Obstetric Violence, Traumatic Childbirth, and PTSD

Over the last decade, a large corpus of attention and research has been dedicated to “abuse and disrespect,” “mistreatment” during childbirth, and “obstetric violence.” Although these terms are sometimes used interchangeably, their implications are not the same. Michelle Sadler and colleagues have argued that of these concepts, only “obstetric violence” has the potential to address the structural dimensions of the violence involved, highlighting that abuse in maternity wards is a form of gender violence and that biomedicine is a cultural system that mirrors societies’ broader ideological frameworks (Sadler et al. Reference Sadler, Santos, Ruiz-Berdún, Rojas, Skoko, Gillen and Clausen2016). Thus, obstetric violence is gender violence that exercises obstetric power over women: a form of gendered disciplinary power, which naturalizes medical control over biosocially constructed functions such as gestation, childbirth, and motherhood (Arguedas Reference Arguedas, Quattrocchi and Magnone2020).

Much has already been said about how birthing subjects experience obstetric violenceFootnote ²: physical and emotional pain are constants in these descriptions, as is a feeling of humiliation that persists long after the birth is over (Baker et al. Reference Baker, Choi, Henshaw and Tree2005; Bohren et al Reference Bohren2015; Cohen Shabot Reference Cohen Shabot2016). As a result, posttraumatic stress disorder (PTSD), centrally featuring the sense of lack of control, power, and agency to make sovereign decisions in childbirth, is a postbirth reality for far too many women (Grekin and O'Hara Reference Grekin and O'Hara2014; Ayers et al. Reference Ayers, Bond, Bertullies and Wijma2016; Yildiz, Ayers, and Phillips Reference Yildiz, Ayers and Phillips2017; Beck and Casavant Reference Beck and Casavant2019). Structural ailments such as racism, classism, and, mainly, sexism have been recognized as being responsible for the propagation of obstetric violence through medicalized childbirth all over the world (Bellón Sanchez Reference Bellón Sánchez2014; Cohen Shabot Reference Cohen Shabot2016; Davis Reference Davis2019; Cohen Shabot Reference Cohen Shabot2020a). Many recent investigations have inquired into the gendered nature of the phenomenon: its connections to gendered shame, to the patriarchal need to put women's bodies back in their place and control women's subjectivities by controlling their birthing bodies (Cohen Shabot and Korem Reference Cohen Shabot and Korem2018; Cohen Shabot Reference Cohen Shabot2020a). Epistemic questions regarding the phenomenon of obstetric violence have also been pondered, since much of obstetric violence is in fact normalized violence, which is therefore barely or not at all recognized as violence (Cohen Shabot Reference Cohen Shabot, Pickles and Herring2019; Reference Cohen Shabot2020a; Liese et al. Reference Liese, Davis-Floyd, Stewart and Cheyney2021). Its similarities to sexual violence have also been seen as precluding recognition, since much of sexual violence is also normalized: unrecognized as violence because of patriarchal structures that allow harm toward women, making it appear necessary, deserved, or ultimately not actually harmful (Bradby Reference Bradby1998; Cohen Shabot Reference Cohen Shabot2020a; Reference Cohen Shabot, Herring and Pickles2020c). These epistemic problems inform many of the hermeneutical debates over obstetric violence: the experiences of women who after their labors complain of having suffered from obstetric violence are severely questioned because a) there is a lack of epistemic structures allowing these descriptions to be understood as “real violence”; and b) it is inconceivable that violence could be part of such an essentially benevolent scenario as a hospital (Mardorossian Reference Mardorossian2014). It is difficult or impossible to recognize these abuses as crude, gendered violence because biomedicine is commonly thought of as a value-free system, free of cultural and ideological frameworks, the product of supposedly neutral “science” (Rhodes Reference Rhodes, Sargent and Johnson1996).

We thus agree with previous studies that “mistreatment” in labor is violence, in many cases extreme violence; we believe that this is also why so many women speak of their birthing experiences as rape, or even as torture. The term birth rape has been used to describe certain experiences of obstetric violence. Sheila Kitzinger clearly states that women who experience traumatic births usually use the same language as rape victims (Kitzinger Reference Kitzinger2006). Some studies have attempted to look closely at this term, with the goal of understanding why and how precisely the concept of “rape” has been used to speak about experiences of violence in the labor room (Richland Reference Richland2008; Fernández Reference Fernández2013; Cohen Shabot Reference Cohen Shabot2016). In spite of questions about whether medical procedures can ever be compared to rape and/or blanket statements that rape is a term to be used only to describe coerced sexual encounters, researchers into obstetric violence have found that “birth rape” is indeed not a metaphor used to magnify or exaggerate the complaints of victims of obstetric violence, but rather a term that expresses precisely how many women experience violence in the labor room, that is, as nothing less than rape (this is also reported by women who had previously been victims of nonobstetric rape; see Hayes-Klein Reference Hayes-Klein2014). In Cheryl Beck's qualitative study of birth trauma in forty women, traumatic childbirth was portrayed by some as having been “raped”, with everyone watching and no one offering to help (Beck Reference Beck2004a, 34).

In the following, we will show how, much as the word “rape” used not metaphorically but literally has found its way into many descriptions of obstetric violence, so too has the word “torture” been used to express the horrors that victims of violence in the labor room have lived. Thus, we argue that the concept of “torture” is not used only in a loose, colloquial way to express the extreme violence that women have experienced in their labors: what women are describing is the experience of obstetric violence as literal torture. The presence of the concept of torture in reports of obstetric violence has already been noted in the research, as we will show. However, there has been little in the way of deep analysis of why precisely the word “torture” is used, and how these descriptions of violent experiences might or might not be rightly compared to experiences already recognized as torture. We will show that when we look closely at women's descriptions of these experiences, we can indeed find many of the phenomenological elements constituting the experience of torture.

Obstetric Violence as Torture

Despite the fact that within the research on obstetric violence (by both academics and activists), it is not uncommon to see “torture” being used to refer to extreme cases of violence in childbirth, few reports or articles have analyzed the implications of this use,Footnote ³ and there are no studies philosophically reflecting on this subject, to the best of our knowledge. Gill Thomson and Soo Downe's phenomenological study, carried out in the UK with fourteen women who had experienced a traumatic birth, showed that women described their childbirth in terms of abuse, torture, and violence. Those who described their experiences as torture expressed a “profound sense of being disassociated from the childbirth experience, and annihilated from societal regard” (Thomson and Downe Reference Thomson and Downe2008, 268). The authors argue that in a way similar to victims of torture, “the women's agency was limited physically (movements), psychologically (feelings) and cognitively (through lack of choice, understanding and involvement in decision making). The utter sense of helplessness led women to feel ‘completely in the hands’ of the clinical professionals” (271). These findings show similarities with the broader literature on violence and abuse (but not specifically with that on torture): in the inducement of passivity, helplessness, and dependency through standardized rituals and procedures (Davis-Floyd Reference Davis-Floyd2018); in the imbalance of power between women and the health staff; in sensations of disconnection, alienation, and isolation from social bonds; and even in the belief that death was imminent because of the severity of pain, suffering, and trauma.

The links among torture, gender, and childbirth have been raised by international human rights organizations, which increasingly recognize that numerous human rights are violated when women are abused during childbirth, including the right to be free from torture and other ill-treatment and the right to privacy, information, health care, nondiscrimination, and equality. Although this recognition is recent, it sets the ground for a stronger and more urgent debate on the seriousness of these abuses and their consequences (Khosla et al. Reference Khosla, Zampas, Vogel, Bohren, Roseman and Erdman2016; Zampas et al. Reference Zampas, Amin, O'Hanlon, Bjerregaard, Mehrtash, Khosla and Tunçalp2020).

A human rights report on reproductive health care in public hospitals in Argentina (INSGENAR 2008) established clear links between the abuses committed in maternity hospitals and torture, identifying a continuum of abuses across different degrees, ranging from infantilizing women to inhumane and degrading treatments that can be considered torture. Kylea Liese and colleagues have labeled this a continuum of “obstetric iatrogenesis” and state that it ranges from invisible forms of obstetric violence, such as harmful, non-evidence-based routine procedures, to overt forms such as yelling at, insulting, or slapping birthing women (Liese et al. Reference Liese, Davis-Floyd, Stewart and Cheyney2021). A report by the Spanish Observatory of Obstetric Violence stated that women who have lived obstetric violence describe their experience as torture—physical, but also and mainly psychological, being neglected and humiliated (El Parto es Nuestro 2016). In a recently compiled volume on obstetric violence in Latin America, several chapters mention the concept of “torture” (Quattrocchi and Magnone Reference Quattrocchi and Magnone2020), as Sadler discusses in the introduction to that volume (Sadler Reference Sadler, Quattrocchi and Magnone2020). The concept appears in women's narratives of childbirth (Muñoz García and Berrio Palomo Reference Muñoz García, Palomo, Quattrocchi and Magnone2020) and when dealing with legal frameworks addressing the problem, as in Paola Sesia's chapter on obstetric violence in Mexico (Sesia Reference Sesia, Quattrocchi and Magnone2020). Sesia mentions that Mexico's Supreme Court has published guidelines for the country's judicial system on how to act in the event of torture or mistreatment, including a mention of obstetric violence, briefly described as behaviors that may constitute acts of torture or abuse.

Several United Nations reports during the last decade have referred to violence against women, and during childbirth, as torture. Two reports by the UN's Special Rapporteurs on torture and other cruel, inhumane, or degrading treatment or punishment are especially relevant here. Manfred Nowak's report on human rights focused on the protection of women from torture. In his gender-sensitive interpretation of torture, he argued that “a society's indifference to or even support for the subordinate status of women, together with the existence of discriminatory laws and a pattern of State failure to punish perpetrators and protect victims, create the conditions under which women may be subjected to systematic physical and mental suffering, despite their apparent freedom to resist” (Nowak Reference Nowak2008, 7). Many forms of violence in different parts of the world, he argued,

With the phrase “classic” torture, Nowak is referring to the definition of torture in Article 1 of the Convention against Torture:

To ensure that this framework could be applied in a gender-sensitive manner, Nowak proposed adding the criterion of “powerlessness,” which arises when one person exercises total power over another. Nowak argued that “if it is found that a victim is unable to flee or [is] otherwise coerced into staying by certain circumstances, the powerlessness criterion can be considered fulfilled” (Nowak Reference Nowak2008, 6–7). This dimension appears to be fundamental in many cases of obstetric violence, in which women have no choice but to acquiesce to the power of health professionals (Dixon-Woods, Williams, and Jackson Reference Dixon-Woods, Williams and Jackson2006).

Almost a decade later, Juan Méndez, in his report on gender perspectives on torture, argued that because historically the analytical frameworks around torture and ill-treatment had evolved in response to practices and situations that disproportionately affected men, those frameworks had “failed to have a gendered and intersectional lens, or to account adequately for the impact of entrenched discrimination, patriarchal, heteronormative and discriminatory power structures and socialized gender stereotypes” (Méndez Reference Méndez2016, 3). This applies to sexual and reproductive services in health facilities, where he reported that “women and girls seeking reproductive health care in professional settings are often exposed to severe pain and suffering and coerced into or subjected to unwanted, degrading and humiliating procedures and examinations” (13) and that women seeking maternal health care encountered a high risk of ill-treatment, with abuses that “range from extended delays in the provision of medical care, such as stitching after delivery, to the absence of anesthesia. Such mistreatment is often motivated by stereotypes regarding women's childbearing roles and inflicts physical and psychological suffering that can amount to ill-treatment” (13).

Three years later, another UN report focused solely on abuses during childbirth. The UN's Special Rapporteur on violence against women, Dubravka Šimonović, presented a thematic report on a human-rights-based approach to mistreatment and violence against women in reproductive health services, with a focus on childbirth and obstetric violence (Šimonović Reference Šimonović2019). The report recognizes obstetric violence as a systematic and generalized problem worldwide; validates women's experiences as a basis for denouncing this type of violence; and acknowledges the lack of any human rights approach to this issue to date (Castrillo Reference Castrillo2020). The document mentions several obstetric practices—some of which are no longer used but were part of medicalized childbirth in the past, and some of which are still currently in wide practice across the globe—as constituting torture. Among those no longer used is the technique known as symphysiotomy, which was the surgical separation and widening of the pelvis to facilitate childbirth.Footnote ⁴ Practices still in use that may amount to torture or cruel, inhumane, and degrading treatment include forced sterilization and abortion, women being restrained to bed during labor and birth, and incarcerated women being physically restrained to bed and/or shackled during labor and delivery. Significantly, the report states that “when practiced without a woman's consent, caesarean sections may amount to gender-based violence against women and even torture” and that episiotomy, “if unnecessary and/or done without informed consent, may have adverse physical and psychological effects on the mother, can lead to death and may amount to gender-based violence and torture and inhuman and degrading treatment” (Šimonović Reference Šimonović2019, 10).

As we can see, a link between violence during childbirth and torture has been posited. But what does it mean, exactly, to affirm that obstetric violence is or can be recognized, at least in some cases, as torture? In what follows, we reflect on this connection by clearly accounting for the common aspects of torture and of some forms of obstetric violence. We will show that women not only use the word “torture” but also that they provide a myriad of details to confirm why such experiences are in fact nothing less than literal torture. We will use different analyses of torture—mainly phenomenological ones—to examine the descriptions of obstetric violence given by Chilean women in which the use of the term torture is central.

Why a Phenomenology of Torture?

Dealing with torture phenomenologically means that what is examined is mainly the experience of torture rather than its goals or motives, or the question of whether something should legally count as torture or not. This of course cannot be done without a clear justification, since it might be argued that motives and goals are essential to the definition of torture: that it must be intentional, done consciously and purposefully by the torturer. Analyses of torture from the perspective of the law, for instance, emphasize the intentionality of torture and that it is performed in order to extract something (usually information) from the tortured. Official declarations against torture normally refer exclusively to torture inflicted by organized bodies such as the state, the military, or the police, thereby eliminating any forms of torture occurring in nonofficial scenarios (Gudorf Reference Gudorf2011, 615; Olson Reference Olson, Olson and Molloy2019; Viterbo Reference Viterbo, Olson and Molloy2019).Footnote ⁵ Since we already know that obstetric violence is frequently perpetrated unintentionally (as part of structural, normalized, and unrecognized mechanisms of violence) and that it is almost always performed without the goal of harming the birthing woman—frequently even with the express intention of helping and benefiting her—we will need, in order to deal with torture in the context of obstetric violence, to make use of different discussions on torture, mainly recent phenomenological ones. These are usually broader discussions, in the sense that they engage more fully with the experience of torture from the first-person point of view, putting to the side for now the question of the torturer's motives and goals—and this move makes it possible to imagine torture happening as part of structural, “invisible,” and unorganized violence (with no clear intention behind it).

Yet one of the important similarities between “classic,” or officially recognized, forms of torture and torture as experienced in the labor room is that the tortured subject is always considered a means, rather than an end in herself: she is always seen as an object open to manipulation in order to obtain something else, and this is also how she is made to feel. Thus, in the same way that the victim of intentional torture constitutes a medium for acquiring information, the birthing woman victim of obstetric violence is generally considered a vessel, a passive recipient of procedures deemed obstetrically necessary for the baby to be born (Rothman Reference Rothman1982; Martin Reference Martin1987; Reference Davis-FloydDavis-Floyd 1992/2003). We can affirm, then, that one of torture's general features is that it is a reifying practice—one that converts a person into a concrete thing—with a reifying intention; meanwhile, reification is also one of the main characteristics of the phenomenon of obstetric violence. We will explore this connection between obstetric violence and torture as being driven by the need to reify the subject and control her by controlling her embodied self when we deal later with obstetric violence as gendered torture.

Much of the theoretical discussion on torture has been focused on the question of physical pain. We challenge this emphasis on pain, for reasons to be explained below. In one of the most renowned accounts of torture, Scarry considers torture a destructive force that erodes subjectivity, since it manages to break our links to the world to the point that we are left alone with our aching bodies, and nothing else (Scarry Reference Scarry1985). The body here turns into a pure object, voided of meaning as a source of communication and of contact with the world and others: it becomes plain flesh. Such a body-object, uncommunicated and without language—incapable of expressing what it is experiencing—can never be constitutive of a subject; it is in fact the opposite of a subject, if by subject we understand a lived body deeply rooted in the world and constructed through relationships with others (as phenomenologists have clearly and repeatedly argued).Footnote ⁶ In torture, Scarry argues, our world is “unmade”; we are estranged, alienated from it. Even though we find Scarry's account productive for discussing and reflecting on many of the characteristics of the experiences of torture in the labor room, we would like to step forward into newer accounts of torture, mainly because Scarry still puts considerable weight on physical pain as constitutive of torture and its effects. Pain is, according to Scarry, what reduces the body to an object in torture, and it is mainly pain—intense, unbearable physical pain—that isolates us from the world throughout the experience. However, we argue that, although the pain inflicted in many instances of obstetric violence might be unbearable indeed, and surely constitutive of what women reflect on as being “torturous” in that experience, pain is not at all the only (and often not even the central) reason why women describe these experiences as ones of torture; in fact, many women who experience intense labor pain actually report perceiving the pain itself as positive, even empowering and rewarding (as described in Heyes Reference Heyes and Käll2013; Cohen Shabot Reference Cohen Shabot2017; and Dahan Reference Dahan2019). Some recent phenomenological research investigates torture from a broader perspective and refers to the infliction of physical pain as only one of the many elements constituting the experience of torture. We find this research to be much more fruitful for our investigation. Thus, in the following, we will present some of these accounts that focus on how torture affirms the torturer's power over the body of the tortured, not primarily or only through the infliction of physical pain but rather through coercion, intimidation, humiliation, oppression, isolation, and distrust—the essence of torture becoming here the severity not of the pain inflicted but rather of the “undermining [of] the victim's dignity” (Olson Reference Olson, Olson and Molloy2019, 76) and the disregarding of their human rights.

We shall discuss some of the broadest definitions and analyses of torture: some of them challenge the centrality of severe physical pain in torture; others challenge the need for a clear intention for torture to be recognized. We will make use of these in order to illuminate various instances of obstetric violence and to argue that they should certainly be considered and acknowledged as forms of literal torture.

Torture Beyond (Physical) Pain: Ontological Shattering

Several recent phenomenological accounts of torture take as their basis Jean Améry's forceful reflections on torture and its effects. Améry writes from his point of view as an Auschwitz survivor and elaborates with detail on torture as one of the main dehumanizing tools employed within the camp (Améry Reference Améry, Rosenfeld and Rosenfeld1980). Ilit Ferber, and Yochai Ataria and Shaun Gallagher, discuss and interpret Améry's analysis, emphasizing how torture in Améry's eyes appears to be mainly a means for destroying the social bond and trust in the world—for isolating victims and shattering their worlds by positioning them in a state of absolute uncertainty and unpredictability, where violence and pain are all that undoubtedly exist, and no form of transcendence is possible (Ataria and Gallagher Reference Ataria and Gallagher2015; Ferber Reference Ferber2016). Ferber writes: “The ‘first blow' reveals that the brutal aggressive act strikes not only the physical body but every possible framework within which it exists—world, time, others—and shatters ‘the axes of its traditional frames of reference’” (Ferber Reference Ferber2016, 5). One of the most compelling recent phenomenological analyses of torture is David Koukal's, who elaborates broadly on the effect of torture as ontologically shattering the world of the tortured (Koukal Reference Koukal2009). Again, we see that the world of torture victims is demolished and becomes strange and incomprehensible to them not primarily through severe physical pain, but rather through humiliation and detachment.Footnote ⁷ By destroying the phenomenological links between the lived body of the tortured and their worlds, the damage of torture is perpetrated. Thus, Koukal argues, the infliction of unbearable physical pain is not a necessary feature of torture—but humiliating the embodied subject to the point that her resources for connection with the world and others are severely (sometimes permanently) damaged, clearly is. Koukal bases his analysis of torture on phenomenological conceptions of subjectivity, especially Maurice Merleau-Ponty's (Merleau-Ponty Reference Merleau-Ponty and Smith1962). Thus Koukal argues that if the subject is first and foremost embodied and open to the world and others, intertwined with the flesh of the world and creating meaning through this bond with the world, then torture in fact consists of closing down the space around the victim, limiting her possibilities of movement and confining her to places where she is alone, or surrounded by strange objects or people. Isolation and disorientation (in time and place) are thus crucial within the experience of torture: we find ourselves in an unknown, arbitrary, and unexpected reality; we do not know what else might happen; and we become vulnerable to the point where the disorientation finally becomes disorientation from our own selves: we become strange to our “self”; our body is not ours anymore; sometimes it even feels as though it were turning against our own self.

When taken to extreme degrees, when torture is constant and helplessness absolute, we can develop a kind of apathy toward our bodies and even experience a complete loss of self, a loss of boundary between ourselves and the world (Ataria and Gallagher Reference Ataria and Gallagher2015). These are features of what Martin Seligman termed “learned helplessness” (Seligman Reference Seligman1972; Reference Seligman1975)—behavior exhibited by people after enduring repeated aversive stimuli beyond their control: with no other options, such as fight or flight, they “freeze” and passively accept whatever comes at them (Melancon Reference Melancon and Davis-Floyd2021). Seligman and others have shown that clinical depression and related mental illnesses may result from such real or perceived absence of control over the outcome of a situation.

In Thomson and Downe's analysis of women's experiences of traumatic childbirth, this sense of the body not being ours anymore, this learned helplessness, is portrayed in women's accounts of going through typical “out-of-body” dissociative experiences. These authors argue that the dissociation of mind and body is a powerful psychological strategy for coping with violence and trauma. Dissociation has been identified in literature on torture, sexual abuse, and domestic violence as a defense mechanism against fear and threat of death. To illustrate, Thomson and Downe quote Kate's experience of a forceps delivery: “it felt like an absolutely, out of body unreal experience, it was like I was in a corner and watching everything” (Thomson and Downe Reference Thomson and Downe2008, 271). In some of the literature, we can even find echoes of Ataria and Gallagher's most extreme scenario: the complete loss of self in some of the most severe cases of violent traumatic labor (Byrne et al. Reference Byrne, Egan, Neela and Sarma2017).

Uncertainty, arbitrariness, and isolation are thus crucial for understanding the experience of torture. It is important to stress what Koukal is precisely arguing: in our lived world, we do experience uncertainty, randomness, and vulnerability, yet we also ought to experience agency, a sense of freedom, possibilities of moving and at least partially constructing our realities, with the help of caring others (Koukal Reference Koukal2009). This is also the kind of agency we are supposed to experience during a humanized birth, notwithstanding the pain and the sensation of unpredictability. It is this kind of agency that we are robbed of in torture, when we are transformed into pure objects at the disposal of others’ power and arbitrary decisions. Koukal explains why it is not pain (physical pain) that plays the main role in this process: pain is normally encountered in our everyday lives; we are vulnerable to pain and always suffering. But we are not unarmed against pain if we are free to move our bodies, make decisions about them, and seek help. Thus, again, it is not only pain that marks torture, but also the lack of freedom, the terrifying confinement, and the absolute absence of power that characterize it: the “powerlessness” that Nowak refers to (Nowak Reference Nowak2008). It is mainly the isolation from others who might otherwise be able to help us and with whom we could build meaning that can be devastating.

These elements are all present in Alma's account of her childbirth experience in a public hospital, as she described it in the First National Survey on Childbirth in Chile. Alma was a young woman in her first pregnancy. It was 2015 when she was admitted to a public maternity ward in the city of Santiago, Chile, after her waters had broken. While undressing her and preparing her for admission, the midwives mocked her pubic hair and scolded her for coming in without having shaved. After admitting her, and before she had begun any contractions, they put her on an oxytocin drip with no explanation of the procedure. She speaks in the first person from that point onwards:

Later in her narrative, Alma recalls being at home: “Depression, panic, and anxiety attacks were finishing me off. . . . Never again in my life do I want to have a baby.”

Alma was tied to a bed and had her mobility restricted; she was denied food and water and was humiliated, scolded, and slapped. She was called a horny bitch and was left in pain for long hours before being given an epidural, which is a guaranteed health benefit in Chile. She stopped perceiving the world around her; she stopped seeing and hearing. She experienced great emotional pain: her “soul hurt.” She felt as if she was going to die. Depression and panic attacks followed. And yet, for a while during her labor, she had been given support and affection by the young midwives. Alma felt as if they “had been sent by God”; while they were with her, her experience shifted significantly, from one of torture to one in which she felt heard, visible, and present.

Among the main themes arising from traumatic childbirth experiences, Beck has documented that women feel stripped of their dignity, alone, and abandoned; they feel invisible, as if they were not there (Beck Reference Beck2004a). Similarly, Rakime Elmir and colleagues found that many women felt invisible, ignored, and not considered as individuals; had a sense of powerlessness and vulnerability; and vividly described labor and delivery care as “inhumane and degrading” (Elmir et al. Reference Elmir, Virginia Schmied and Jackson2010, 2147). In Thomson and Downe's study, the three main themes that emerged were feeling “disconnected,” “helpless,” and “isolated” (Thomson and Downe Reference Thomson and Downe2008, 270). Some of the women in their study wished for death as an opportunity to escape their ordeal, an extreme option that is also imagined by women in the cases we reviewed from Chile: “I just wanted to die so all that pain and suffering would end,” Carmen (3364) recalls of her traumatic birthing experience; and Rocío (1006) remembers that after spending hours of what she describes as torture in the maternity ward, “I could no longer bear it. Several times I looked out of the window of that hospital with the intention of jumping down.”

Torture Beyond Intention: Obstetric Violence as “Gendered Torture”

Šimonović quotes the NGO Mother Hood that “violence against women in childbirth is so normalized that it is not (yet) considered violence against women” (Šimonović 2019).Footnote ⁹ This normalization could account for how little attention women's experience of childbirth as torture has received to date. It is always against the backdrop of human rights that torture is considered as such; that is, it is only when we agree that persons have the right to agency, to be cared for, and to have their embodied subjectivity defended against acts of violence, that we can look at torture as an intentional defilement of these rights. According to Christine Gudorf, this might be why it is so difficult to recognize the many instances in which women are tortured: women frequently appear as already unworthy of rights, or of deserving any agency and power over their own bodies. Thus, Gudorf claims that even though much of the violence against women worldwide could be considered torture, since it is effectively directed toward actively depriving women of agency and reinforcing their condition as objects, as the property of others, through humiliation and domination, this violence is rarely even considered real violence (to say nothing of torture): women's lack of agency and their availability as sexual objects for male consumption are so deeply entrenched in patriarchal cultures, so unquestioned, that they are considered normal and unchallenged facts. This is why, for example, some instances of rape that have lately been claimed to be forms of torture (that is, rape as a weapon of war) took so long to be recognized as such: women naturally constitute men's property, especially within essentially “male” territories such as war. In Gudorf's words:

Gudorf thus believes that torture of women is pervasive and that it functions globally to put women “back in their place,” to control them and reinforce their weakness and lack of power. She also emphasizes that this systematic, “pervasive torture” of women has been normalized, such that many of its victims believe this suffering to be a natural fact of life, an unchangeable reality about which nothing can be done:

Several recent investigations into obstetric violence have argued that violent practices in labor do indeed have much in common with sexual violence. Sexual violence is not fully perceived as violence within patriarchal societies, since women are commonly perceived as inherently available for sexual consumption (and as naturally shameful and deserving pain) and men as naturally entitled to act on women. Thus, it has been claimed that the same mechanisms that make sexual violence invisible in patriarchal societies also act to mask the presence of obstetric violence or to hinder epistemic recognition of the phenomenon altogether (Cohen Shabot Reference Cohen Shabot, Pickles and Herring2019; Reference Cohen Shabot2020a; Reference Cohen Shabot, Herring and Pickles2020c). Gudorf's analysis perfectly matches these arguments regarding obstetric violence: in the same way that sexual torture and torture through rape have been rendered unrecognizable as torture, in spite of their pervasiveness and their function as a global tool for controlling women and stripping them of agency, and in the same way that many women have interiorized the inevitability of such torture and thus been emptied of the power to resist it, so too has obstetric violence remained a pervasive phenomenon wherein human rights are constantly violated, with no clear recognition of that fact by medical staff or, frequently, by laboring women themselves.

Yet Gudorf insists that not all violence against women can be called torture, and that there needs to be intention behind torture. Thus, accidental damage or involuntary infliction of suffering cannot count as torture, for which a clear and present “commitment to deny the victim any claim to agency” is imperative. However, she adds, “much of the pain inflicted on women should qualify as torture” (Gudorf Reference Gudorf2011, 615).

So, then, can obstetric violence count as gendered torture Footnote ¹⁰ even when we take intention into account? Research on obstetric violence shows that even though medical staff do not, in most cases, intentionally act violently toward birthing women, it can be argued that behind obstetric violence there actually is a structural intention to reduce and challenge birthing women's agency. Thus, assuming that the various analyses framing obstetric violence as structural and as a power tool for making women docile are correct, then it could be said that the performance of violence in the labor room does have a clear goal: it is intended—if not by individuals, then by the obstetric structure—to control labor and to control women in labor. Thus, we cannot say that obstetric violence is merely accidental, and therefore, the question of intentionality is answered in such as a way as to allow obstetric violence to be categorized as a form of torture.Footnote ¹¹

Cohen Shabot argues that obstetric violence is gender violence because it serves as a tool of “feminization” to take away women's power, agency, and strength mainly through shame, humiliation, and the restriction of embodied space and freedom. In Cohen Shabot's words:

Clara's childbirth experience, another birth that was documented in the First National Survey on Childbirth in Chile, clearly illustrates these last descriptions. She is a woman of high cultural capital; she was educated in private schools and has private health insurance. She attended prenatal workshops during her first pregnancy because she wished to experience a birth without the unnecessary routine obstetric interventions that are common in her country, Chile. She did all this in order to defy the cultural imperative of being a docile body in birth, and that defiance proved useful in her first childbirth experience, during which she felt respected and cared for and had the natural birth she wished. For her second birth, in 2014, she had a different medical team, and things developed quite differently:

Clara resists the pressure to have an epidural and yells back at the midwife, which makes the violence escalate. She tries to move from the bed, and in response the midwife threatens to tie her down. She defies the midwife's orders and leaves the bed to get on her hands and knees, only to be further scolded and threatened. If she misbehaves, the midwife tells her, she will be putting her baby at serious risk. Her loud body is silenced; she is “put in her place,” pushed back toward being feminine.

“Whoever Was Tortured, Stays Tortured”

It might seem shocking to equate obstetric violence to torture. It is important to stress that we in no way desire to diminish the horrors of torture—just as the literature on birth as rape is not intended to diminish the experience of rape. On the contrary, as recent theories of torture have shown, the concept needs to be expanded to incorporate forms of torture that have been obscured or overlooked because of blindness caused by sexism, racism, and other social and institutional ailments.

The sense of powerlessness that is characteristic of torture, as discussed earlier (Nowak Reference Nowak2008) is pervasive among obstetric violence reports. One of the key reasons that it was important for us to theoretically ground this connection between torture and obstetric violence is that, as in torture, the obstetric violence victim's sense of powerlessness, reification, loneliness, and loss of agency prevails long after the event is ended. Sometimes it lasts throughout life.

Referring to Améry's powerful words on torture—“Whoever was tortured stays tortured . . . whoever has succumbed to torture can no longer feel at home in the world” (Améry 2008, quoted in Koukal Reference Koukal2009, 312)—Koukal concludes that torture not only constitutes a violation of the body, but results in an absolute shattering of the subject, ontological in kind, where trust in the world and others is lost, frequently with no return. Thus, torture is not over when it physically ends: the victim of torture carries this ontological shattering with her. She will move through the world estranged and enwrapped in a deep feeling of distrust toward others, and she will expect, consciously or unconsciously, absolute randomness, no solidarity, and no protection.Footnote ¹² This has been widely documented in research on traumatic childbirth (Chadwick Reference Chadwick, Pickles and Herring2020) and on PTSD as a consequence of traumatic childbirth (Beck Reference Beck2004b; Elmir et al. Reference Elmir, Virginia Schmied and Jackson2010; Polachek et al. Reference Polachek, Harari, Baum and Strous2014). In the testimonies in which Chilean women compare childbirth to torture, this “staying tortured” and no longer being able to feel at home in the world are clearly depicted. Mariana reports that “the damage to my person was irreversible” (7578); Patricia recalls that after childbirth, she “suffered physical and psychological damage, and I took the decision not to have any more children; to this day I have nightmares about my experience, even though my son is 20 years old” (6054); and Camila reports that she “went through a long depression, nightmares, pills, insomnia . . . I couldn't go near the hospital because I would have a nervous breakdown” (8173).

Several analyses of obstetric violence and the resulting trauma propose that what is lost in those cases is, mainly, the victim's trust in the world and other people (Elmir et al. Reference Elmir, Virginia Schmied and Jackson2010; Simpson and Catling Reference Simpson and Catling2015). Recently, Sara Cohen Shabot has discussed obstetric violence as constituting a rupture between the birthing subject and the significant others around her who are expected to participate in her labor and to engage with her and with the specific state of vulnerability she finds herself in, with solidarity and support. In obstetric violence, Cohen Shabot argues, our original link with the world and others and our intersubjective and ambiguous phenomenological conditions are violated and destroyed. Thus, what is painfully absent is the recognition of our being interdependent subjects and the fact that we usually “birth with others.” Cohen Shabot writes:

In conclusion, if we recognize the need to acknowledge victims of torture and the lifelong consequences of torture that they carry (including a profound ontological solitude and a devastating loss of trust in the world and others), then we are also undoubtedly obliged to acknowledge that many victims of obstetric violence remain wounded and scarred forever as well. This might bring us closer to universal agreement on what should by now be a categorical and indisputable truth: that a healthy baby is not “all that matters” and that obstetric violence, as torture, constitutes a dehumanizing practice that takes an enormous, shattering toll on its victims and must, as such, be forcefully resisted.

For obstetric violence, as well as other forms of gender violence, to be resisted, the androcentric and sexist cultural frameworks in which they are embedded need to be made visible. As we have discussed, obstetric violence is a particular kind of gender violence, one that is hidden behind the good intentions of a medical system that declares care to be a fundamental principle. Thus, it is only by understanding biomedicine as a cultural system that reproduces the power and gender inequalities of the broader societies that we can adequately tackle the problem. Otherwise, we run the risk of defining the debate either around individual cases of malpractice, creating unproductive hostility toward any discussion of the problem (Sadler et al. Reference Sadler, Santos, Ruiz-Berdún, Rojas, Skoko, Gillen and Clausen2016); or as a mere problem of “quality” of service resulting from the difficult working conditions of the health personnel or from the lack of ethical training (Castro Reference Castro2014); or as an issue of women's lack of “autonomy” or “empowerment” (Sadler Reference Sadler2021). That is, we run the risk of reducing the problem of the violation of human rights in childbirth—which can even rise to the level of torture—to individual or organizational problems, instead of understanding it as involving collective and structural ones (Castro Reference Castro2014; Sadler et al. Reference Sadler, Santos, Ruiz-Berdún, Rojas, Skoko, Gillen and Clausen2016).

A broader approach needs intersectional measures that promote comprehensive gender and sex education curricula beginning in early childhood and continuing through university, exploring explicit and hidden agendas, in this case especially those concerning health; that question the fragmented and pathological description of female bodies that biomedicine reproduces; and that recover the psychosocial dimensions of health and care, which have been subsumed under the hegemony of the physiological body.

Relevant legislation to address obstetric violence should be pursued, as several Latin American countries have done over the last decade And although “legislation alone will not solve the problem of maternal mistreatment . . . it provides a solid foundation on which to build societies that protect the human right to dignified, quality maternity care” (Williams et al. Reference Williams, Jerez, Klein, Correa, Belizan and Cormick2018, 3). Legislation has in fact been accelerating the discussion of new guidelines and accountability procedures in the region, hand in hand with advocacy groups documenting women's experiences of care and informing women of their rights in obstetric settings (Williams et al. Reference Williams, Jerez, Klein, Correa, Belizan and Cormick2018). In fact, women's embodied experiences have taken center stage in the latest international health guidelines for childbirth, which highlight the importance of woman-centered care through a human rights-based approach (WHO 2018; Lalonde et al. Reference Lalonde, Herschderfer, Pascali-Bonaro, Hanson, Fuchtner and Visser2019).