Abstract
This paper addresses epistemic aspects of the phenomenon of obstetric violence—which has been described as a kind of gender violence—mainly from the perspective of recent theories on epistemic injustice. I argue that what is behind the dismissal of women’s voices in labor is mainly how the birthing subject, in general, is conceived. Thus, I develop a link between the phenomenon of testimonial injustice in labor and the marked irrationality that is seen as a core characteristic of birthing subjects: an irrationality that appears to be always at odds with the kind of knowledge that is, wrongly, privileged within medicalized childbirth. I use Miranda Fricker’s analysis to argue that a central part of obstetric violence involves laboring women being “wrongfully undermined specifically in their capacity as knowers” (2007: 9): they are disbelieved in the labor room because of a double prejudice, one deriving simply from their condition as women, the second involving the kind of knowledge that many women find useful in the process of birthing. Women in labor thus suffer from both systematic and incidental kinds of testimonial injustice.
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Notes
This discussion inserts itself in a recently developing broader feminist theorization of violence generally and gender violence in particular. Intention has frequently been considered a necessary part of violence properly defined (Landau 2010). More recent conceptualizations, however—mainly feminist ones, infused with Foucauldian interpretations and often also heavily relying on phenomenological accounts—discuss violence as pervasive within modern capitalist, patriarchal societies, where embodied subjects are dominated and disciplined through “invisible” violence, often normalized and perpetrated with no clear intention on the perpetrator’s part and not necessarily including physical harm (Butler 2004, 2020; Mardorossian 2014; Murphy 2012; Taylor 2018). The very invisibility of this violence is problematic, making it hard to recognize even for its victims. This raises important philosophical problems—ontological, epistemological, and ethical—that current theories of violence address. These theorizations make it clear that violence always demands to be discussed in the context of power relations and the epistemic obstacles to recognizing it. The research is far from complete; this paper contributes to the particular discussion of testimonial injustice as epistemic violence, within the broader phenomenon of obstetric violence.
I use “women” here throughout. Although trans men also give birth, women are the most common birthing subjects; the specific case of birthing trans men, who surely suffer from similar but also more hideous forms of oppression, requires further research. Bettcher’s discussion (2007) of transphobic violence as partly originating in the stereotype of trans people as “deceivers” will be a good place to start thinking about the testimonial injustice experienced by birthing trans men.
For more on labor as an event where women are seen as less rational, more animal, and less in control than the patriarchal narrative already considers them, because of the centrality of their uteruses and reproductive systems in this event, see, for instance, Villarmea (2020); Villarmea and Kelly (2020). I will return to this argument and its consequences for epistemic authority in childbirth.
Dismantling this privilege does not necessarily lead to an infinite plurality of discourses, each possessing equal validity. The difficult paths that must be followed to erode power structures to obtain plurality without falling into absolute relativism, already widely discussed by feminist epistemologists, are beyond our scope here. See, for instance, Hartsock (1983); Alcoff (2008); Code (2008); Harding (2008).
Fricker sees this particular credibility excess as a burden for the doctor—contrary to most cases, where credibility excess constitutes an advantage. Fricker’s example is problematic in assuming that the GP is “forced” to respond to his patients’ questions, even if he does not know the answers, or his patients’ trust in him will be diminished. I consider it possible and desirable to imagine a doctor-patient relationship not based on blind trust in medical knowledge and authority, where doctors can reveal their (partial) ignorance and in the process gain more, rather than less, trust and respect from their patients.
On female reproductive processes conceived as risky, dangerous, and pathological within the medicalized discourse, see Martin (1987); Wagner (2001); Katz Rothman (2014); Zacher Dixon (2015); White and Queirós (2018). Zacher Dixon (2015) suggests that the framing of female reproductive processes as medical problems contributes to the conception of normal birth as inherently dangerous, requiring constant medical surveillance and technological intervention:
Once reproductive processes are defined solely in terms of medical problems, scholars argue, they must be managed and treated with biomedical interventions.... As technological intervention into all reproductive processes proliferates, “normal” reproduction becomes classified increasingly as a dangerous throw-back that could detract from women’s ability to achieve perfection as feminine bodies and mothers. In fact, what counts as normal is itself being redefined, as Davis-Floyd and Dumit (1998: 9) point out, for example, technology in childbirth has become so naturalized that now a hospital birth with any number of biomedical interventions is being called “natural,” in opposition only to cesarean births. (Zacher Dixon 2015: 441f.).
On “too much too soon” versus “too little too late,” see Miller et al., (2016).
See also Martin’s account (1987) of the birthing body in medicalized settings becoming itself a machine to be “fixed” by doctors, using new technologies.
Villarmea (2020, 2021) shows how the supposed irrationality, animality, and lack of control of female reproductive organs generally and the uterus in particular were used throughout.
Enlightenment medicine and philosophy to justify women’s general incapacity for rational thinking or reliable decisions.
Facebook pages such as “The Positive Birth Movement” and “They Said to Me” feature dozens of testimonies by women, mainly from the United Kingdom, who were systematically and pervasively distrusted in childbirth: “They said to me I wasn’t having contractions would not believe me in 3 occasions sending me home with no examination, nothing. 4th time I could no longer tolerate the pain again I wasn’t believed so I asked them put me on the baby monitor” (“They Said to Me,” Facebook, February 23, 2021).
Serena Williams’s experience was another famous case of obstetric racism as testimonial injustice: Williams insistently reported her severe postpartum condition to medical staff, but they disbelieved her until she was close to death (Dawes Gay 2018).
Edwards’s argument (following the more general argument of the body as a legitimate producer of knowledge and critiquing the mistaken belief that only a purely rational, disembodied mind can produce reliable knowledge) is enriched by renowned phenomenological accounts presenting the embodied subject, or lived body, as itself producing meaning and knowledge. This challenges Cartesian understandings of the body as a lifeless “machine” at the disposal of consciousness, and of subjectivity and agency residing mainly in the disembodied mind—understandings that reinforce dualistic models implying a passive body versus an active consciousness. Merleau-Ponty’s (1995) theory of embodiment as meaningful in its own right, as well as feminist phenomenological accounts (for instance, Beauvoir’s [1948] and Young’s [1980]) of subjectivity as intimately embodied and ambiguous (constituted by both flesh and consciousness), provide rich possibilities for future exploration of the rejection, within medicalized labor, of the knowledge produced by the body and its fleshly experience.
Women’s voices are more trusted in non-medicalized childbirth settings. Jordan contrasts American medicalized childbirth with the midwife-led childbirth that occurs in the Netherlands: within less hierarchized childbirth scenarios, the woman (or the midwife, after consulting with the woman or checking on her state) usually gives the cues for when to start pushing, for instance. There is no need then to “wait for the doctor,” as Jordan puts it, quoting Kirkham, since the birthing woman’s voice is not systematically undervalued: “Midwives... by contrast, actively listened to the woman. Such listening is rare in most hospital settings because the staff's primary responsibility appears to be listening to and waiting for the doctor” (1997: 75f.).
On unassisted births as strongly defying medical authority, a form of resistance to “bio-power,” and on the stigmatization and persecution by medical and legal institutions and society in general of the women who choose them, see Chasteen Miller (2012).
Martin describes this “essentialist” rhetoric about natural childbirth and the dangers of an anti-feminist backlash that it might nurture:
In Odent’s view, birthing women are perceived as moving back in time and down the evolutionary tree to a simpler, animal-like, unselfconscious state. This assessment must be viewed in light of the historical exclusion of women from “culture”—that higher activity of men.... It is ironic that Odent’s efforts to give birthing back to women occur at the cost of reasserting a view of women as animal-like, part of nature, not of culture. Even though Odent has been made a hero by many birth activists in this country, we would do well to realize that his views share a lot with those of nineteenth-century writers who relegated women to the “natural” realm of the domestic. (1987: 164).
For more on problems around the constructed concept of “natural childbirth,” as well as an alternative to these through existentialist and phenomenological feminist theories, see Cohen Shabot (2017b).
Other recent studies based on interviews with women postpartum (Hall et al. 2018), as well as on plasma oxytocin levels as coincidental with certain specific subjective childbirth experiences, strengthening the hypothesis that childbirth constitutes a psycho-socio-neurological event (Olza et al. 2020), equally suggest that women going through respected and undisturbed physiological labor experience fluctuating states of consciousness similar to those described in Dahan’s work on the “birthing brain,” and that they manage to labor more effectively in consequence. It is important to stress in this context that Dahan’s investigations constitute theoretical hypotheses and not empirical evidence. As she makes clear in her most recent essay on the “birthing brain” (Dahan 2021), the states of consciousness present in childbirth still constitute a lacuna in neuroscience since women’s brains during childbirth have not been empirically investigated. Theoretical hypotheses about the brain states of birthing subjects and their recognition as part of women’s efficient knowledge while laboring, however, urgently call for empirical research on consciousness during childbirth. Such research, if it confirms these hypotheses, could be very helpful in making a convincing case to medical staff that they should recognize, actively legitimize, and support these modified states of consciousness as productive and as providing “true knowledge” during labor. Even with the current lack of that particular empirical evidence, however, Dahan’s studies (especially Dahan 2021) do allow us to conclude that since the empirical evidence demonstrates that the pregnant brain and the postpartum brain present multiple alterations coinciding with the state of “transient hypofrontality” and its already discussed features (such as diminished rationality and diminished inhibition), it would be at least questionable to assume that precisely during childbirth (the brief period between pregnancy and postpartum) those alterations would suddenly disappear and women’s brains completely return to their “normal state”—rather than hypothesizing that the “birthing brain” most probably behaves similarly to the “pregnant brain” and the “postpartum brain” that immediately precede and follow it.
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Acknowledgments
I am deeply grateful to the two blind reviewers of this article for their valuable comments and recommendations - I believe they made this research a much better one. I also want to thank Orli Dahan for her illuminating insights and her support. I thank all the wonderful participants of the Feminist Perspectives on Gendered and Sexual Violence virtual Working Group for their helpful inputs while I was working on the paper's major revisions. Lastly, I thank Marie F. Deer for her helpful comments. This research was supported by the Israel Science Foundation (grant No. 328/19).
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Cohen Shabot, S. “You are Not Qualified—Leave it to us”: Obstetric Violence as Testimonial Injustice. Hum Stud 44, 635–653 (2021). https://doi.org/10.1007/s10746-021-09596-1
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DOI: https://doi.org/10.1007/s10746-021-09596-1