Breastfeeding professionals and the practice of testimonial silencing

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When I was a third year medical student, a surgery resident on my team hit on me.

It was exceedingly unpleasant and rather surprising since I made it clear that I was happily married. That didn’t deter him from making a suggestive phone call at 2 AM waking me from sleep in the on call room adjacent to his.

The next morning I reported his behavior to the Director of Surgery who immediately declared: “That didn’t happen!”

Imagine if the scientific literature were filled with papers referring to sexual harassment as “perceived sexual harassment”.

When I insisted that yes, indeed, it had happened, he announced that he was sending me to a psychiatrist to find out what was wrong with me; henceforward I would be viewed as a trouble maker.

The Director was engaged in a form of epistemic injustice known as testimonial silencing.

Every day breastfeeding professionals do the same thing to women who experience breastfeeding complications.

According to the Wikipedia article about epistemic injustice:

The term was coined by Miranda Fricker in 2007 …

In Fricker’s 2007 book Epistemic injustice: power and the ethics of knowing, she defines two kinds of epistemic injustice: testimonial injustice and hermeneutical injustice… [T]estimonial injustice occurs when someone’s knowledge is ignored or not believed because that person is the member of a particular social group … A hermeneutical injustice occurs when someone’s experience is not understood (by them or by others) because there are no concepts available that can adequately identify or explain that experience.

My report of sexual harassment was not believed because I was a woman. I was immediately pathologized as a liar and labeled a troublemaker.

Breastfeeding professionals routinely treat women with breastfeeding complications exactly the same way. They aren’t believed; they are pathologized and they are viewed as trouble makers.

Tactics of testimonial silencing include: erasure from breastfeeding literature, refusal to believe, pathologizing, claiming “lack of support,” disparaging women’s stories and banning from social media feeds.

1. Breastfeeding professionals erase women who experience physiological complications from the breastfeeding cannon.

Although breastfeeding complications are common — insufficient breastmilk alone is experienced by up to 15% of women in the days after birth — the breastfeeding literature routinely ignores reality in favor of fantasy, claiming falsely that breastfeeding complications are rare.

It’s the equivalent of insisting that sexual harassment in the workplace is rare. If you’ve been taught that sexual harassment uncommon, you are unlikely to look for it, recognize it or know how to deal with it. Your first response may be: “That didn’t happen.”

The same thing applies to breastfeeding professionals and complications. When you are taught they are rare, you are unlikely to look for them, recognize them or know how to deal with them when they occur. The first response when faced with breastfeeding complications is often: “That’s not what’s happening.”

It would be difficult to overemphasize the impact of the erasure of breastfeeding complications from the breastfeeding literature. It serves as the proximate cause as well as the justification for the testimonial silencing that follows.

2. Women aren’t believed.

Imagine if the scientific literature were filled with papers referring to sexual harassment as “perceived sexual harassment”. The implication would be that women who report sexual harassment at work cannot be believed; they must have “misperceived” the interaction. Only others can judge what “really” happened because a woman’s judgment is not reliable.

The breastfeeding literature is filled with papers referring to insufficient breastmilk as “perceived insufficient milk.” The implication is that women who report insufficient breastmilk cannot be believed; they must be “misperceiving” their babies cries of hunger. Since women’s judgment can be dismissed out of hand as unreliable, only breastfeeding professionals can judge what “really” happened.

3. Women are pathologized.

The first response of breastfeeding professionals to women who report complications is to pathologize the reporters. At best, reporters are pathologized as incorrect in their assessment and not trying hard enough to make breastfeeding work. At worst, they are pathologized as lazy, selfish women who are looking for an excuse not to breastfeed.

Since breastfeeding complications are supposedly so rare as to have been nearly erased from the professional literature, those who report them must have sinister motivations in making claims that can’t be true.

4. “Head patting”

There are many ways to ignore and undermine women’s claims while pretending to take them seriously. In the case of breastfeeding complications, head patting takes the form of claiming “lack of support.” Breastfeeding complications are routinely dismissed by insisting that women just need more breastfeeding support.

Tell lactation professionals that breastfeeding is painful and they’ll insist that it wouldn’t be painful if you had received support.

Tell lactation professionals that your nipples are cracked and bleeding and they’ll claim that wouldn’t have happened if you had received more support.

Tell lactation professionals that you don’t produce enough breastmilk and they’ll tell you that you would be producing enough if only you had the correct support.

5. Disparaging women’s stories of complications.

You can’t make this tactic any clearer than Prof. Amy Brown did in her horrible piece Here’s Why You Should Ignore Those Breastfeeding Horror Stories:

Try not to pay too much attention to breastfeeding horror stories. People like to share stories – it makes them feel better – without thinking about the consequences for you.

Women claim they experienced breastfeeding complications? Just ignore them!

6 Banning from social media feeds.

Amy Brown is a master of another tactic of testimonial silencing, banning those who report breastfeeding complications from her social media feeds. She is hardly alone in making her social media “complication free.” No doubt she and her colleagues would justify it as deleting and banning trolls. But what does it say about them that they view women who have suffered and whose babies have suffered as nothing more than trolls? It’s no different from labeling women who report sexual harassment as trolls.

Social media banning completes the practice of testimonial silencing begun by the erasure of women with breastfeeding complications from the scientific literature.

Women are no longer willing to go along with the testimonial silencing of sexual harassment. In my case, the dean of my medical school believed me, although he told me that the best he could do was to get the resident transferred to another surgical team without any acknowledgement of what had happened.

It was hardly a good result, but I never forgot that when institutional forces were trying to silence me, someone in authority believed me and fought for me.

Women who experience breastfeeding complications are no longer willing to go along with the testimonial silencing — erasure, refusal to believe, pathologizing, claiming “lack of support” disparaging women’s stories and banning from social media feeds — at the hands of breastfeeding professionals.

I hope they know that I believe them and will continue to fight for them.

  • Volyund

    Somewhat unrelated, but with all of the concerns I see on other forums along the lines “I don’t think my baby is getting enough milk”, why don’t more moms weight the baby and verify? When I was concerned I just weighed my baby before and after feeding on a kitchen scale (I put a cutting board on top, and then baby on the cutting board). It was easy enough, and told me that my baby was in fact consuming close to 3oz, and everything was a-ok. Kitchen scales are under $20, and a lot of people have them…

    • Heidi

      My guess is they didn’t have a kitchen scale and letting a baby possibly go hungry between now and a week until you get from Amazon wasn’t an acceptable option. Plus, thinking about your setup, I don’t think I’d be comfortable with it personally.

      • Volyund

        You can get kitchen scale at Target, and a lot of people have Amazon Prime now a days. What kind of problems do you see with my setup? I have repeatedly used it until my daughter outgrew max weight on the scales (5kg/10lb). I needed to weigh her at least every week to adjust reflux medication dosage, and our pediatrician didn’t have any problems with my setup… I could probably weigh her by putting her into a cooking pot or a baking dish then on the scale; but those were heavier than the acrylic cutting board and were cold (being metal), so I stuck with acrylic cutting board.

        I just think it can alleviate so many worries of “is my baby getting enough?!” so easily.

        • Heidi

          I don’t think there was anything wrong with your setup. I just don’t think I’d want to do it. If I needed to for meds, I would. Honestly though when it comes to is my baby getting enough, I think it’d be easier to just top up with formula and see if baby wanted more.

  • Courtney

    “I hope they know that I believe them and will continue to fight for them.”
    You’re a hero Dr Amy.

  • niteseer

    It is ironic that in a reply to an article about patient silencing, my post was marked as spam and deleted. I am not sure why anyone would do that, maybe the post was too long. Oh well.

    • PeggySue

      It’s there. People read and replied.

      • niteseer

        Now it is back. Thanks to whomever reversed that.

    • rational thinker

      It is just a disqus problem it will eventually show back up. Disqus can just be really screwy sometimes. Nobody will ever sensor you here.

    • mabelcruet

      Dr T doesn’t delete comments (even those from the belligerent and insulting people that parachute in from lactivist/homebirth sites). Disqus sometimes will automatically flag a comment as spam-its occasionally happened to me, usually if it’s a longer than normal post. If you message or email her, she can de-spam it.

  • rational thinker

    Remember when Mayim Bialik tried to shame the woman who shared her story about how she was treated by lactation consultants in the hospital.

    • EmbraceYourInnerCrone

      Ah yes, that was right up there with her victim-blaming piece in the New York Times about how she hasn’t been sexually harassed as an actress because she was taught to be modest and not dress “provocatively” and how maybe some of what women are subjected to is really their own fault. She does self righteous very well.

      • The Bofa on the Sofa

        But you can’t question her because, you know, she has PhD in neurobiology.

        And I will say, when it comes to knowing about the role of the hypothalamus and obesity (I think that’s what her thesis is about), she is an expert. But in aspects of breastfeeding and sexual harassment and immunology and vaccines? It’s not more relevant than my PhD in chemistry.

        • rational thinker

          yeah I hate it when people defend her with “she is a scientist”. They dont realize that she often lectures other people about subjects that half the time are not at all related to her PhD. In my opinion she is just a glorified judgemental sanctimommy.

          • The Bofa on the Sofa

            Half of the time? I don’t know that she has done any “lecturing” on stuff related to her PhD since she got her PhD.

          • rational thinker

            Yeah you are probably right.

      • rational thinker

        Maybe someday she will realize that a self righteous additude can make you very unattractive.

  • The Bofa on the Sofa

    I think of the more recent work that has identified sodium levels as a marker for insufficient milk, where it was found that, surprisingly, women who had “perceived insufficient lactation” had, indeed, markers for insufficient milk supply!

    IOW, they weren’t making it up, they were right on the mark.

    • Heidi

      Isn’t it rich how “mommy intuition” is always reliable until a mother suspects they are not making enough milk?

  • alongpursuit

    Thank you, Dr. Amy, for recognizing that this is going on and writing so well about it. I’m touched by your compassion and impressed by your incisive critique of this misogynist phenomenon. Thank you for not ignoring mothers like me and believing us when we say we struggled and suffered with breastfeeding.

  • niteseer

    Not related to birth, but over a year ago I had a total shoulder joint replacement on my dominant side. I knew there were likely to be issues with pain, because I was on pain management protocol and was on daily meds that were stronger than those post op protocols usually call for. I knew that there were likely to be issues with self care, because I have a colostomy, and my right arm would be immobilized in a sling constantly. I spoke with the surgeon, and he said my pain needs would be addressed, and that I would stay an extra day in hospital to help me be more able to tend my colostomy on discharge.

    What actually happened was that I only got adequate pain treatment for the first night, and the next morning (while the local nerve block was wearing off), they swapped me to oral pain meds that were about half the potency of my usual daily, and they discharged me at less than 24 hours, over my protests and my requests that they call my surgeon. I finally gave in because I had stronger pain meds at home, and they were treating me so hostilely that I didn’t want to stay. They saw me as a drug seeker, and didn’t want me to mess up their “one day joint replacement” stats for length of stay.

    I was sent home in the most severe pain of my life, and I felt angry and betrayed by my care givers. When the patient opinion survey came, I detailed these events, and requested the adminstration contact me. A guy called back, said they had reviewed my records and talked to the nurse and charge nurse, “and your care was consistent with standards of care”. I never had a chance to speak with them about disregarding my reports of pain, and disregarding that the doctor said I could stay an extra night (yes, he should have written the order, but doctors forget, and nurses are supposed to relay concerns to them). In retrospect, I should have called my surgeon’s office directly, but when you are in pain, you can’t advocate well for yourself.

    I was so depressed. I was afraid I’d be on pain management for life, and would always be treated with suspicion and disrespect by the medical establishment. Since I’ve had multiple emergency surgeries for bowel obstructions, having my pain and symptoms downplayed can be excruciating and life threatening. I was afraid that one day I’d be screaming in pain and just be dismissed.

    As it happened, the shoulder surgery, as well as other health improvements, diminished my pain, and I was able to request weaning down on my meds, and within a few months, requested discharge from pain management. Now, after 5 years of narcotic treatment, I have been taking nothing but occasional OTC tylenol for a year.

    They made assumptions about me, based on perceived incidents of patients abusing drugs, and caused me physical suffering and emotional pain. As with breast feeding problems, and sexual harassment, using preconceptions about general populations to dismiss individual cases is wrong and dangerous

    • rational thinker

      I am sorry you had to go through that. I have had a similar situation with chronic pain so bad I wanted to die or have my legs amputated and it took a long time to get my pain taken seriously (years) and it seriously disrrupted my life and my family’s lives in the process..

    • PeggySue

      I can’t really “like” this. I’m so sorry they were such jerks. “Standards of Care” is what happens when you give guidelines to hospitals. They become rigid standards because insurance companies will not pay for deviations. Even if your doctor had written the order, they might still have turfed you if the insurance won’t pay. It is simply horrible.

    • mabelcruet

      I had abdominal surgery a couple years ago, and ended up in the high dependency unit post-operatively. I’d been written up for plenty of pain relief, but this wasn’t dispensed. The nurse asked me if I needed any analgesia, and when I said yes, her response was ‘I’ll come back in a hour and see how you are then’. Luckily there was a doctor on the unit who overheard this and he got me pain relief.

      As you say, I think there is a worrying tendency to dismiss someone’s perception of pain and write it off as faking or drug seeking. I don’t know if this is a nursing issue or misogyny-its well recognised that female patients commonly have their symptoms dismissed, even something like angina and myocardial infarction pain is more commonly written off as indigestion in women compared to men. I’m a doctor myself, and generally loud and gobby, and usually have no problem standing up for myself. But when you’re lying naked in a hospital bed, catheter in, lines up, groggy from anaesthesia and worried about the outcome of surgery, it’s very hard to assert yourself. I did feedback too, same as you, and I got a response to the effect of ‘you must have misinterpreted the nurse on duty, she didn’t refuse to give you pain relief’. So even with another doctor as witness, they wouldn’t take it seriously. This was in the UK, so it was a standard NHS hospital. I know that there are some patients who do try and obtain drugs (I think a typical scenario is someone attending emergency care and claiming they have renal colic), but when you’re lying in a high dependency unit within hours of having major abdominal surgery, they should realise there’s a good reason why you’re asking for pain relief.

      • AnnaPDE

        Can I just add that in my impression it’s usually less the doctors and more the nursing staff who tend to be somewhat dismissive of patients’ discomfort, and reluctant to provide pain relief as and when requested.
        I’m not sure whether that’s because they can’t prescribe it and are therefore a bit suspicious of doctors whom they view as “over-prescribing”, or if it’s just fatigue from patients who, by definition, tend to be in pain and achy, but there’s a pattern here that’s quite similar to the “should we supplement” decisions going on with babies.

        • mabelcruet

          That was my impression too-the doctor on the HDU was an anesthetist (in my area ICU and HDU are staffed by a mix of intensivists, physicians and anesthetists) so it was lucky that he was there as they do most of pain management. I’d actually been written up for PCA pump (patient controlled analgesia) but it hadn’t been set up and I’m absolutely convinced if he hadn’t been there it would have been ignored completely. But I got a lovely dose of diamorphine and when I woke up again, the PCA was up. The stupid thing is I barely used it over the next 48 hours, a couple times at most. If they’d given me analgesia when I’d needed it, I probably would have managed fine, especially if I knew they were amenable to giving it if I thought I needed it. As it was, the nursing staff ended up with a lot more work to do, monitoring the pump and the line etc.

          • I had much the same experience when I was operated on for an ectopic pregnancy. Ultimately I had to demand to see the nusing supervisor to get my prescribed pain medication that the nurse was refusing to give me.”You’ll become an addict”, she told me.

    • alongpursuit

      I’m so sorry you had to go through that. It sounds so scary and distressing. I am glad you’re feeling better.

  • Cartman36

    Just yesterday I sent a complaint to an executive at the hospital that I had baby # 3 at complaining about their implementation of BFHI including the closure of the well baby nursery and not telling mothers about the risks and possible complications of breastfeeding. I haven’t heard anything back but it felt good to send it.