*Trigger Warning for Survivors of Obstetric Violence*
There is no excuse for abuse. Abuse is abuse. To eliminate abuse, it is helpful to understand what breeds and enables it.
Recently, I posted on the Birth Monopoly Facebook page about healthcare workers sometimes performing procedures like cervical checks on sleeping women, triggering a thread of outraged comments. Soon after, I got an email from a practicing obstetrician who had seen my post and offered to tell me “why doctors do a lot of the terrible things they do.” She hits the nail on the head, and physician trauma has a lot to do with it. Medicine is a culture of trauma, where well-intended folks are immersed in abusive training, traumatized both in training and practice, and then expected to care for others with no support or treatment for their own wounds.
Obstetric violence occurs on both an individual and a structural level. Physician trauma is an aspect of a breakdown on the individual level that enables the structural violence.
Physician Trauma Breeds Patient Trauma
Here’s what the obstetrician said in her email:
Why would a doctor do cervical exams on women who are sleeping? The reason is the same for why doctors do a lot of the terrible things they do–because of the culture of medical training. For example, during residency, we had to check EVERY patient EVERY two hours, with rare exceptions. If we missed a check, we got in trouble. You could be yelled at, berated, punished with extra work, whatever. Now, when you start residency, you pretty much know nothing. You may not have ever even checked a cervix. The inadequacy you feel is overwhelming. You are called “Intern”, not doctor and not by your name. Lots of crying and hiding in stairwells. You are working 80 hours a week, with 24 hour shifts where you are going non-stop. You are given this instruction to perform these checks, without fail, every time. No one tells you to check the patient while they are sleeping, but the message is (either indirectly or directly), “Do what you are told, or I will make your life hell.”
So you go in and a patient you’ve never met before is sleeping after some IV pain meds. You try to wake her up and tell her you want to check her cervix. She might moan or stir but she certainly doesn’t wake up. What do you do? If you don’t have a cervical exam to tell the team, you will pay. She knew we were going to check her cervix, right? She understood that when she came into the hospital, right? So you do it to save yourself. She loses her humanity because you’ve lost yours. And by the end of four years of that culture, you’ve forgotten. You’ve forgotten that you can wait. That you won’t get in trouble, or get yelled at. That there is a person that belongs to that vagina. So you just keep doing it.
I totally understand traumatized women not wanting to see their doctors as victims. My mother (non-medical) tells me that no one feels sorry for doctors. Our income is too high. I think it is true and it is a shame, because behavior like this is the result. 400 physicians kill themselves every year. That’s the entire class of four medical schools gone every year. Our healers are hurting. People who are treated like shit treat people like shit. The abused become the abusers, you know?
I think it is important to emphasize that just because we trained that way, it is still NOT acceptable to behave in that way. I think it should still be discussed in the context of how we fix this problem. Our training and the lack of support following bad outcomes are the two areas that absolutely will have to change if we want to make progress. There are a ton of other issues facing physicians (liability, burnout, etc), but I think those two are the most important when we are talking about respectful treatment of patients and patient autonomy.
None of this will change until our training changes.
Another obstetrician, Dr. Jesanna Cooper in Birmingham, Alabama, talks about her own trauma as a provider in Birth Allowed Radio episode 6.
Among the two biggest group of people caring for women and babies during birth, the rates of suicide, PTSD, and burnout are astronomical. Physicians are also facing litigation trauma (three out of four obstetricians will be sued in their careers), while nursing has the distinction of being the “most bullied profession.” Horizontal violence–hostile behaviors among members of a marginalized group–is well documented within nursing. (Horizontal violence is also prevalent in midwifery and doula work.) I talk about physician trauma and nurse trauma in my new online course, Know Your Rights: Legal and Human Rights in Childbirth for Birth Professionals and Advocates, as one of the big factors affecting how we are treated as patients during birth. People with major deficits of their own around self-care and mental health are not in an optimal position to care for other vulnerable people in high-pressure situations.
Circle of Trauma in the Birth Room
I created this conceptual image for a talk I gave to several obstetric departments earlier this year as an illustration of all the trauma that may be coming into the birth room–most of which people are probably unaware they are carrying or how it affects their attitudes, behaviors, and words.
I want to thank this anonymous doctor and Dr. Cooper for being honest about their own experiences and the impact on their practice. We can’t fix a broken system without understanding exactly what’s broken. And as difficult as it may be to conceive of abusers as victims themselves, the reality is that victimization and abuse are not opposite ends of a spectrum; they are intertwined with each other. In maternity care, this is a crucial piece of the bigger picture.
Are you a physician or nurse who can relate? Comment below.
Would you like to share your experience on air (anonymously)? Contact Birth Allowed Radio.
All of these things are true, but there is a big piece of the puzzle missing. There is incredible peer pressure and regulatory board pressure not to rock the boat. Those of us who do support the choice and autonomy of our clients face a constant barrage of complaints filed by doctors in peer review committees, loss of hospital privileges, and medical board action. If you opt out of that system you under even more scrutiny as hospital-based “colleagues” file complaints with medical boards knowing they will trigger investigations which take months, often years and result in loss of privileges, public humiliation, and ultimately loss of license.
I became a physician later in life precisely because of an interaction my family had with the medical system. I became an obstetrician because I fell in love with supporting and empowering women at a very vulnerable time in their lives, only to discover that Obstetrics was the worst abuser of women in all of medicine. I am facing two board investigations right now, and though I have fought and prevailed over many, many more, all instigated by doctors, I am worn out and ready to retreat and take care of myself. Hopefully, after some time to heal, I can contribute in other ways to pry open the obstetric culture and expose the abuse and disrespect of women and those who choose to support them with evidence and information.
The outrage against obstetrics is real and fully justified, but when you find people who are doing the right thing, it’s crucial to understand the tremendous pressures they are under and support them with more than an occasional facebook post. And be aware that there are many obstetricians and family docs who understand the problem and support our positions in private but justifiably fear the loss of their lives and careers if they rock the boat.
The work you are doing is more important, but also more difficult than you know.
I am a registered nurse of 9 years. The first time I experienced face to face abuse from i coworker i was just stunned. I couldn’t wrap my head around how she could do this to me 1. Because she was actually a friend before we worked together. And 2. The was literally no amount of respect or dignity left for me, she didn’t act like she had any respect for me as a person, much less a colleague. Someone who had the same degree in my head as she does. And the fact that she minimalized her behavior towards me, with other peers, is really not that surprising. We hear the phrase “nurses eat their young” in school and i think, why would you go in to a field that relies so much on empathy, sensitivity of you cannot treat a minor disagreement as just that. (I know for a fact that i was right in this instance about a medication taper, my bodd reaffirmed that to me. But she shouldn’t have had to “clean up” my coworker’s mess.”
I have experienced very abusive relationships in the labor and delivery area of acute care hospitals particularly in the United States. I am a Canadian trained Nurse Leader now in the United States and I will agree that the abuse that is permitted by facilities is unacceptable and results in many retention issues among the nursing staff. More nurses are also leaving the profession….it’s just not worth it anymore. Certain geographical areas and private hospitals have more abusive relationships than others. If you speak out you are ostracized or labeled as “emotional” by hospital administrators who want to bury their heads in the sand instead of dealing with this issue…..I am guessing it’s because they would rather ignore it than deal with it because they don’t know how to fix it.
I find it interesting that the suicide rate for OBs is characterized as high. And that the reasons for that high suicide rate is externalized to job pressures and abusive training. I too have experienced obstetrical violence but that is a story for another time. I will offer that I was 100% cogent when it happened and knew exactly what was going on at all times. The ugliness I encountered wasn’t “work pressure” or the results of “abusive training.” I submit that the high suicide rate among OBs is not due to externalized factors but rather due to mental health issues that were likely present before they entered medicine. Their attraction to such a field probably warrants examination, as this is a field that permits such unfettered access to women’s bodies while also permitting myriad opportunities to abuse women. This can’t be normal, although their “medical” behavior has been normalized in the context of “accepted practice.”