”Hedra din fader och din moder för att det må gå dig väl och du må länge leva iHäromdagen slog det mig om det första budordet (fick lova att kolla vilket nummer detta budord har och det är alltså till och med det första) och vad hon skrivit om guruer:
”Du ska inga andra gudar hava jämte mig.”Tänker på nyauktoritära tendenser idag, behov av starka ledare… Auktoriteter… Och hur vi fostrar barn, kanske redan tidigast i livet... Och vad det sedan leder till...
Tillägg: Egentligen skulle kanske rubriken på detta inlägg ha varit "Du ska inga andra gudar hava jämte mig"!?
The first commandment...
Alice Miller has written about the fourth commandment, that you shall honor your father and your mother...
The other day I came to think about another commandment and actually found it was the first, apropos gurues, which Miller writes about too. This commandment says something in the style that you shall have no other Gods in addition to me...
I thought further on neo-authoritarian tendences today, and shouts for strong leaders here and there... And I am thinking further on how we raise our children, maybe even earliest in life, even seen in the light of this commandment "You shall have no other gods"...
And what this leads to later in life. Evene if we are very secularized we are still living with these commandments...
Maybe this commandment though isn't as powerful as the fourth? But I came to wonder how strong this commandment's "spell" is? Just some thoughts I got suddenly...
Unfortunately I don't have the proper English translation to the commandments.
Tillägg 6 december:
Vill spara det engelska utdraget ur Kirkengens bok "Hur kränkta barn blir sjuka vuxna":
How Abused Children
Become Unhealthy Adults
Anna Luise Kirkengen
Universitetsforlaget, Oslo 2005
Sample Chapters and Excerpts
Translated from Norwegian
Susan Schwartz Senstad
Table of Contents
Intentions and Introduction 15
Part I Individual Experiences 23
Fatal Insecurity 25
Professional Experience 26
Damaging Contexts 28
Dividing Categories 33
Destructive Impact 36
A Possible Analogy 42
Protective Splitting 47
The World We Can Perceive 47
Typology of Pain 49
Serena Sager’s Pain 51
Disturbed Consciousness 53
Harmful Repetition 55
Invisible Life 56
Body Divided 60
Frank Finse’s Pain 67
Body Theory 68
Part II Social Frameworks 79
Violent Trajectories 81
Site-specific Memories 81
Katarina Kaplan and the Hand 81
Tanja Tambs and the Bed 84
Elianne Ekgren and the Doctors 86
Similarities and Differences 87
Similarities in the Abuse Histories of Veronika Vikander,
Fredrik Ferger and Judith Jansson 91
Differences in the Illness Histories of Veronika Vikander,
Fredrik Ferger and Judith Jansson 91
Veronika Vikander and Her Voices 92
Fredrik Ferger and His Epilepsy 98
Judith Jansson and Her Mouth 100
Vicious Circles 103
Typology of Pain 103
Syndemiology of Violence, Pregnancy and Childbirth 107
The Emergence of Violence 112
Injured Girls Become Injured Mothers with Injured Children 114
Childbirth Psychosis 119
Back Pain 122
The Monster 126
Night Noises 129
Part III Structural Phenomena 133
Destructive Authority 135
Victimization and Revictimization 135
Revictimized Through Medical Treatment: Gunhild Grura 136
Abuse of the Role of Caregiver 139
Revictimized Through Medical Treatment: Elisabeth Engh 140
Persistent War Experience 142
Differing Realities 144
Revictimized Through Medical Treatment: Camilla Crohn 148
“Overlapping Pains” 150
Revictimized Through Medical Treatment: Thora Tjessem 152
“Sexual” Pain 158
Revictimized Through Medical Treatment: Arja Askild 160
“Sexual” Infection 167
Paternal Power 171
Linnea Lindberg 171
A Letter 171
A Dialogue 172
Julia Jensen 181
Three Medical Attestations 181
The Hierarchy of Medical Knowledge 187
Medically Based Justice 191
Intentions and Introduction
I address this book about how personal integrity violations lead to illness to my colleagues who practice, do research, teach and write within the field of general and specialized medicine. I also address researchers and clinicians within health-related professions, such as nurses, psychologists, physiotherapists, midwives, pediatric nurses, and consultants in ergonomics. Furthermore, I address all professionals working with children, such as teachers, child care consultants, speech therapists, social workers, and special education teachers. I wish, moreover, to reach those in the legal professions. This includes the police because lawyers, judges and police personnel come in contact with people, old and young, who are being hurt or have been hurt in the past by other people's lack of respect for their personal integrity.
I also address politicians and lawmakers since they are in a position to translate knowledge regarding boundary violation into viable initiatives and laws. The initiatives must have as their goal the prevention of humiliation, violation, injury or abuse, particularly of people who are young and dependent. They must also aim to insure that all people, regardless of where they are or where they go, can trust that they will be valued and treated with respect. Laws must have as their aim that all people, especially those who are small and dependent, who have already been humiliated, violated, injured or abused receive the help they need, and in abundance. They must also aim to insure that all people who have been treated with disrespect or contempt can regain their sense of self-worth and self-respect.
First and foremost, however, I address this work to students within medicine and other health professions. My declared aim here is to point out in what ways a dualistic view of the human being and his body is untenable, how it leads both to a dualistic health system, one somatic and the other psychiatric, and to a dualistic conceptual world, divided into one classification system for somatic illnesses and another for mental illnesses. Medicine and related fields of study rest on this divided and dividing knowledge and students are trained to think those terms. I beg students not to allow this way of thinking to wipe out what they know about themselves, and, consequently, about other people as well: that they are unique individuals with mindful bodies.
In the hope that this book may also reach people outside the medical professions, I have chosen to use everyday language. Issues of integrity and violation are, in fact, themes all people share. We are all vulnerable, not just a few of us. In addition to our being mortal, what human beings have in common is the fact that we can all be humiliated.
In a way, I represent two different fringes, one professional and the other socio-cultural: I speak from the lowest rung of the medical knowledge hierarchy and on behalf of humiliated people. I have learned from anthropologists, however, that fruitful analyses and critiques of what is regarded consensually as normal may well come from precisely such marginal positions. And that is just what I intend to do – to offer explicit and, hopefully, constructive professional criticism.
My entire concern here is ethical in nature. By that I mean that what I consider to be the basis of the entire realm of medical knowledge – a biological, organ-divided body rather than an embodied being and which thus bears within it neither meaning nor experience – to be wrong. The nature of such knowledge – a concentrate of objectifying and abstracting observation – seems to me to do the nature of the human being an injustice.
To make my position as clear as possible, I have asked the help of philosopher and ethicist Arne Johan Vetlesen to sort out and clarify my thoughts. Our exchange of thoughts was prompted by a report on a conference in a field which, in medicine, is often referred to as "the front lines." This war metaphor implies that here, in the neurosciences, in brain research and genetics, is where the "battle for health is fought."
The year is 2003. When 30,000 researchers within these specialties agree to meet in the
to discuss the topic of "Neuroethics," we can be certain that medicine's elite are assembled. In his keynote lecture there, Donald Kennedy, Editor-in-Chief of the journal Science, thematizes the potential ethical dilemmas connected to new medical imaging technology. He focuses on the MRI (magnetic resonance imaging), a technique that makes it possible to observe brain activity in subjects who are awake. Using a hypothetical though realistic scenario, he problematizes the use of MRI as a psychotherapeutic tool. U.S.
Kennedy opens with the question, "I am much more than my genes, they are not my essence, they are not my soul; is then my consciousness, my brain, me?" Then, he guides his listeners through the tale of a teenage boy who suffers from sudden episodes of rage during which he goes berserk and smashes everything in sight, though he never attacks people. He is diagnosed as having an antisocial personality disorder and enters into psychotherapy. His rages, however, only increase and he is eventually expelled from school. An MRI examination of his brain reveals alterations in certain areas. The results are interpreted as indicating that he is suffering from post-traumatic stress disorder, possibly as a result of having been abused earlier by one of his parents.
To further clarify the results, the examination is repeated under slightly altered circumstances. This time, and with no prior warning, the boy is shown manipulated film footage of his parents arguing and of one of them hitting the other. Upon his seeing these scenes, the MRI reveals intense activity in the area of his brain called the amygdala, but not in the frontal cortex. Those examining him conclude that the boy has a predisposition to go into intense rages in situations that elicit his anger. They consider it likely, based on these same findings, that the boy will continue to suffer such outbursts in the future. Moreover, they are convinced that the condition will worsen with time rather than improve.
Kennedy adds the following questions to this scenario:
· Was it legitimate to manipulate film footage in order to study the boy's reactions?
· Did this case represent a legitimate usage of the MRI?
· Ought the use in this case of MRI have been approved by the institution’s authorities?
· What routines ought to be followed in cases such as this?
· Who should have been involved in the diagnostic process?
· Should the boy have been forewarned regarding the film's contents?
· Should consultants or the boy's parents have been informed or present?
· Should the boy be informed of his prognosis?
· Were the boy to be involved at a later date in an assault against a person, could the center where he was diagnosed be held accountable?
To me, Kennedy' ethics-related questions, taken singly or as a group, as a mere cosmetic exercise in deference to the etiquette of research and clinical practice, provide evidence of an ethics "gone astray." According to my understanding, something fundamental is missing here, and something extremely important seems to have been forgotten. I interpret this scenario as an incidence of medical injustice. What does the ethicist say about this story and these questions?
Arne Johan Vetlesen
To be honest, I'm at a loss for how I, as an ethicist, am to relate to the case description you present. Were one to respond to the nine questions Donald Kennedy asks, it might seem as if one had tacitly accepted his premises and were adopting his perspective, as if there were agreement as to what is ethically relevant or problematic about this casuistry.
The alternative to being trapped with the cards as Kennedy had laid them out would be to reject his list of questions. One may place oneself at a safe distance from Kennedy’s premises and his perception of what constitutes ethical relevance. One might declare, with an air of superiority, that such manipulation must be rejected as a matter of principle because it involves a violation of the boy's moral status, his capacity to think, feel, draw conclusions and act on his own premises and toward his own objectives; he is not someone who simply "responds" in such-and-such a way to the stimuli which the manipulation of him (or the experiment, if you will) subjects him to and makes him the object of. In short, one may protest that such an objectification of his role and behavior is morally abhorrent, and that, consequently, the list of questions which Kennedy prepares – on the basis of a manipulation – must be rejected en masse.
I experience a certain discomfort and dissatisfaction with both these response alternatives as they stand here as if mutually exclusive. With that said, I do lean toward the latter opinion. It seems that Kennedy overlooks something fundamental when posing the questions he does. The implication may be seen as the drawing of a distinction between a person’s becoming a means (an object) serving extreme influences or aims versus that person being protected and inviolable, an aim in and of him/herself (as in Kant's concept of a person's intrinsic, inviolable dignity, or Würde).
Anna Luise Kirkengen
I share your discomfort in that I can not accept Kennedy’s premises. Consequently, I will not suggest any answers. At the same time, I don’t feel quite comfortable simply rejecting the questions as a group since something of great importance emerges from the manner in which they are formulated: they reflect a general medical supposition concerning the professional level at which ethical questions are to be considered relevant. I’m glad that you too find that anyone posing such questions is overlooking something fundamental, and I have an idea what that may be.
All the questions relate solely to the application of medical knowledge that in itself is defined as both valid and value-neutral. They relate to the situation, one in which the latest medical expertise and technology are applied to give access to previously “unseen” and unknown places and functions within the human body but before this new and advanced approach has found its place within the routines.
The questions do not relate to the boy’s person, situation, needs, or to his relationship to the people examining him or his experience of that examination. Even the one question that apparently focuses on him as a person, whether he ought to be informed about his prognosis, is not posed with the idea of taking care of him as its basis. In fact, that question makes of him even more of a non-person than do the other questions. The people examining him seem to believe that they have knowledge regarding both what they have “found,” by help of a manipulating and abstracting technology, and about what their findings enable them to predict for the future. Based on mapped brain activity, both a truth and a certainty about a person, about the brain’s so-called “owner,” are established. He becomes literally invisible, unreal and unimportant: invisible, because he does not fill his examiners’ field of vision, only his brain does; unreal, because his personality and distinctive characteristics are subordinated to knowledge about brains in general; and, unimportant, because the technology and not the nature of a human being informs the premises on which the results are interpreted.
Nor do the questions concern the origin or nature of the knowledge. To ask such questions is defined as irrelevant since methodological purity is presumed to underwrite how the knowledge is generated. This means that during the process of producing the knowledge, throughout all the steps involved in the examination of the person, including his brain, one has applied methods that assure objectivity. In such research, the person is an object. His personal qualities, his human experiences and his other characteristics are excluded from the observation.
To summarize and clarify what I’m saying: The questions reveal that those conducting the examination do not relate their ethical considerations to the person they are examining, the knowledge base from which they are drawing, or the production of that knowledge, but solely to how the knowledge shall be handled such that their professional practice may be defensible ethically. That is what I was referring to at the outset when I spoke of “ethics gone astray.” Would you be so kind as to evaluate my arguments?
Arne Johan Vetlesen
What modern medicine names and recognizes as knowledge is information and data of the sort which is suited to being observed, measured, weighed, predicted and controlled. In short, the medical gaze on the human being (regarded as a biological unit divided up into organs, a complex machine with many functions per part) is one which sees and attributes relevance to that which can be dealt with technologically; relevance is determined in reference to the investigator’s possibilities, although without this affinity, this reciprocal reference, actually being thought about, being brought into awareness as only one of a variety of possible perspectives open to the professional.
To the extent that there is something selective, yes, even blind, in this approach to the human being and his suffering and pain(s), one may presume that “the error will be discovered.” But can this approach, this seeing with an objectifying eye, be revealed as deficient? It would have to reveal itself, to succumb to its own methods. I doubt that can happen. We know from Thomas Kuhn that the way “normal science” functions is that the individual practitioner is on the lookout for validations of his fundamental, tacit presuppositions (prejudices, according to Gadamer), sooner than for their negations. This tendency is strengthened by the continual arrival of more sophisticated equipment and apparatuses for observing, measuring, predicting, and controlling what is defined (contingent upon diagnoses, etc.) as relevant patient data precisely at the, in principle, measurable and visible symptom level.
It may seem as if medicine lacked a core concept for, and adequate access to, the causal dimension of suffering and pain. Is this the dimension with which etiology should be concerned? But, in what way, and true to which premises as regards methodology, ethics and the human being himself?
At the level of causation, medicine must ally itself with the best of the philosophic tradition, which, of course, is not singular but manifold. Heidegger’s early work has an important contribution to make here. In the event of sickness, the phenomenon which is to be understood, the suffering to be assuaged with human assistance, is a constellation of irreducible factors: the person’s biography as a strictly individual sequence of events; that same biography, but now in intimate interaction with the “lifeworld” as a collective phenomenon; the same again, this time situated within a specific historical epoch, which provides a horizon, a repertoire of interpretations and ideas, of projects for the single individual. No sickness or suffering is without history. The sufferer is doubly situated, within a societal lifeworld and within its historicity.
Anna Luise Kirkengen
It strikes me as very important that you emphasize the existence of reciprocity, presumably not reflected upon, between the technologies that medical practitioners have at their disposal and the phenomena they consider relevant in the research they do and the treatment they offer. It is precisely the way each one refers back to the other that influences or determines what is not seen and cannot be made visible. It sets the stage for excluding information and for a special form of blindness.
What is excluded is characterized by being precisely the essence that is invisible to the technological, medical eye. Since suffering can not be separated from life as biography and history, and as suffering can neither be objectified nor made abstract, an apparent paradox arises: ever more sophisticated medical knowledge and technology result in less understanding and greater powerlessness in the face of an ever increasing variation in the forms of suffering. The paradox points to its own origin: the knowledge, though very advanced, is inadequate. The paradox points also to a flaw: The high degree of sophistication of one type of knowledge does not compensate for the nearly total lack of another kind of knowledge.
An abstract, objectified micro-knowledge of human genes and human brains is ascribed the utmost medical prestige. So dominating is this prestige that the professional practitioners who create and use the knowledge become accustomed to thinking that it expresses what is most important about human beings. As a result, they also get used to believing that it expresses what is most important about that individual person.
Thus, we come back to Donald Kennedy’s opening question, “Is, then, my brain me?” Would you please round off our exchange of ideas by reflecting on that question?
Arne Johan Vetlesen
It is probably no better to declare or suggest that I – a person, after all – am my brain than that I am my genes. My ethically relevant identity, or integrity, or personhood, cannot – particularly not in the form of a reductionist one-to-one relationship – be accounted for, organized or conditioned by one side of my existence as defined in terms of natural science or medical biology, whether that be on the basis of my genes or my brain.
The ethically relevant aspects of our being-in-the-world, of our humanity, transcend the characteristics (properties) that enter into these sciences’ or approaches’ instrumentarium. What are they? Are they metaphysical, or speculative? Well, they concern precisely the qualities we have that enable us to go beyond such properties and their measurable and observable factuality. The ethically relevant aspects of our being point in the direction of something non-material, because that is precisely where they originate
As we all know, the way we view the world, the ideas and categories we use to interpret and to sort our thoughts, and the frameworks or spheres of interest within which we orient ourselves all influence what we consider to be a problem. In other words, it makes sense to say that anyone regarding a phenomenon or discovering a problem is, himself, situated, and, being situated, he is not free to think everything possible about that phenomenon or the problem. To be situated is every person’s fate; as social beings all people are deeply influenced by the society in which they live and the life they experience. No professional socialization can wipe out this fundamental premise for human existence. On the contrary, each socialization into a profession or field of knowledge leaves a person doubly situated: once within the general society and again within that specific field. Consequently, doctors exist within their own lives and experiences, are members and bearers of the values of their society, and are also representatives and practitioners of their profession. These three fundamental aspects of doctors’ lives constitute the basis for their duties and obligations. Thus, doctors’ knowledge base is not neutral but rather is governed by choices and evaluations. Nor, then, is the basis on which doctors act neutral but is governed by ranking and prioritizing. This means that the entirety of their professionalism, not just their mandate but also their practice and their attitudes, is justified by and grounded in ethics. Ethics, consequently, must take precedence over all their knowledge and competence.
Even more specifically, General Practitioners are not just situated by virtue of their life, society and profession, but also through their role as the point of entry into the medical system: they stand where the people seeking help meet the ones offering it, in the arena for unsorted needs, at the entrance into vast yet limited resources and possibilities, the system designed to take care of people’s health. This means that the mandate of General Practitioners is crystal clear in theory yet almost completely impossible in practice. They are to sort people according to distinctions that, while being unambiguous in theory, do not exist in actual practice. Their mandate presupposes that social relationships – people’s lives and relationships to others – and their health situation – their illnesses – exist independently of one another. That mandate is built on an assumption that social theories about life within relationships, society and a specific context represent one field of knowledge, and that this field of knowledge is distinct from, and different in essence from, medical theories about the human body, the body’s parts and those body parts’ function.
I have been a General Practitioner in western
for 30 years. Most of my patients have been women, of all ages and stages of life. I remember well my shame when I realized how little I actually knew about my patients' lives. I had been examining and trying to treat two of my female patients for extensive loss of function for quite some time, though without success. I then discovered, and at about the same time, that they were both being beaten regularly by their husbands. Both men customarily "legitimatized" their violent acts. One blamed his drunkenness, the responsibility for which he assigned to my patient as she had provoked him by nagging, and for that provocation she would have to accept her punishment. The other man cited the Bible giving him the right to chastise a sinful and disobedient wife, which he claimed she was. For him, it was always useful to drink a little hard liquor before the punishment began, but that too was her fault: he, a believing Pentecostal Christian and a highly regarded leader of the congregation, had to drink from time to time because she was promiscuous and “cozied up” to other men at the Church meetings. Both women later developed breast cancer, and both told me after their operations that their men had stopped beating them. One of them experienced severe complications during follow-up treatment. The other struggled with unyielding pain in the area where she had been operated on. Both died of their cancers within two years of their operations. Both left behind teenage children. Oslo
It is possible that these women might still have been alive had I understood sooner just what of a strain they were under. However indirectly, their bodies had in fact sent me signals of their powerlessness. Both had an abundance of those symptoms which medicine tends to define as “diffuse and indeterminate.” What appeared that way medically would have been quite palpable socially. But they each had a public standing to uphold and a family’s reputation to protect. They were ashamed of being married to such men and tried as hard as they could to act as if all were well – even as their ebbing energies betrayed them. This took the form of an illness with no medical findings, and pain without organic malfunction. They were constantly on the alert to prevent an outburst and, failing that, to keep the children from noticing and the neighbors from hearing. Still, they knew well that the neighbors knew. But “everyone” entered into a tacit social agreement to maintain silence about the paternal violence going on behind closed doors within the protected zone called private life. I contend that this protection cost these women their lives.
I had to admit that I had been a blind and deaf physician to these two women. During the same period, I gradually understood that even nonviolent violation can kill, albeit indirectly. One of my young, healthy and happily pregnant, well-educated and self-aware patients was expecting a second child with her equally well-educated and healthy husband of her dreams. From the 24th week on, she became increasingly ill and the outpatient maternity clinic and I were at our wits’ end. The baby needed to be rescued in the 32nd week by means of Caesarean section. Once the woman came out of the anesthesia, she fell into a deep depression and the staff at the women’s clinic mobilized all their resources. An experienced family therapist was called in to meet with the couple and, it emerged slowly that the woman’s husband had had sexual relations with six different partners during her pregnancy. She had known nothing of this but had felt a deep sense of anxiety that she could not attach to anything concrete. His escapades, which he covered up with politeness and seemingly generous care, had nearly cost their child his life.
In the meantime, several others of my female patients, whose extensive medical problems necessitated their going on disability, revealed to me another destructive font of suffering – sexual abuse during childhood. This led me to conduct a half-year pilot study in my practice in which I followed-up gynecological examinations with a questionnaire about sexual violation experiences. Eighty-five of the 115 women who met the study’s criteria allowed me to interview them. Twenty-four of these had been sexually violated at least once in their lives. I had known all of these women prior to this study, most of them for years, yet I knew about the violation experience of only one of them. My further research into how childhood sexual violation can lead to adult health problems sprang from there.
I have spoken with many adults who lived out their childhood in what I would call “unboundaried” families. By that I mean families in which the adults did not respect closed doors, personal letters, diaries or closed drawers, in which the children’s body parts were not off-limits to other people’s hands, in which all confidences were made public, homes where children were shamed and ridiculed in front of others, where corporal punishment was meted out, arbitrarily, and where the adults lied and refused to take responsibility. In short, these were homes in which the child was not shown respect, and where the child’s personal integrity was scorned.
To bring life to the previous theoretic and clinical reflection, let me turn now to Lene Larsen. As she says:
I moved out of the house when I was nine because my mother drank. I was sent to an institution a couple of years later and was diagnosed with AD/HD. My time at the institution was very heavy. I kept to myself a lot and never went out with friends or people my age. I felt terribly down and depressed, no one understood me, and I didn’t feel like I fit in anywhere. I sat alone in my room a lot those days. Then I started to take drugs. I’m not even 20 yet and I’ve already been a drug addict for 7 years. I’ve been sent to
for treatment since there’s no good institution for me in the area I come from. Here is the scene much tougher than where I come from. But dope is much cheaper. Still, it’s expensive enough that I have to steal or work as a prostitute. Here in Oslo , it’s easy to steal, and then easy to sell things to small stores. The place I come from is so small that everybody knows you, so it was impossible to sell the stuff you stole. Oslo
I will analyze Lene Larsen’s story with reference to three phenomena. The first regards a theoretically based division between life and suffering. The second is anchored in epistemology and has to do with categories. The third concerns a medical artifact called chronification. Just how these three are connected to my daily work as a doctor will become clear through three pieces of research: a Norwegian sociological study; a U.S. Community Medicine study; and, a British General Practice study.
Researchers at the
for drug-related problems carried out a study of 291 users from all the public addiction institutions and clinics in the districts of Oppland and Hedmark. The study shows that 90 percent of the drug abusers had suffered from psychological disturbances during their lives, with depression and anxiety being those most frequently cited. The research indicated that the number is probably too low since the youngest addicts, among whom psychological disturbances are quite common, are under-represented in the study. Three of five drug abusers report having suffered from these disturbances before they began using drugs, often while they were still children. The researchers concluded that the use of drugs is an effect rather than a cause of psychological disturbance. They understood it as a form of self-medicating, a self-administered anesthetic. Eastern Norway Resource Center
The researcher’s use of this interpretation points to structural conditions creating or reinforcing both social and medical problems. Until recently, psychiatric patients who use drugs were considered psychiatry's responsibility. Psychiatrists are members of the health services that are led by physicians who are influenced by a biomedical language and knowledge base. Drug users suffering from psychiatric disorders, in the meantime, were considered the responsibility of the drug abuse agencies. Their clinics are part of the social services, led by social scientists who are influenced by their own disciplines' diverse languages and knowledge bases. Drug users with psychiatric illnesses have often been without access to psychiatric institutions specifically because of their taking drugs. Many of the drug abuse sector’s patients have been psychiatric patients previously. This does not mean that they started out in the wrong place but rather that they have received the wrong treatment. The help offered them failed to prevent their use of self-anesthetizing intoxication as a destructive form of "self-help" for an unidentified condition. In other words, an illness has become chronified as a result of the health services' incorrect interpretation of its cause. According to medical categorization, such patients have "double diagnoses." The term documents two situations: First, medicine defines substance abuse and mental illness as two independent variables. Second, medicine conceives of the mentally ill, substance abusing individual as the locus of two types of pathology. Only now are attempts being made to offer a treatment to people diagnosed with both depression and substance abuse that is based on the hypothesis that these might be connected or share a common, underlying cause.
Let us return now to Lene Larsen. She grew up in the care of a substance abuser, her alcoholic mother. The mother's abuse was so severe and the quality of care she gave so poor that this nine-year old "moved out." That phrase can either summarize the entire drama – Lene was moved out of her house at the initiative of Child Protective Services – or can be seen as a euphemism for fleeing. Lene's house was not a home; it was an un-homey place. American sociological studies have shown that so-called "run-away-kids" are fleeing from un-hominess. That may mean violence, abuse, maltreatment, or neglect under a variety of circumstances, including substance abuse and mental illness among the adults in the child’s home. We know that the children of depressed mothers run a high risk of future depression. In the teenage children of depressive women, this may be seen as being mediated through characteristic day and night rhythms of cortisol. We know that the children, particularly the sons, of women suffering from depression during and after pregnancy may develop cognitive problems later and may become violent, acting-out teenagers. We have indications that maternal stress and difficult events within the family can contribute to the development of childhood diabetes.
Furthermore, we know that the probability is great that mothers of sexually and physically abused children are themselves abused women, and, with a nearly equal likelihood, were sexually or physically abused when they were girls. We know that female substance abusers often live in unstable relationships, quite often with various partners who are violent. Therefore, in addition to being badly cared for, their children are also at particular risk of being sexually and physically abused. We know that women who abuse alcohol often bear children with birth defects, and that their children are more often diagnosed with AD/HD. We now have documentation that connects pregnant women’s levels of anxiety and stress to their children’s pre-natal health and future learning disabilities. Studies also show a statistical correlation between severe stress during the first trimester of pregnancy and specific forms of deformity.
Un-hominess early in life creates extreme vulnerability. In an American study, this was documented using epidemiological methodology. Among 17,000 adult users of a primary care polyclinic, all of whom held full-time employment as a pre-condition for being included in the study, researchers quantified the correlation between certain adverse childhood experiences and risk factors for the most frequent causes of death among
adults today. The study has now been deepened through over thirty sub-studies, all of which have been published in prestigious medical journals. U.S.
These “adverse childhood experiences” were divided into two categories, one for the psychological, physical and sexual abuse of the child himself, and one for various problems such as growing up with a single parent, living with an adult who abuses alcohol or narcotics, living with a mentally ill adult or one who has attempted suicide, seeing one’s mother be abused, and living with an adult who has been convicted of a crime or imprisoned. These were then correlated to the following ten risk factors for illness: smoking, obesity, physical inactivity, depressive mood, suicide attempts, alcoholism, all forms of narcotics abuse, parents with substance abuse problems, having had more than 50 sexual partners, and sexually transmitted diseases. The possible correlation between the above mentioned childhood experiences and the ten risk factors were then analyzed with reference to the seven leading causes of death among adults living in the West: heart and vascular diseases, strokes, all forms of cancer, chronic respiratory diseases, diabetes, hepatitis and jaundice, and broken bones (as a measure of injury).
Researchers found strong correlations between adverse childhood experiences and risk factors for premature death among adults. These increased in strength when several types of adverse experience were present. The conclusion arrived at was that the adverse impact of adverse experiences is both strong and cumulative. Vincent Felitti, the leader of the study, summarized the findings, under the evocative title, “Turning Gold into Lead,” as follows:
We found that such adverse childhood experiences are quite common although typically concealed and unrecognized; that they still have a profound effect a half century later, although now transmutated from psychological experiences into organic disease; and that they are the main determinant of the health and social well-being of the nation. Our findings are of direct importance to the everyday practice of medicine and psychiatry because they indicate that much of what is recognized as common in adult medicine is the result of what is not recognized in childhood. The ACE Study challenges as superficial the current conceptions of depression and addiction, showing them to have a very strong dose-response relationship to antecedent life experiences. (Italics mine)
The researchers themselves posed the most significant question the study had generated, which they found imperative to address although the study’s design did not suggest an answer: “Exactly how are adverse childhood experiences linked to health risk behaviors and to adult diseases?” I have taken the liberty of amplifying the question as follows: “What thoughts and ideas about human experiences and the human body must the field of medicine develop so that health professionals can understand how violations which, while not taking the life of the child may, nonetheless, kill the adult whom that child becomes?”
With that question, we return to Lene Larsen. Even the brief, newspaper vignette version of her 20-year life opens the way to comprehension. There can hardly be a shorter description of: how a childhood filled with great insecurity put her future adult life at great risk; how the child’s life is marked by the mother’s risks; how degradation, gross neglect, and sexual and physical abuse interact, spiraling through the generations where wounding, vulnerability, krenkethet (a Norwegian word meaning violation) and Krankheit (a German word meaning illness) operate in a joint, destructive dynamic. Lene’s mother abused alcohol. She most likely had experiences that made her longing to anesthetize herself so intense that she failed to care for her daughter and eventually lost her. By the time Lene is 9-years old, she has already had her existentially crucial trust in life destroyed. She has learned that she must tolerate being neglected by the person or people closest to her. She has not learned from respectful adults how to show respect for other people’s dignity. Consequently, she has no foundation for self-respect or self-esteem. An upbringing filled with instability, unpredictability, irresponsibility and injury leaves its imprint on her existence. This deeply troubled child, accustomed to chaos and precariousness, receives no help to calm down. On the contrary, she is assigned a psychiatric diagnosis. She is abandoned to her diagnosis, impotence and chaotic self-image and image of the world. That she soon repeats her mother’s strategy for escape, self-anesthesia, follows life’s logic. It makes psychological sense that her life’s choices be characterized by self-destructive negligence. It makes sociological sense that she has to pay for her escape from pain and upset with money garnered through self-degrading thievery and prostitution. And these connections multiply her risk of death by a factor of five as compared to other women her age.
Lene exemplifies how early violation becomes embodied. She “answers” researchers’ questions as to, “exactly how adverse childhood experiences are linked to health risk behaviors and to adult diseases.” People like Lene don’t actually practice “risk behavior” as the objectifying researcher’s external view regards and defines it; she practices learned powerlessness, self-contempt and self-destructivity. She has known since she was small that she’s not someone anybody cares for, protects or values. How then could she think of herself as worthy of respect? No one has helped her to understand what she does, the behaviors she repeats, or why she does precisely those things, apparently willingly. She has been placed within the categories which the health and social services have created and divided among themselves: those who are grossly neglected, Child Protective Services children, the mentally ill, substance abusers, drug addicts, prostitutes, risk takers, criminals. This can be inferred from what Lene tells the journalist. Ordinary professional knowledge and life experience call to mind more categories that might be or become relevant; truancy, unskilled labor, eating disorders, bullying, teenage pregnancy, injuries due to violence, sexually transmitted diseases, infectious hepatitis, HIV-positive, self-mutilation, abortion.
All these categories subdivide life’s coherence. The fragments belong to various areas for “special care” where the personnel treat each fragment as if it represented a whole, lived life. They treat the pieces, the constructs, that is, the artifacts. They base their intervention on current science but ignore current experiential knowledge. They have a mandate to help, treat, and heal, but they practice subdivision, and they chronify the experience of powerlessness.
Lene Larsen is thus both a person and a prototype. There are many women whose lives contain similar elements. New American and Canadian studies of women diagnosed with severe psychiatric disorders show a 55% to 79% occurrence of having experienced violence incidents, often repeated and of various kinds. There is also a high rate of experienced violence among women who visit General Practitioners. In one study of childhood and adult trauma among female patients at 13 primary care offices in
, researchers found not just that the incidence of general violence was frighteningly high but also that the experience of violence during childhood carries with it a high risk for being exposed to violence again in adult life. Incidents of rape during childhood were predictive of rape and violence in adulthood; experienced childhood physical violence was predictive of rape, violence and other trauma during adulthood. The researchers concluded that, “Childhood abuse substantially increases the risk of revictimisation in adulthood. Women who have experienced multiple childhood abuse are most at risk of adult revictimisation. Identification of women who have undergone childhood abuse is a prerequisite for prevention of further abuse.” London
Both the British and the American studies document an indisputable connection between early violation and future illness and premature death. Researchers’ unambiguous message is that these correlations ought to be of interest to experts in all professions which are mandated by society to care for people with special problems, such as: drug addicts, alcoholics, prostitutes, the psychologically disturbed, abused children, women at crisis centers, rape victims, victims of bullying, those injured through violence, smokers, obese people, anorectics, people with heart and lung diseases, cancer patients, etc. Researchers provide the raw data for discussion of how such connections come about. They do not, however, offer even a rudimentary way of thinking to make it possible to comprehend the destructive power which, while not taking the life of the child may, nonetheless, kill the adult that child becomes. But Lene Larsen has the answer hidden in her story. Early wounds, even those leaving no visible trace of where the violence occurred, create a pain which provokes strategies for flight and self-numbing which, in turn, maintain the woundedness and increase the vulnerability. A child whose dignity is violated becomes an adult who cannot value life and health.
These two studies were considered so significant and sensational that they were accompanied by editorial comments. The commentators explicitly stressed the inherent ethical responsibility the results places on all health professional. The studies show not just that violation and illness are undeniably connected, though it is still unclear, medically, just how. They also document how little weight health professionals give to traumatic experiences as a factor in people’s health. They make it clear that doctors, by and large, do not collect information regarding trauma except for those stemming from accidental injuries. Consequently, the commentators deem it professional negligence not to inquire actively as to the existence of violation experiences, or to ignore reports of helplessness which the patient offers unasked. In fact, both of these occur, and they contribute equally to the fact that such experiences are not part of the medical experts’ evaluation of an actual illness.
Moreover, the commentators call attention to the British study’s finding of a pathology reinforcing dynamic, which they characterize as, “the interaction between the cycle of domestic violence and the cycle of professional neglect.” They say that health workers’ lack of interest in and knowledge about the kinds of violation taking place in private and behind locked doors is a strongly contributive factor enabling such violations to continue, to be transmitted from generation to generation and to result in an enormous number and variety of illnesses. They paint a picture of the cycle of this professional disregard involving all levels, from health research to teaching to medical practice. Ultimately, they place the responsibility on politicians, research institutions, health profession educators and clinicians who “close their eyes to a great deal of suffering.” They state that such disregard is incompatible with both the health professions’ mandate and self-image. They underline, moreover, what is made clear in a WHO report overview, “Violence and Health,” namely, that the extent of ill health being the documented result of violation places this source of public health problems on a par with the other most important causes of illness and death, such as cancer, heart diseases, strokes and infections.
Implicit in what the commentators say is that it is unethical to disregard life experience if one is to help sick people adequately. On the other hand, what they do not say – and perhaps do not see – is the ethical problem at the core of the West’s production of biomedical and medical technological knowledge. This regards the scientific nature of medicine, medicine’s view of the human being and perception of the human body. Biomedical knowledge is anchored in an objectifying theory and a reifying methodology. The view of the human being is group based, alienating and abstracted from life as the human body is regarded in fragments, mechanistically and materially. Yet no living person is such a body, nor is any group of people so homogenous that their shared characteristics constitute a more accurate description of them than do their individual traits. No knowledge about the person’s health or sickness can be adequate if it ignores what characterizes a person most of all, that is, his own experience and a consciousness of his own dignity. A human being’s inviolability is the core of an almost globally recognized statement of specific, fundamental human rights. This means, among other things, that the production of knowledge – as practiced by a medical profession that treats people as things by turning them into research specimens – is ethically indefensible. It follows from this that applying such knowledge about the alienated person is also unethical. Such knowledge is offensive because it ignores the experiences, significance and goals of each individual’s life project. It misinterprets the body by defining it as matter and not as history. It seeks “solutions” detached from lived life. This is how up-to-date knowledge correctly applied can injure and chronify. It is how the medical professions and their practitioners violate people who have become ill as a result of being violated.
Ethics should form the foundation on which the concepts shaping the field of medicine are based and be the framework for comprehending those concepts. It ought to be the overriding premise for the building of theories, for research, teaching and practice. The fact that it is not is a consequence of the history of Western medicine. Since the Age of Enlightenment, researchers have been trained to believe that it is possible to acquire and accumulate value-neutral knowledge based on continually more sophisticated methodologies. This is to assure that no “contamination” pollutes the pure knowledge about human beings. Such knowledge is only pure when everything human, including the ethical, esthetic, social, emotional, cultural, historical, personal and individual aspects have been excluded qua design, and when appearing as value-abstract as possible qua mathematical calculation.
When looking from another theoretical perspective than an objectivistic one, it is easy to comprehend that such knowledge of the human being is not knowledge about a living person including his life in his body, but rather of an idealized human body, one in which there abides nothing human. But no physician encounters such bodies. At least, no General Practitioner does. People come to their GP with “unsorted” bodily complaints which lead to and result from problems in their lives. Here are gathered people who suffer from conditions that cannot be found within the specialists’ abstract system for the classification of abnormality. This places the General Practitioner in a field of tension at the point where profession and life intersect. Here, GPs encounter many dilemmas and conflicts that no other physicians meet, or so would seem. Thus, they feel that they carry the burden alone of either tackling these dilemmas and conflicts, or living with the reality that they can not be tackled.
Let us now explore how a destructive effect of early negative, silenced and hidden experiences can be understood. The study by Felitti and his collaborators showed a quantifiable correlation between such experience and future health problems which could be demonstrated as much as five decades later. For example, such a connection could be documented regarding heart and vascular diseases. The authors of the latter study write:
We found a dose-response relation of ACEs to IHD and a relation between almost all individual ACEs and IHD. Psychological factors appear to be more important than traditional risk factors in mediating the relation of ACEs to the risk of IHD. These findings provide further insights into the potential pathways by which stressful childhood experiences may increase the risk of IHD in adulthood.
This conclusion is supported by a study of 6000 adults of the correlations among serious illnesses and physical abuse, sexual abuse and overall neglect. The study shows that physical abuse leads to increased risk for lung diseases, gastric ulcer, and rheumatism; neglect leads to increased risk for diabetes and autoimmune diseases; sexual abuse leads to increased risk of heart disease as well. Also, a population study of 1359 women and men at an average age of 75 showed a correlation between childhood sexual assault and diseases of the thyroid gland in men and both arthritis and breast cancer in women.
With that, we are back to my two female patients who died of breast cancer. Both had grown up in so-called “strict” homes. They spoke of abuse, meted out in the name of discipline and parenting, as well as of the adults’ use of alcohol and their socially unacceptable behaviors that had to be kept secret. Already as young girls, both women had taken on the task of concealing the family’s social shame. They were not simply overly responsible but were also powerless to fulfill the impossible assignment they had taken upon themselves. As a consequence of their childhood role as the family’s social worker, both women were in effect predestined to serve as overly responsible rescuers of violent men without ever daring to resist or protest.
I want to link the histories of these two women to general knowledge about neuroimmunological and endocrinological trajectories toward cancer. Throughout many years, both women had been in a state of constant alert fearing the next unpredictable outbreak of violence. Is it fruitful to reason that such a mental condition, enduring the continual experience that one’s life and health may be at risk, nourishes the development of cancer? There exists strong documentation of the negative impact on the immune system of so-called distress, that is, emotional overload. Experimental inquiry into that correlation has taken various forms. In immunological studies, “natural killer cells” are central objects for study; in studies of hormones, the role of cortisol holds an important place. Natural killer cells are measurably suppressed in research subjects exposed to stress, for example intense noise, as many as 72 hours afterwards, but only if the subjects believe that they have no control over the noise. The same noise level over the same period of time does not have the same effect, however, if the subjects believe that they can turn the noise off, even when that is not actually the case. In other words, the determining factor is the person’s own perception of either authority and control, or impotence and the feeling of being at the mercy of their circumstances. The person’s subjective experience that his reality is overwhelming and unyielding weakens his natural killer cells. The effect is intensified by repeated experiences of powerlessness, and even more so by chronic powerlessness. This paves the way for pathological cells to take hold in the body’s tissues and organs.
Subjective interpretations also affect the hormonal interplay between the hypothalamus, the pituitary gland and the adrenal glands, the so-called HPA-axis. There now exists a considerable body of documentation regarding these hormones, particularly as to their effect on the naturally fluctuating daily production of cortisol. The concept of “allostasis” comes in here. Allostasis means stability through change and it includes all the internal systems that make possible a flexible accommodation to both routine and shifting daily life. An allostatic “loading” arises during repeated experiences of danger. It has been measured during long-term strain as in social crises such as war and emergencies, during school examinations, when experiencing grief, loss of livelihood, and divorce – as well as during the ongoing suppression of strong feelings such as while providing long-term care to a partner with Alzheimer’s disease. The loading is reflected in continually hyperactive cortisol production. This brings with it all of the known consequences accompanying raised levels of cortisol: weight gain, elevated blood pressure levels, disturbances to blood sugar regulation, loss of skeletal minerals, just to name the most central effects.
In short, people subjected to a sense of chronic powerlessness develop such conditions as osteoporosis because of chronically elevated levels of cortisol. It is very tempting to place this hormonal causal relationship into a more complex system of potentially convergent phenomena. It could be, for example, that rather than considering osteoporosis, and many other conditions, an epidemic it ought to seen as part of a syndemic. The concept of a syndemic was introduced by anthropologist Merrill Singer in a study of three interacting, mutually impacting, and mutually intensifying “epidemics”: narcotics abuse, violence against women, and AIDS.
The following documented correlations can be understood through applying the concept of a syndemic: It follows logically from the most recent immunological findings that anorectic girls whose bone density, as a consequence of neglect or sexual and/or physical abuse, does not reach optimal levels before they reach full maturity and who later are again beaten or abused, are at many times the risk of developing osteoporosis. Abused girls seem to be highly over-represented among youths suffering from seizures. It appears that women who have seizures enter menopause earlier and run a higher risk of developing cardiovascular disease. Early menopause in itself increases the risk of both osteoporosis and heart disease. Abused girls often have their schooling and further education interrupted which leads to a low degree of economic autonomy later in life. Difficult living conditions, little education and bad finances seem to bring women into menopause earlier. A high proportion of women with osteoporosis suffer from anxiety and heart disease. Women with osteoporosis are at greater risk of developing Alzheimer’s disease. Pre-menopausal women diagnosed with heart and vascular diseases have an increased risk of developing dementia, as do women with metabolic syndrome whose immune systems have a high level of activity. Women with metabolic syndrome are often severely overweight which in itself carries an increased risk of breast cancer and heart and vascular diseases. A high occurrence of panic anxiety is found among post-menopausal women. Anxiety – particularly in the form of phobias – appears to increase the risk of fatal heart attacks (myocardial infarctions). There is also a very high incidence of migraines with auras, asthma and other lung diseases, heart and vascular diseases, angina and depression among women suffering from anxiety.
All the above-mentioned findings are from studies utilizing classical epidemiological methodologies. I gather them here in a single footnote in a shortened form for those who are particularly interested. Their authors have not placed these results in relationship to one another as I have taken the liberty of doing here. For now, it is simply my assertion that it would be productive to interpret these studies’ internal connections using Singer’s concept of syndemics in order to free them from the limiting, and most likely misleading, risk “factor” thinking which characterizes traditional epidemiological research.
Let me now link the concept of allostasis to the cortisol curves found under various kinds of stress. Allostatic “overload”, which results from being constantly emotionally overburdened, is presumed to have the potential to exhaust the allostatic system. Immunologists believe that there exist two mechanisms – or one double mechanism: a cessation of the body’s response to cortisol and/or a reduction in the production of cortisol to consistently low levels. As a result of this lack of responsiveness, flexibility is either diminished or lost; in other words, the organism’s adaptation capacity breaks down. It has been established that such mechanisms exist both in the pancreas’ insulin producing cells and in the thyroid’s thyroxin production. Exhaustion of the system that maintains stability through making adjustments appears as a flattened curve, which is experience as “numbness” or resignation. Such a flattened curve has been documented among many adults with the “diagnosis” of fibromyalgia and chronic fatigue syndrome and among adults with PTSD. This kind of lacking responsiveness has shown to be predictive of the development of cancer. Moreover, measurements of diurnal cortisol level variations among 104 women who had been operated on for breast cancer showed that women with this kind of flattened curve had both the lowest activity level in their natural killer cells and the shortest post-operative survival time.
This discussion around the connection between psychological factors and the development of cancer has been going on for many years. Nor does it show any signs of ending. An overview connecting the studies of cancer survival and relapse with seven types of coping styles has not been able to document that certain ways of being are better suited to assuring the survival of cancer than are others. This study’s theoretical perspectives are quite narrow; they are based on the assumption that the seven categories into which they divide cancer patients’ objectively observable behavior are sufficient to establish, and are identical with, how the people suffering from cancer themselves experience their disease. In a recently published study from
, a comment on the incidence of signs of severe stress among 37% of cancer patients in an oncology clinic was given the title, “Cancer and Psychosocial Stress: Frequent Companions.” The commentators registered, and seemed to consider as quite obvious, that an emotional overload among those with cancer resulted from their disease. There was no suggestion, however, that it might have been the reverse. Canada
A meta-analysis of 27 statistically based studies found no support for a correlation between breast cancer and various stressful events, with the exception of a possible slight increase following the death of a spouse. The studies included were all based on the presumption that “life events” were unambiguous and discrete categories rather than multifaceted experiences with the potential for carrying diametrically opposing significance for different people. None of the studies sought information regarding experienced violence, abuse or maltreatment.
Here we return once again to my two patients with breast cancer. An attempt to describe their coping styles according to the above mentioned study would reveal that they fit into none of the seven categories. They might, therefore, have been excluded from the study. Moreover, when I imagine how they would have answered the study’s questions regarding stressful events, I doubt they would ever have brought up their childhood violation experiences, their alcoholic husbands or their years living with violence. They were, after all, raised to see themselves as bearing the guilt for being abused and were accustomed to keeping silent about these socially shameful and stigmatizing experiences, in line with what sociological studies have documented.
Yes, I am convinced that it would have been important to their lives had I, or someone else, understood early enough that they lived in constant fear and had helped them to protect themselves. I find support for this assumption in three very recent studies.
The first concerns a contribution to the on-going discussion of how to make sense of the increasing documentation of a correlation between the use of antibiotics against various kinds of infection, urinary tract infections among them, and breast cancer. Researchers do not believe that antibiotics “cause” breast cancer but, rather, that the need for high dosages of antibiotics to combat specific types of infection reflects an immune system that is overburdened by something other than the actual cause of the infection. In other words, one can assume that both the cancer and the unidentified bacteria share common fertile soil.
The other study presents the results of 24 years of observation of a cohort of 1,462 Swedish women. It registers a doubling of breast cancer risk among women who report having experienced severe emotional stress during the five-year period before they were included in the study. The author describes the following: “In conclusion, the significant, positive relationship between stress and breast cancer in this prospective study is based on information that is unbiased with respect to knowledge of disease, and can be regarded as more valid than results drawn from case-control studies.”
The third study is from
and involves 10,808 female twins. This shows that daily irritations and “stress” do not have any impact while significant incursions into the women’s lives, such as divorce, the loss of a spouse, close relative or friend, do have an effect. The researchers emphasize this as follows: “The findings suggest a role for life events in breast cancer etiology through hormonal or other mechanisms.” Finland
A Possible Analogy
Allow me to conclude Lene Larsen’s history with an analogy. One can only infer from what Lene told an Aftenposten journalist that she was mistreated and neglected as a child. For whatever reasons, this childhood burdened her to such a degree that, already by the age of twenty, she was close to going under. However, if one assumes that she was also sexually abused, one can imagine that her history is even more differentiated, as was the life of Mary May.
From before she started school, Mary was sexually abused by her father and was admitted to the children’s psychiatric ward showing signs of regression. Among other symptoms, she developed a speech impediment. Once she began school, her speech defect returned and she was referred to a speech therapist. During the coming school years, Mary was treated for self-injuries – she cut into her own upper abdomen. The child’s aim in doing this was to get out the nasty stuff Daddy forced her to swallow, and which she feared could harm her from the inside since she never observed it coming out again.
Mary’s story can now be read within the context of Singer’s concept of a syndemic to weave together several “epidemics”; these ought not to be viewed and evaluated as separate if one wants to understand their origin and to craft an adequate response. Doing so involves the documented correlations between, on the one hand, abuse, maltreatment and neglect in childhood with, on the other hand, the occurrence of: violence and abuse experiences during adulthood; use of various intoxicants; depression; overweight and all forms of eating disorders; sexually transmitted diseases; self-injury and suicide; damage caused through alcoholism; prostitution with its accompanying dangers of injury and infection; infection related to intravenous substance abuse; and, unwanted and early pregnancy. All of these health risks belong to a complex of problems that lead to a huge number of severe illnesses and premature deaths.
Mary’s history makes emphatically clear that an onset of disease can, in itself, be an expression of bodily logic in relation to hidden violation, and that self-destructiveness points to something destructive in the child’s life, something that can neither bear the light of day nor be spoken of. Medically speaking, the phenomenon of self-injury is important to tackle in the right way. In
, for example, an estimated 140,000 hospital admissions annually are due to self-injury. Medical treatment of those suicide attempts that are an immediate or delayed reaction to violation are registered statistically in the category of self-injury. Self-inflicted poisoning, as an example of a self-injurious behavior with death as its aim, have recently been evaluated in a Norwegian study to investigate the frequency of occurrence and their follow-up. In this study, such self-inflicted injuries are explored in relation to psychiatric illness. Neither the article nor the references point to prior trauma as a possible cause of such expressions of self-destructiveness. England
A similar omission of the experience-based causes of people harming themselves can be found in a British study of the effect of a standardized self-injury treatment in General Practice Medicine. The results of this expensive study were predictable given that no attempt was made to understand the phenomenon prior to treatment: no positive effect came of the intervention. In fact, the “debutants” among those treated became even worse. Seen phenomenologically, it is obvious that treatment measures that ignore the cause of the person’s feelings of desperation are not experienced as helpful but rather as rejection and, thus, actually augment that desperation.
A Scottish research team has documented that 4% of people injuring themselves will take their own lives within five to ten years. People who injure themselves have a higher rate of death due to other causes as well. A 2003 Norwegian study of the incidence of self-injury in 35 high schools in two Norwegian districts, Hedmark and Oppland, showed an extremely high level of risk for self-injury among both boys and girls under the following conditions: when they had experienced physical or sexual assault, had friends who injured themselves, used drugs and had been in trouble with the police. These elements seem to work together logically and become iconic for a young person whose life is at risk.
Mary ran away from home. Run-away children often have something to run from; frighteningly strong correlations have been found between a childhood filled with neglect and a homeless adulthood. Mary began to prostitute herself as young as ten years old in order to buy anaesthetizing substances so that she could bear the life she had to live. This documents a horrifying lack of morality among many well-established, adult men – including in
– who give children money in exchange for the children allowing themselves to be exploited. Mary represents one of the many young drug addicts who live by prostitution and who receive no psychiatric care because drug programs and psychiatry are under the auspices of two different agencies. She is also one of the many people who have been assigned psychiatric diagnoses during childhood, adolescence or adulthood without anyone understanding what kind of life this child, teenager or adult woman was living. A fragmented health care system fragments lives such that the meaning of illness, abnormality and malfunction disappears from view as the connections among them remain unseen – whereupon, these fragments are “treated.” Norway
It is highly likely that sexually abused girls will become self-destructive and self-contemptuous young women. This self-contempt, or self-hatred as some of them call it, manifests itself in ways of living that are characterized by a lack of boundaries, by taking risks with life and health, and by a lack of protection or attention. A quite new study from the
shows that teenage girls who score high on measures of distress stand a far greater chance of becoming pregnant than do non-stressed teenagers. The researchers assume that chronic stress leads to a lack of confidence in one’s own strength that manifests as a lack of the courage it takes to demand that male partners use condoms. United States
Excerpt 1 from Chapter 5: Destructive Authority
Revictimized Through Medical Treatment: Elisabeth Engh.
Elisabeth Engh had been abused by her step-father from the time she was five years old until she turned seventeen and was a grown woman and a mother by the time of her first psychiatric hospitalization. She asked the doctors directly if the earlier abuse might have something to do with her condition, but they said they did not think so. Elisabeth improved, she was discharged, but then suffered a relapse and was referred to an out-patient psychiatric clinic. There, she again reported having been abused but, once again, that information was not considered important. She began, then, to have visual hallucinations, became completely mute and was deemed psychotic. She saw things from her infancy that she neither recognized nor understood regarding her and her father. Two years later, her mother could identify the concrete details within Elisabeth’s “visions.” Elisabeth’s father had abused her when she was a baby. Her mother had never told her, but it was a result of this that her mother sought a divorce before Elisabeth reached the age of three. Through her mother’s story, the visions transformed into truths as the apparently meaningless images acquired meaning: what Elisabeth had seen was her own past. As Elisabeth Engh (EE) puts it:
EE. I was forcibly committed. That deprived me of my rights over my own life. It was just one more assault. I hadn’t injured myself, I didn’t try to hurt anybody else, I hadn’t attacked anyone. All I was was terrified. I have tried to get away from it, get away from psychiatry. And that diagnosis. That’s going to stick to me for the rest of my life. There it stands, and there it will always remain. It’s awful that the people treating those of us who struggle with having been abused get so hung up on a diagnosis. Why should we have a diagnosis? Can’t the fact that we sit here with our childhood experiences be cause enough? These diagnoses, they do damage! And they stay there. I feel it now, when I meet someone from that ward, they look at me like I’m an idiot. The parents of some of my kids’ classmates work at that hospital. Still now, I can’t stand to meet them. So I don’t go to the kids´ sporting events or when there’s something going on at their school. I don’t want to bump into them. But that just means I let my kids down, I never show up at their activities.
Elisabeth’s history illustrates how revictimization can happen in psychiatry. It makes reference to how psychiatric theory continues to attribute only minor or marginal significance to violation experiences. Thus, because of the system, patients who report violence or violation are neither listened to nor understood. This is so, despite the fact that there now exists considerable documentation linking earlier abuse to future behaviors or symptoms, appearing during adolescence and in adulthood, that psychiatry considers to be mental disorders. As mentioned in previous chapters, this connection is seen most clearly among people who are diagnosed with depression, suicidality or post-traumatic stress disorders; there is much evidence that this connection is also relevant in people experiencing health problems including nightmares, flashbacks and hallucinations. Long-term abuse committed by someone close to the victim has been shown to have a particularly destructive impact on the health of women and men, regardless of age.
Elisabeth was met from within a theoretical framework in which specific behaviors and states of consciousness – her depression and her altered perceptual and consciousness states – are taken as proof of mental illness. This view was invoked independently of, or without relation to, her experience of violence and abuse from the first through the seventeenth years of her life. The fact that she suspected a connection –and, therefore, repeatedly brought up her traumatic childhood – was not considered relevant to the evaluation and treatment of what was perceived to be her real illness. This, despite the fact that what she referred to, was a situation fraught with daily danger, constant threat, continual powerlessness, and permanent insecurity. Elisabeth had been “besieged,” the enemy had lived in her house and could neither be avoided nor defeated.
Persistent War Experience
Experiences during wars or serious social crises are now recognized as sources of particular behaviors, altered states of consciousness, and extensive health problems that currently, are labeled as post-traumatic stress disorders. “Invented” in order to cover a wide spectrum of war veteran complaints, the concept was meant to divert attention from the individual and focus it instead on the problems’ source, namely, war and violence. As a diagnosis, however, as a name for a condition characterized by deteriorating health, it lends itself both to legitimatizing the demands traumatized people make for social service support, and to clearing war criminals of allegations of criminal acts. As a result, the “diagnosis” is both controversial and instrumental. When the prevailing definition is applied in a country involved in a long, civil war, the term “fits” 99% of the population. Does that mean that 99% of the population (in this case, in Sierra Leone) qualify for a psychiatric diagnosis because they behave inappropriately or cope badly with a daily life of endless war? More likely, the opposite is the case: given their life circumstances, it would be a symptom of collective insanity, were they not to react with almost constant fear, vigilance and insecurity.
Both men and women who have known war are marked by having experienced horrible things. They carry lasting and unforgettable memories that will not leave them “in peace,” even in those cases where the soldiers return from war to a peaceful homeland. For a large number of them, the effects are exceedingly severe, and, among these, there is an overrepresentation of people with “war wounds” from childhood and adolescence. However, among female soldiers showing severely compromised health and function, one group stands out as being at a strikingly high risk of developing heart disease: women who have been raped by their male “colleagues.” This can be interpreted in various ways, all of which help underline how the experience of constant threat, or the absence of a “safe haven,” has a destructive impact on health, in line with the allostatic model mentioned earlier. The same results are supported by the ACE study findings that show an increased incidence of heart and cardiovascular diseases among participants who had adverse childhood experiences, as well as the documented increased risk associated with childhood sexual abuse.
Actually, female soldiers who are raped by male fellow soldiers have much in common with girls and women who are raped in their homes by male family members:
· They are forced, both in daily life and in crisis situations, to put their trust in men whom they have every reason not to trust.
· They are forced to remain in close vicinity to their abusers despite society’s official, legal and political condemnation of sexual violence.
· They are forced to endure the same kind of psychological terror, with the same kind of unpredictable dangers as totalitarian regimes employ to break down even the most upstanding resisters, without needing to use physical violence.
The reported incidence of female soldiers being raped by male fellow soldiers is so extensive that the American Congress held a hearing on the topic in February, 2004. There, it was also revealed that committing rape while serving in the military, and under military jurisdiction, had no consequences for the rapists as they were rarely called to account. On the other hand, the rapes had dramatic consequences for the rape victims; they were often accused of having incited the assaults and forced to continue to serve with their attackers. In addition, there was no therapeutic emergency help set up for these women out in the field. Frayne et al. conclude as follows: “Since coronary heart disease is the leading cause of death in women, a thorough understanding of direct and indirect contributors to its pathogenesis is critical. Prevention of sexual violence (and perhaps other forms of trauma) may prove relevant to the campaign against coronary heart disease.” If we also add to these statistics for “on-the-job injury rapes,” to coin a phrase, the extremely high numbers of rapes against civilian women during war, particularly the ethnically motivated rapes such as those committed in Rwanda, Bosnia, the Sudan and other African countries, this “civilized” recommendation of Frayne and her colleagues can seem disturbingly naïve and utopian.
Elisabeth Engh lived in a war zone, though that could not be seen. The “front” was her home, a place where all children ought to be able to live in peace. And, she was attacked and violated by the two men who were closest to her while growing up, her father and her step-father. They did things to her that were so painful and so unthinkable that Elisabeth’s conceptual and perceptual universe “ripped apart,” beginning when she was a baby. She had to tolerate the same experiences of constant vigilance, risk, insecurity, threat and torture as described earlier. She learned about such pain and danger before she had language, during the time before any verbally based concepts existed, when everything was pure perception. When these perceptions once again filled her mind’s eye, reactivated by specific adult-life experiences, Elisabeth had no idea with which events these visions, voices, and bodily sensations were associated. She knew only that they had to do with her and her father – whom she thought, until then, that she had only “seen” in photographs. She knew for certain that the images warned of danger and of unmentionable things. When the sensory perceptions were reactivated, Elisabeth became as wordless and lacking in the capacity to inform her surroundings of her situation as she had been when she was small. She was terrified, and what little she had told people earlier had not been heard.
Her care givers interpreted the visions or voices she mentioned, though she never described them in detail, as well as her apparently irrational fears and mutism, according to a construct regarding mental disabilities and degrees of mental illness that justified their forcibly committing her, in other words, taking away her freedom. She was forced to take medication and to keep quite about her war experiences. Such a professionally, that is, theoretically, based rape is thematized in an article in which the author, reflecting critically on psychiatric diagnoses and their application, writes the following: “In particular, strategies for dealing with the issue of childhood abuse and neglect are not often considered by adult psychiatric services for the chronically and severely mentally ill, despite there being important predictors of suicidal behaviour, hospitalisation and prolonged disability.”
Using a case study of a female abuse victim, the professionally legitimatized use of force and the providing of incorrect, long-term treatment were analyzed with reference to systematic errors in applying psychiatric theory. The author emphasized how psychiatry interpreted one woman’s repeated abuse claims as evidence of an incurable schizophrenia. Only when someone treated her reports as descriptions of actual events could both the patient and her care giver recognize the “hallucinatory” elements as the child’s sensory impressions. These were not irrational, but simply disproportionate. “Giants” had taken control over her little body, and everything was “too big and too painful” to be “true.” The now acknowledged memories were corroborated by the woman’s mother who confirmed the details regarding time, the surroundings, the people and other circumstances. This made it possible not only to place the abuse into its biographical context, but also to identify several abusers. Through that process, the woman became more herself and could leave a locked ward after years of confinement.
Elisabeth Engh, too, finally received information from her mother to help her get her bearings when, some years after the period of forced commitment described above, Elisabeth dared to share with her a detailed description of what she had felt, seen and heard. At that point, an early insanity was indeed confirmed. But it was not Elisabeth’s. It involved the very real, legally punishable offences committed by her father.
Her reports of insane events had not been accepted by the authorities in charge of her treatment. Instead, they defined the “insanity” in terms of a professionally legitimatized diagnosis of the person reporting it. Yet, when the actual perpetrator of the insanity, her father, was identified, its victim, Elisabeth, was not cleared of the charges. The diagnosis that documented that she was the “owner” of the insanity, was never removed. It stands, uncorrected, in her medical records.
Given psychiatry’s authority and the weight attributed in a variety of contexts, particularly legal contexts (and there, both in criminal prosecutions, civil proceedings and insurance decisions), to a medical record as an objective document, the following implications for the individual as well as the society become self-evident:
· Reports of punishable offences are not acknowledged.
· Consequently, the punishable offenses are neither documented nor assessed by the judicial system.
· Instead, the reports are used to confirm a mental disorder that is then treated by the health system.
· The mental disorder is named (diagnosed) and thus made real and documented.
· When the document’s falsity is revealed, it is not reevaluated.
· The false document remains unaltered, as if it were correct.
· As a personal document, it represents a life-long stigma.
· As a medical document, it is incorporated into health statistics.
· Statistics based upon such theoretically erroneous grounds create false truths about health.
· These false truths transform a social injustice into “gender differences” in sickness.
Elisabeth Engh is still suffering, but now primarily as a result of a medical revictimization. While the clarity resulting from having identified her experiences has allowed her to reconcile herself to her traumatic past, her future remains stained by a stigma, one inflicted upon her by a profession with authority. This profession does not, in fact, use that same authority to liberate her publicly from that “mark in the middle of my forehead,” as Elisabeth calls it. She knows that in other people’s eyes she appears as “crazy”; various neighbors have “seen” her in that way because they are part of the system. This leads her to develop a new “phobia”: her efforts to avoid people looking at her result in her not accompanying her children to their activities. Thus, the violation that began with her father and continued with her stepfather takes a new logical turn: it comes “between” Elisabeth and her children.
Undoubtedly, the revictimization of people in medical contexts involves a complex of professional problems but it also points to a complex of ethical problems. The medical revictimization of people seeking help for health problems following boundary violations, in other words, after falling victim to an abuse of power, constitutes more of the same, that is, yet another abuse of power. Medicine no longer lacks information regarding the health consequences of abuse and maltreatment, oppression and humiliation. In some strange way, however, this information seems to be neither prioritized nor considered relevant in treatment settings. This knowledge, that, by virtue of the methodology followed in collecting it, ought to be considered first rate, is treated, nonetheless, as second rate. Perhaps this is because of its specific content. The knowledge regarding the abuse of social and political power is, in both its essence and its significance, so heavily and inescapably charged with value implications that it may not be deemed “fitting” within a universe of knowledge that so defines itself as value-neutral as does the field of medicine.
It is striking that the considerable epidemiological documentation connecting boundary violations, regardless of type, to a broad spectrum of illnesses is not integrated into clinical medical practice, and that this is the case within both the somatic specialties, and perhaps to an even greater degree, within psychiatry. To resist and underestimate this information, to treat it consistently with disinterest and skepticism, must be deemed ethically indefensible. It represents the exercise of professional power, or, seen another way, the abuse of that power. It can bear witness to the fact that the natural science-based field of medicine, including psychiatry, which increasingly looks to biological models to explain mental illness, participates in processes that the medical profession, according to its own theoretical definitions, ought to rise above: turning away victims of the abuse of power and declare them as incompetent, whether that abuse be social, cultural, or political; and, stigmatizing injured people because their health or their reaction patterns deviate from the norm.
Szasz was met with this same “logic” when he maintained that wrongs are committed in psychiatry’s name: a wave of professional suspicion flooded the pages of that professional journal. His colleagues also attacked the journal’s editor-in-chief for having published the unscientific contribution of a biased and unqualified author. Just as asserting ones rights becomes evidence of illness, criticizing professional practice was taken as evidence of being unqualified. The dispute set off by a logical discussion of a customary professional procedure was, in fact, proof that the people who denounced an impartial critic by invoking the authority of the academy were, themselves, neither the one nor the other.
Excerpt 2 from Chapter 5: Destructive Authority
Revictimized Through Medical Treatment: Thora Tjessem
Thora Tjessem’s medical treatment also focused on lower abdominal pain, but the pain was acute, with no warning or any clear, outer cause. She was an otherwise healthy, fifty-year old woman about to leave on a long trip to
on a prestigious professional assignment. During her travel preparations, Thora had come into conflict with the person in Italy who had full authority over important planned events. Thora had reason to fear that he would exploit his opportunities to control her without her being able to stop him. Italy
Some days before her planned departure, she experienced acute, severe abdominal pain which increased in the course of a day. The physician she saw in the emergency room referred her to a university gynecological clinic. There, performing three operations in the space of ten weeks, they removed Thora’s ovaries, fallopian tubes and uterus and also performed diagnostic endoscopies of her bladder, intestines and lower pelvic organs.
The reason behind these comprehensive and disabling interventions was an intense, and, in the patient’s own words as cited in her medical records, “deep drilling pain from below my pelvis up toward my right hip.” When Thora had been admitted, she told the doctor on duty that she wondered if the pain had to do with her having had a “somewhat unsavory childhood.” Without asking what she meant by that, the gynecologist answered that there was probably no connection. Nonetheless, he had written down her description of that deep pain word for word, though without explaining why he chose to do so. At the same time, he neglected to record her “somewhat unsavory childhood” remark or her reflections on a possible connection between that and the acute pain.
Thora had described precisely the pain a violent penetration would cause. She also had a dying father to relate to at the same time. In addition, she had recently experienced a breakthrough in the long-term therapy she was receiving for anxiety, nightmares and depression. Plus, she now found herself in the above-mentioned conflict with a manipulative and controlling person. The gynecologist heard about none of this because he did not follow up on her allusion to her “somewhat unsavory childhood.” Obviously, Thora did not want to bother someone with her unsavory history if he did not seem to want to know about it. Besides, her pain increased steadily and, according to the gynecologist, the ultrasound finding of fluid behind her uterus constituted an indication for surgery.
He explained that to her and, based on the information he gave her that the surgery was necessary, Thora consented to the first procedure. As that operation failed to relieve the pain, it was followed up by two more in which organs were removed, and, between those operations, by various invasive, exploratory examinations in search of the cause of her persistent pain.
After the third operation, the same kind of pain at the same location was still there, and just as strong. Here is what is written at the end of her file: “Completely satisfactory post-operative condition, but the pain has not disappeared. The connection between all earlier examinations and those taken today create the suspicion of myosis of the psoas musculature. It has been strongly recommended to her that she receive psychomotor physiotherapy. She has already made the contact.”
It is unclear just what is satisfactory about such a result after ten weeks of continuous, surgical intervention. Then, a nearly authoritarian treatment recommendation made at a university clinic that has almost emptied her out, so to speak, links her situation to some unidentified patho-physiological model. It is not mentioned in her records just why this pain, which had set off a chain of three large and sundry other smaller interventions, should suddenly be interpreted as muscularly related. All the same, the advice is given as if the gynecologist knew something about muscular pains in general that he had not previously considered relevant, and as if he now had an idea that this pain in particular ought not only to be treated by a physiotherapist but by a psychomotor physiotherapist. Nor did his discharge interview with the patient include any reflections on this matter.
The patient had offered relevant information upon admission. She had portrayed it as something from her own prior experience that she was just wondering about, but it did refer to an experience of a similar type of pain. The acute pain she had now strongly evoked the memory of some earlier pain, and at the same location. The gynecologist took in and assigned significance to her description of the pain itself, but not her hinting as to it potentially being associated with something else. He wrote up in her file only the information to which he attributed relevance in accordance with a medical understanding of acute pain, its characteristics, localization and intensity.
When the pain resisted a presumably adequate treatment and an intervention based on medical knowledge, the same approach was repeated until the repertoire of available interventions had been exhausted. Only then did the gynecologist take into consideration the possibility that the cause of the pain might be inoperable in nature. The professional advice the gynecologist then gave testified to his having suddenly attributed the problem to the patient’s suffering from “somatization,” a painful tension deep in the pelvic floor muscles. Even though the diagnosis “somatization” was not mentioned, it was implicit in the recommendation of psychomotor physiotherapy, specifically.
Thora had been involved in a course of treatment to which she gave her consent, step-by-step, because each action was explained to her as justified and necessary. At no point had she received information as to the existence of any but organic causes requiring surgical treatment. After the interventions, freedom from pain – their actual goal – had not been achieved.
Pain that persists despite long-term, presumably correct and appropriate medical intervention is often linked to the concept of “somatizing.” Used as a diagnosis, it effectively exiles to psychiatry those physical complaints that have no medically demonstrable physiological substrate. We know now with great certainty that hidden sexual trauma always express themselves bodily. These expressions most often lead to medical diagnostic or therapeutic interventions. “Somatizing” carries with it a high probability that doctors will undertake interventions that neither produce the expected findings nor have the intended effect. A Danish study carried out by Dr. Peter Fink sheds light on the scope of the phenomenon “somatizing” as well as on the medical problems related to the concept. Using data from an overview of ten years of Danish health statistics, Fink compared the possible risks and costs associated with interventions carried out on “persistent somatizers,” that is, patients who persistently present with pains or complaints that have no clear medical cause, to those associated with interventions performed on “non-somatizers.”
Fink concludes as follows: Somatizers were exposed to more frequent and more extensive surgical procedures and other medical interventions than were non-somatizers; the greatest part of the operations carried out were abdominal and gynecological surgery; three out of four of the interventions failed to have the intended effect; the same was true in two out of three of the cases in which other treatment forms were utilized; the calculated costs connected to these inconclusive surgical and medical explorations were enormous; and, even greater were the risks of injury being inflicted during these procedures.
The gender distribution in this material was not made explicit, but if one examines the numbers it becomes clear that there were five times as many women as men among the “somatizers.” Women underwent both more unnecessary and fruitless interventions than did men; this was also the case for other medical procedures. In short, it is women who bear the greater share of these unmeasurable costs of providing the wrong treatment: the physiological danger inherent in each procedure; the mental stress associated with a continuing series of new and painful interventions; and, the social stigma attached to treatments in which the doctors find nothing or that fail to result in any improvement.
Some of the documented findings are not discussed at all, such as the fact that a complete hysterectomy was the most frequently performed procedure, having been carried out on one out of every three “somatizing” women. Their average age was thirty-two; the youngest woman whose uterus was removed due to medically unexplained conditions was twenty-two. The intended results were achieved for only two of the fifteen “somatizing” women undergoing a hysterectomy. In only one of those two cases was any pathology found in the removed organ.
The study shows a striking inconsistency in both the way of thinking and the concepts applied. Patients who, for unknown reasons, persist in a bodily strategy are called “persistent somatizers.” One of these people underwent twenty-four procedures while five others underwent more than twenty. Yet, the doctors who treat them again and again, who cling to a single professional strategy for interpreting bodily symptoms, are not called “persistent neglecters.” Their persistent response to other people’s persistent physical appeal is not problematized at all.
During the previously mentioned study of 3,543 female soldiers, of whom 805 (23%) had reported being raped while on active duty, the researchers asked all the women if and when they had had their uterus removed. This was a step in assessing the existence of a connection between rape and heart and cardiovascular diseases linked to known risk factors, including early menopause. One in ten of the women who did not report being raped on duty had had her uterus removed before she reached forty years of age. Among those women who reported that they had been raped while on duty, that number was one in five. The difference was highly significant.
Considering the finding mentioned earlier that a large number of women with chronic stomach or pelvic pain are among the patients on gynecological and gastrological wards, it is not surprising that much experimental treatment is being offered to help women in pain. In clinically controlled experiments, the effects of various pain treatments are investigated. This is reflected in the literature. New techniques are tried or “old” techniques are compared with “new” ones. Or, the results of a supposedly effective technique, such as loosening adhesions (places where organs seem “stuck” to one another), is compared with the results of not doing so. Endoscopy was utilized in both these trials; when the examination involved the insertion of the endoscope into the abdomen but without loosening the adhesions, it was considered a placebo procedure. It has been shown that the “loosening” treatment results in such a small improvement as compared to the effect of a simple examination (the placebo procedure) that the method is no longer recommended.
One method being tested is to sever nerve fibers in the lower pelvic region of women who suffer from extremely painful menstruation. Such a procedure seems to bring lasting pain relief to very few of the women. Moreover, each such intervention risks causing adhesions – that may then be characterized as the source of a “new” pain. In other words, one problem is (perhaps) solved while a new problem is created. The conclusion reached is that a much smaller group of women than had been presumed can benefit from such an intervention. It has been demonstrated, in fact, that neither chronic pelvic pain nor vaginal pain during intercourse are relieved by the severing of nerves.
For some years, there has been considerable professional disagreement about the causes of and solutions to the type of vaginal pain that makes intercourse intolerable. This kind of pain presents the same problems for making an objective diagnosis as does the pain called fibromyalgia. In neither case have any tissue changes been found that might be considered causal. As with fibromyalgia, the procedure for objectifying or medically validating the pain is to apply external pressure and note how the pain reacts or spreads. While, with a person suffering from fibromyalgia, the pain is “objectified” by applying a certain kind of thumb pressure to specific points, with someone suffering from genital pain (dyspareunia), it is “objectified” by applying pressure to the specific area using a certain kind of swab.
There exist striking analogies in how medicine approaches the presentation of a kind of pain that occurs most often in women and, in this case, one that appears only in women. That applies also to the assumption that this problem, as is suggested in fibromyalgia, lies at the interface between somatic and psychiatric medicine. “Sexual pain disorders” are a group of female pains that present without any clear anatomic or organic delineation, or any demonstrable tissue damage. Definitionally, such a lack of objectifiable findings leads to the phenomenon being “psychiatrized” via being termed either a functional or mental disorder. As a result, the so-called social profile of women with such pains has also been examined.
The authors conclude that women suffering from this kind of pain form such a non-homogeneous group that no uniform treatment recommendation can be made. They express doubts about any theoretical concept that defines a presentation of pain in terms of the activity to which it is connected; terms that would be analogous to a concept of “sexual pain” might be something like “sport pain” or “occupational pain.” They do believe, however, that such pain is a composite illness calling for both gynecological and psychosocial approaches. The most recent treatment recommendation is connected, however, to neither the gynecological nor psychosocial models. It rests, rather, on the same principle as the treatment of “heart pains,” that is, angina pectoris. The recommended medication is a nitroglycerine cream, to be applied to the vaginal opening before intercourse. It is not made clear just what might be inferred about the cause of the pain from the measurable effect of the nitroglycerine cream.
Given the information about how many of the chronic pain patients on gynecological and gastrological wards are women who have experienced sexual abuse, it is shocking how often experiments with technical procedures and interventions are conducted versus how seldom the actual women are approached as autonomous individuals in possession of a kind of knowledge about their own lives the relevance of that can no longer be questioned. Just for pragmatic reasons, it ought to be obligatory to inquire after this information, not least in order to avoid the women feeling themselves to be, or actually being, revictimized. Documentation already exists that operations and the removal of organs due to pain that is believed to be the result of abuse create their own artifacts. That is, they create new health problems, not only in the form of complications or the physical disabilities resulting from the removal of healthy organs, as discussed above. They also concern emotional reactions, which constitute a new problem even though another problem seems to have been solved. It has been found that among women who have their uterus removed due to bleeding or pain, those who have prior abuse experience suffer far more often from severe depressive reactions during the year following the surgery.
At the same time, it is thought provoking to learn that women with abuse experience tend not to contact a gynecologist unless they absolutely have to. An American study showed that women with abuse experience had a tendency to fail to show up for routine cervical cell Pap tests. Neglect of routine cervical cell check-ups can mean that cervical cancers are not detected and treated while still at an early phase. This can be one of the paths to the previously mentioned high rate of premature death among people who have experienced abuse.
This situation, too, may involve complex and synergetically interacting causes of illness and thus call for the application of a syndemiological rather than epidemiological model. Other important factors may be added to the potential delay in discovering disease, mentioned above. One central cause of the development of cervical cancer has been identified as the Human Papilloma Virus (HPV), a member of the family of viruses causing warts. A genital infection involving such a virus is classified among the sexually transmitted diseases. Among those with prior abuse experience, both women and men, the following conditions have been documented, all of which are relevant to this syndemiology: early sexual debut, inadequate protection against sexually transmitted diseases (such as HPV, Chlamydia, gonorrhea, syphilis and HIV), many and varying sexual partners, unstable life-styles that lead to compromised health, abuse of alcohol and narcotics that cause damage to the liver and other organs, and smoking. It has been shown recently that smoking increases the risk of HVP-related damage to cervical cells in all women, and in HIV-positive women in particular. Cell research has also demonstrated that an extract of tobacco affects cell surfaces and other cell characteristics such that they risk becoming malignant, and that these malignant cells are not “discovered” by the body’s killer cells. When killer cell activity is further reduced as a result of allostatic loading, a variety of mechanisms and many different phenomena may lead to the same result – increased risk of developing cancer and other fatal diseases.
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