic. Saying “menstruators” makes room for more people, more experiences. This linguistic move is boundary smashing, inclusion-in-action and bodes well for feminism’s future.

But, you’ve written that menstrual activists are not successful at all attempts at inclusion.

The first face of the feminist movement may have been white and middle class, but poor white women and women of color across the class spectrum have always been there, often toiling in relative obscurity. This could be the case with menstrual activism, too. However, I’m a white, privileged academic, and this biases my world view. I looked for women of color doing this work and found a few. But, was I looking in the right places? Was I using the right language? One activists of color said that I was likely missing Black women because I wasn’t clarifying how race and gender intersect in menstrual health. Also, menstrual activism is risky business for all, and especially for women of color, whose bodies have been denigrated throughout history. Taking on the menstrual taboo can make others see you as nasty, gross, improper…and if you’re already struggling to be accepted and taken seriously, then why go “there”?

Well, I and many other women’s health activists appreciate that you ‘went there’!

——————————————-

For more on this topic and her research, check out Chris’s new book — New Blood: Third-Wave Feminism and the Politics of Menstruation (Rutgers University Press, 2010), previewed in the Our Bodies, Ourselves blog and in a provocative article in the Guardian last fall.

Health posts are my thing, and today I cannot stop thinking about the health of the Gulf Coast…which clearly impacts the health of more living creatures than we can fathom.  News coverage may talk about bodies of water like they are distinct things, but ‘the Gulf’ is merely a cartographer’s distinction.  It’s hard to watch the live feed of the endless spray of oil shooting into the ocean.  It feels like watching a massacre, like a spray of machine-gun bullets ending life after life.  Calling this catastrophe a “spill” is like calling an amputation a “boo-boo.”    And, frankly, I can think of nothing more important to write about for this month’s column. 

So, allow me to compare our planet to a patient, a very ill patient who has suffered a severe injury and is receiving really crappy medical care.  Or, let’s take it to a more intimate-level: we can anthropomorphize one affected area, the Mississippi Spillway, as the vulva of the U.S.  One of my favorite sociologist bloggers, Mimi Schippers, Ph.D. (a.k.a. Marx in Drag), did just that in a post where she calls British Petroleum (BP) a pimp — and not the MTV/”pimp my ride”/bling-bling/Snoop Dogg kind of pimp.  No, we’re talking a stone cold, cruel, exploitative, abusive, criminal.  In the words of Dr. Schippers:

 BP and the rest of the oil industry are the johns and the federal government is the pimp.  Federal, state, and local politicians pimp us out to put money and power in their own pockets while, by paying the right price, Big Oil gets to take what it wants and needs.  And they-the pimp and the johns, do so with absolutely no regard for the needs or well-being of the body they use.  The body—the living environment, including the people—is, however, a breathing entity.  And though it appears as if it is just an object to be used, the people know what they are doing.  They strike a bargain that, for the moment, benefits themselves but sacrifices the rest.  You give me jobs, and I’ll give you whatever you want.  Invoking the vulva as metaphor suggests there is something feminine or female about this place and that masculine or male power is the problem.  But don’t let that confuse the issue.  This is about class and economics. 

Whether you prefer to see the U.S. government as an incompetent physician (allowing a patient to inch towards death) or as a corrupt police officer (being too kind to a felon), we have got to ramp up our demands for swift, safe, effective action.  And, perhaps, we need to think seriously about how to safely shut-down all of the deep-water drilling before the next tragedy.  All the money in the world cannot buy a healthy ocean.  Even if this torrent of BP oil is the last one we ever have to deal with, don’t think that we’re close to knowing how bad things really are..in the words of that 70’s BTO classic:

Here’s somethin’ that you’re never gonna forget. B-, b-, b-, baby, you just ain’t seen na, na, nothin’ yet!