“I write for those women who do not speak, for those who do not have a voice because they were so terrified, because we are taught to respect fear more than ourselves. We’ve been taught that silence would save us, but it won’t.” – Audre Lorde
Midwifery care begins by meeting women where they are, physically, emotionally, holistically, and medically. Our philosophy of care focuses on human dignity, self-determination, acknowledgement of life experiences, individualized care, and evidence-based approaches. There is an inherent respect for individuality, informed choice, and human rights within the midwifery framework. Similarly, this model embraces hopeful empathy in its students and subscribers, seeking, by definition, to encourage all providers to have the capacity to see humanity in the people they serve, and thus find acceptance and understanding in care provision. To me, this is not only a feminist framework, but a humanistic one, and I embrace it fully as a feminist and midwife.
Not all healthcare providers learn within this model of care. Many schools of thought still create foundations on the provider’s opinion trumping the patient’s, informed choice only occurring under the best of circumstances, and, ultimately, the power differential between provider and patient being one of importance and strength within medicine. “Doctor knows best” is not only institutionalized in schools, but also acculturated, imprinted, and repeated within the patient communities we seek to keep healthy by way of one model. To me, this is not only a patriarchical framework, but a dehumanizing one, and I negate it fully as a feminist and a midwife.
I recognize many caveats within midwifery and other healthcare professions that I broadly generalize above. Not all midwives identify feminism within their care framework, as many struggle with the term feminist and how its gendered linguistics or cultural history integrate into their practice: call it feminism, call it humanism, or just call it midwifery, but embrace and advertise its foundational difference from other care models far and wide. Similarly, not all midwives facilitate a humanistic model of care, and identify more with a patriarchical model in the name of patient safety, under the guise of best intentions. Finally, not all non-midwives learn or practice a patriarchical model: I am so proud of my Nurse-Practitioner, Physician, and Physician Assistant colleagues who began school with humanistic intentions, facilitate that learning with their cohorts, and bring that empathy and individualism in full force to their ERs, labor floors, and clinic settings. This model of care is not siloed with midwifery, or at least it shouldn’t be: it is a basic foundation for approaching care provision in an individualistic, respectful, and empowering way.
I work in a busy community health center, serving women who are uninsured or on public aid, mostly Spanish-speaking, and for whom holistic care typically means home bound paperwork or prison release documentation rather than aromatherapy and acupuncture. I am a midwife, and not in what many consider the traditional sense, though purposefully so: my passion is bringing the midwifery model of care to populations that might otherwise not access midwives, and work with other like-minded providers in delivering intentionally humanistic care to anyone who walks in the clinic or hospital door. It is in this setting that I find feminism, and humanism, most challenging, but more important than in any other. Affirming language, empowering approaches, and sex positivity can be disarming to those who are accustomed to brief visits and rushed explanations: while each of these have their time and place and should be individualized, reinforcing their importance by walking the walk in healthcare is vital to creating powerful spaces and embodying a feminist healthcare model.
As written by Olivia Armshaw in the upcoming book “Roar Behind the Silence“: “Humanization is not just about lowering the intervention rate, but the simple addition of kindness, compassion, and respect to our work, shown through eye contact, smiling, holding a hand, explaining and discussing options clearly, appropriately exploring consent, and including birth partners. These simple behavioural changes are how we make a difference wherever we are.”
Here are 12 easy ways for any healthcare provider to do just that.
1. Radically listen.
Radical listening is the act of unfiltered engagement in conversation. Its practice involves intentionally clearing the mind of other thoughts to purposefully hear what the speaker is saying. When radically listening, we must “not” do many things: not think about the million other tasks on our mind, not interpret on behalf of the speaker before completion of the thought, and not judge what is being said or the person saying it. It is, in its truest sense, just listening, but listening in a different way than many of us are accustomed to. It requires being present for the person in front of you and placing their words on a higher level than your own thoughts: allowing their process, creating space and time for them to speak, and engaging in listening to their experience and needs. Fully listening is a foundation of healthcare provision, not only heart and lungs, but words spoken and cried and exclaimed and whispered. Be a radically present, and a radically listening, practitioner – people immediately notice your engagement and care for them, and you will surprise yourself at how much more you remember their face and their story and feel entrenched in your own work.
2. Intrinsically trust.
Trust when someone tells you they feel their baby move as early as 12 weeks. Trust when someone tells you they aren’t ready to leave their abusive partner. Trust when someone tells you something “just doesn’t feel right.” Trust that at the core of individuality and consent that people can make decisions for themselves. Trust, and trust some more. And then, when you have trusted everything someone has said and the decisions they make for themselves and their family, take the time to remind them that trust in themselves is incredibly important. Something I say multiple times daily, after which I always feel a change in the energy of the room: “You know your body better than anyone else, so I trust you to know when it is time to discuss something or seek care. And if you are not sure, then we will figure it out together.”
3. Remove assumptions.
Gender. Sexual orientation. Preferred language. Single partner status. Economic knowledge. Health literacy. Food access. That a positive pregnancy test is a happy event. That someone knows what an annual exam is and all that it involves, including a possible internal manual assessment. That a teenage pregnancy is an unwanted one. That menopausal symptoms are manageable. That early labor is tolerable. That sexual abuse history is rare. That only certain ages or risk groups should be screening for sexually transmitted infections. That weight is always associated with disease. That it was their choice to see you today. That they are not fighting a battle much harder than the one they will tell you about in a fifteen minute visit. The only assumption you should ever make is that you know nothing about someone until they tell you. See also: #1 and #2.
4. Actively consent.
Consent is an ongoing process. I always discuss what will be involved in an exam, and consent prior. I then continue to inform, and consent, as I prepare for the exam. I always voice that every exam and test and screening process in healthcare is optional, and declining is one of the options each person has during their care. Throughout the exam, I consent: with each touch, with each instrument, with each change in approach. After the exam, I check-in on how someone is feeling, especially if the exam was invasive, such as IUD placement or a bimanual evaluation. In my approach, consent also involves a reminder that consent can be withdrawn at any time. For example, during a visit where I will do an external vulvar and internal vaginal/uterine/adnexal exam, after discussing everything involved, I always say: “None of this should hurt. If you have pain at any time, or want me to stop for any reason, just tell me and I will.” I do not ascribe to the thought that because someone is in your office for an annual exam that there is presumed consent for what is involved in that exam. Nor do I ascribe to the thought that just because someone is in my hospital in labor that there is presumed consent for any and all vaginal exams.
Finally, as part of radical listening and informed consent, if someone’s vagina clamps down, I stop. Even if the person tells me to “just do it,” or “get it over with,” I listen to the body’s immediate response, and stop. Then we have a conversation about what happened, and why, and we decide together whether to wait for a future visit, or start again. To me, if the vagina clamps down, the body is not consenting to a procedure, and words like “just do it” and “get it over with” mean something other than consent for most people, and I stop. And you should, too.
5. Recognize power.
Never push open a woman’s legs in the name of healthcare. Never.
I cannot emphasize this enough. Women will open their own legs by way of signalling consent, and will do so when ready. During birth, it is normal for women to move and push in different positions, sometimes legs closed, and they will spontaneously open them as the baby is born: closed legs during birth is not an emergency, and does not precipitate forcing a woman’s legs open. And during any exam, closed legs should communicate ‘no’ loud and clear to the provider. There is absolutely no need to push knees open, use the back of a gloved hand to ‘guide’ inner thighs outward, or force one’s hand in-between closed legs. If the women’s position wasn’t enough of a ‘no’ on it’s own, a sign to not approach and push your way through, I’m here to tell you: don’t do it.
Consider how you have consented someone for an exam: the “consent during” process should include discussion around positioning. Here’s my approach in clinic: I pull out the secondary table*, ask the patient to bend their knees and put their feet flat on the table, scoot down to the bottom of the top table, and relax their knees to the sides whenever they are ready. If I sit down and have everything prepared, and their knees are still together or not far enough apart, I will say, “When you have relaxed your knees to the side that will be your sign to me that you are ready.” Here is my approach in the hospital: “Whenever you are ready, put the bottoms of your feet together and relax your knees out to the sides. You will let me know that you are ready when your knees are relaxed out to the sides.” I watch students consent women for exams, and then use the time when they say “you will feel my touch” to use that gloved hand to push inner thighs further outward: that is a great big ‘no’ in my book. “You will feel my touch” and pushing legs further open are two very different things: never combine the two. Use your words, and she will use her actions.
Of course, there are a million other important ways to recognize power and attempt to undo its influence. Sit equal to or lower than the patient. Ask what questions someone has before starting on your own standard set. Ask if all of their questions were answered. Raise the head of exam table so they can see you during a genital assessment. Offer the mirror during second stage pushing so she can see how she is doing, and the power to communicate progress is not just in your hands. Offer self-swab testing or separate visits for difficult exams. Do numbers 1-4 of the above. Etcetera.
*Note: I rarely use stirrups/footholders. Once someone is at the bottom of the table with their feet in the stirrups, it is very difficult for them to voluntarily remove themselves from that position. Stirrups, in my opinion, are a forced, permanent position, that removes someone’s power to stop an exam, until the provider changes their position and allows the person to move. I use stirrups only when necessary, e.g. to support someone with physical needs who requires that position to support their legs, or for patients who request them for comfort, or for a certain cervix position or body habitus, or for comfort during an IUD insertion. Otherwise, the secondary table works perfectly well, and people can push themselves out of that position when needed.
6. Practice language.
No one likes to accidentally use the wrong language in any situation, least of all during patient care. Knowledge, and then practice, make perfect. Providers who seek to create safe spaces for all people and clinical needs intentionally use affirming and supportive language, and have language prepared in the likely circumstance that something comes up and words falter.
I encourage my students, and anyone still working through language that is comfortable for them, to practice clinical scenarios, in the quiet of one’s own home, initially alone, and then in the presence of good people. Practice how you would discuss the issue to someone with a similar health literacy level, and then practice it at a fifth grade reading level (the average reading level of my patient population). These practice situations allow you to falter, to hear that yourself or have someone call you on it, and then correct it. Write out scripts, search online for language that works for you, and practice outside of the patient setting. Examples of situations in which one would be remiss to stumble linguistically:
- Unwanted pregnancy
- Sexually transmitted infection diagnosis
- Trans* care
- Choosing an adoption plan
- Female genital cutting
- Fetal anomalies
Example language in case words fail despite all of your preparations:
- Intro, depending on scenario: “Thank you for being honest with me,” or “I am so sorry.”
- Follow-up: “This is an area of care I am not very familiar with, but together we are going to figure out the best way forward.”
7. Sensitively screen.
If you work in a setting where many clinic visits during the day involve people are seeing you for the first time, screening tools are a good place to start discussions around sensitive issues. I tend toward the written screening tool just to allow privacy in completing the form prior to my entering the room, and search for other options depending on individual needs. Sensitive screening mechanisms are a form of recognizing that certain issues, particularly with someone you do not know, are a way of initiating your own empathic process and creating space for individual reporting methods.
Depression. Domestic violence. Financial security. Food stability. Substance abuse. Home safety. Transportation access. Sexual assault history. Should a screening test come back slightly elevated with a new patient, consider repeating it in one or two visits, to allow change in openness once the person becomes more comfortable sharing information with you. Should a screening test come back high on the first visit, consider immediate approaches, including changing the focus of that visit, understanding that if they share such sensitive information with you the first time upon meeting you, it is an absolute call for help. If you note that your particular population struggles with a certain issue, create your own survey to cater appropriate care.
8. Enforce #cliteracy***.
One of my biggest healthcare provider soap boxes is the degree to which we remove connections between sexaul intimacy and vaginal exams. Somewhere between the sex we ourselves had the night before and the clinical exam we provide to patients the next day, we forget that inserting fingers into a vagina is exactly the way women are stimulated, have sex, are violated or abused, relive prior experiences, or have automatic, physical responses to touching. It is of critical importance for all providers to recognize the sensitivity of these exams, each and every time they are performed: cervical checks, bimanual or external vulvar evaluation, rectal examination, prolapse assessment, speculum insertion and removal. Anything to do with the vagina, as rote a clinical procedure it may be to us, should be employed only when necessary and with the utmost sensitivity.
And then, there’s the clitoris. Specifically, what providers do with the thumb when one or two fingers are inside the vagina during a vaginal exam, cervical exam, or bimanual assessment. Natural hand positioning leaves the thumb resting on the clitoris. Don’t. Do. That. (See the paragraph above, and think about how confusing it may be to a body when on one hand the mind knows it’s a healthcare experience but then the thumb presses on the one part of the body that receives signals for pleasure.) I know I am not the only one whose first reaction to teaching students pelvic exams and cervical checks is: “Move your thumb. Further… further. There. Imprint that into your muscle memory. Next time, remember to avoid the clitoris.”
***If you are unfamiliar with Sophia Wallace’s work, check out cliteracy and the 100 natural laws.
9. Refer intentionally.
Referring a patient to another provider should be as considerate and respectful as the care you yourself seek to provide. Examples: Make all attempts to find a Spanish-speaking, or preferred language, clinician if that would be critical to patient care. Utilize LGBTQ* provider networks that are verified and affirming for those patients. Have a general idea as to what insurances are accepted, or public aid or sliding scale options are available, prior to sending patients there. Personally, I have tried to visit each referral site, or at minimum, call them, and ask questions about language availability, queer-friendly environments, and insurance flexibility, prior to sending a patient there. I like to be able to paint a picture for my patients of what their experience will be like, and let them know that if they did not like that referral, I will find another one for them.
10. Read purposefully.
I recognize that clinicians are busy, and keeping on top of the latest evidence is at the height of our professional reading concerns. However, there are a few easy ways to integrate feminist reading into your professional and personal plans. Sign up for email alerts. “Follow” specific groups on Facebook or Twitter, so that personal updates and recent feminist thought also filters through. A few good places to start:
- Human Rights in Childbirth
- Gay and Lesbian Medical Association
- RH Reality Check
- Bitch Media
- National LGBT Health Education Center
- Squat Birth Journal
- National Women’s Law Center
- 4000 Years For Choice
- Childbirth Connection
- Rainbow Health Initiative
- Contraceptive Pearls
- anything involving Jessica Valenti
I also follow my local feminist clinic for their awesomeness – find yours if you don’t know about it already!
11: Expedite treatment.
Find the closest pharmacy to send medications, to minimize issues with transportation or timing. Check the laws around expedited partner therapy (EPT) in your state. Access to effective treatment for your patient and her partner(s) is a reproductive justice issue, and as her provider, your work to get her the treatment as quickly as possible provides a holistic approach to treatment. What I usually say is: “I am sending the medication to your pharmacy with one refill. Pick up the first prescription today, and take that yourself. Return to the pharmacy tomorrow for the refill. As long as your partner does not have any allergies, they should take that refill. If they have allergies, they need to see their own healthcare provider for treatment.”
12. Advertise yourself!
Healthcare providers, what other suggestions do you have? For those who have experienced feminist approaches to healthcare, what did you find affirming and empowering and would like others to integrate?
Note: Later this week I will post a parallel piece to this article, about how to be a feminist patient. Look for that to come!