Gender, sex and anatomy: Sexuality and the Intersexed Individual

Aaah, the wonderful feeling of the last essay of the summer (even if the summer is almost over and the "crazyness" of second year just upon its heels).  It feels good to see something to completion.  I gave up on this essay more than once in frustration for the lack of sources available.  I find that I follow a pattern similar to labour with my essays - the easy "I can do this" part of early labor (akin for me to researching the paper), the active labor (structuring the essay), transition (No!  I hate this paper!  I can't do it!) and pushing - that magical time when all of a sudden the paper that I hate has turned into something pretty good!  Or at least, hopefully good!  : ) 

Here is the most recent one, the final essay in my Human Sexualities course that I've enjoyed so very much (look out, again, its a bit long).  Also, please note the essay also contains some sexually explicit commentary, so read at your own risk. 

Gender, sex, and anatomy:

Sexuality and the intersexed individual

Melissa J. Nowell

Introduction

            Parents often hold specific expectations for the birth of their babies, which vary dependending on the sex of the baby.  When a child is born with genitalia that are indistinguishable as either male or female, a parent is often left with a sense of misunderstanding, confusion, and upset about the future of their child.  These feelings lead to a myriad of expressions and events that alter the course of the child’s life.  This essay attempts to explore the experience of the intersexed individual, and some of the medical interventions that their parents may be faced with.  Most importantly is a particular focus on their sexuality as they reach adulthood; both those who face medical intervention and those who do not.

Description and prevalence of intersex conditions

            The term intersex is a catchall term that includes those who are considered to be true or partial hermaphrodites, or those with ambiguous genitals despite a clear genetic or internal sex (Fausto-Sterling 2003:167). There are several other terms that are used to describe these people; one of the most well-known is the label hermaphrodite.  Reis (2007:535-543) explains that intersex conditions may also be called “disorders of sexual development” (DSD), which she would prefer to rename to “divergence” of sexual development.  The term intersex is used in this paper to the exclusion of others due to its prevalence in the literature.  Intersex conditions can come about in a number of different ways.  During early fetal development, male and female sexual organs begin in the same form, and several factors can potentially influence their development toward the typical male or female expressions that are expected at birth.  Despite having the chromosomes for one sex, a child may develop genitalia that resembles the other, or may have genitals or gonads that incorporate aspects of both sexes.  This may be due to hormonal conditions, a defect in the sex chromosome, or otherwise unknown reasons (Preves 2003, in Gough et al. 2008:494).  Although the most discussed cases of intersex are discovered at birth, many who have hormonal conditions may not show intersex characteristics until, or beyond, puberty (Gough et al. 2008:494).

            Because of the variation in the point in life that the condition might be discovered, and the widespread disagreement about what constitutes a true intersex condition, experts are not in agreement about the prevalence of intersexed births.  Estimates of the prevalence are as high as 2% (Preves 2003 in Gough et al. 2008:494) and as low as 0.018% (Sax 2002:174). Despite its potential prevalence, however, the condition is one that is not generally understood outside of specialized medical fields, because the majority of intersexed children are assigned a sex at birth and are surgically reconstructed to resemble that sex as much as possible (Chase 2003:173). While some intersexed individuals may present genuine health conditions, such as metabolic disorders or higher risk of cancers, this is not the rule, and most intersexed people find themselves to be in good health (Dreger 1998:30).   Chase (2003:174) explains that surgical reconstruction is done not because of a medical risk but due to the fact that the birth of an intersexed child constitutes a “psychosocial emergency” – or rather, an emergency of social and psychological nature whereby the family and others feel the strong need to identify the child as one sex or the other for the sake of his/her upbringing and socialization in the binary sexed world that s/he has been born into. Thus, the surgical reconstruction of a baby’s genitals is generally done for social or cosmetic reasons, and is strongly encouraged within the medical literature (Holmes 2008:169). 

Justification for medical treatment

Those born with ambiguous genitals are met with an intense array of social and psychological challenges not met by the majority of the population.  From the moment of their births, their parents are often found questioning “what” they are.  Indeed, Gough et al.( 2008:499) discovered in their study of parent’s attitudes about their intersexed babies that they were unable to identify their child as being fully human until they could identify the sex, referring to their child as one without status, or like a “no-thing.”  Holmes (2008:173) explains that parents of “non-responsive infants with severe neurological impairments” relate more to their babies as real people than those of intersexed infants. Because of the fundamental affects this attitude can have on a young child, this is often touted as one of the primary reasons that intersexed children are assigned a sex and treated as soon after birth as possible (Gough et al. 2008:494).  These people are thus subject to much medical exploration and treatment in the course of determining and enforcing their assigned sex.  Gough et al. (2008:494) explain that this is due to the widespread belief in the literature that a child should have normal-looking male or female genitals in order to adjust well in the social world.   As a result, much of the treatment these children receive occurs in their first two years of life, before a solid memory of early childhood has formed (Gough et al. 2008:494).  Perhaps to prevent an identity crisis, parents are then generally encouraged to hold silence about their children’s sex change from others and from the child him/herself, despite the frequent necessity of follow-up procedures, surgeries, and hormonal treatments.

Social consequences of treatment

            There is a great deal of counter-culture rising up against this blanket approach to intersexed children, for a variety of reasons which will be explored here. Most assuredly, this medical reconstruction is done with positive intentions to improve the relationship between parents and child, and preserve the child’s integrity and personal identification.  It is widely assumed that a child who cannot relate exclusively with one sex will inevitably become unhappy and stigmatized (Holmes 2008:170; Gough et al. 2008:494).  Yet the stories of many intersexed people who have been altered paint a different picture than this.  Most intersexed children who were surgically assigned sex at or near birth were kept from the knowledge of what was done to them; thus, most of them grow up in silence, not understanding or even being aware of their differences.  Many of the surgeries these children underwent required invasive follow-up care, which is often reported to have gone unexplained to the children being treated (MacKenzie et al. 2009:1778). In the case of a vaginal reconstruction, the follow-up procedures are described as involving a daily dilation of the newly constructed or reconstructed vagina with a prosthetic by parents until the child is old enough to do it herself (Hird 2003:106).   MacKenzie et al.( 2009:1780) summarize that their study did not determine that these practices had the effect of creating “normalcy” that they were intended to have. 

            Despite normalizing surgery, intersexed children are still treated differently by medical professionals and their parents than “normal” children, and thus often find themselves “experiencing a childhood of uncertainty and a sense of being imperfect” (MacKenzie et al. 2009:1778), even when they are unaware of why they are different.  Dreger( 1998:31) takes issue to the fact that nature of the surgeries and follow-up procedures serves to increase a child’s feelings of “freakishness” rather than reduce them.  This is due to the non-consensual and secretive way that they are brought about upon a child unable to decide for him/herself. 

“In cases of intersex, it is the parents who demand or consume treatment; however, it is the children who have to live not only with medicine’s technical shortcomings, but also with the awareness of the message conveyed through intervention, namely, that in their intersexed bodies they were unacceptable, perhaps unlovable, and certainly unrecognizable as persons.” (Holmes 2008:170)

            Clearly, the answer medicine has found is not black and white.  Reis (2007:537) explains that the consensus statement on intersexuality concludes that “there is little evidence” that normalizing surgery improves relations between parents and child or ensures proper gender identity development as it had been expected to.  Far from just affecting parental bonding and gender identity, however, are deeper psychological issues.  Hird (2003:1069) discusses many issues which come up for therapists working with intersexuals, namely trauma from above mentioned surgeries and follow-up procedures and trauma due to loss of erotic sensation. 

Medical/sexual consequences of treatment

Yet, as we have seen, surgical sex assignment is the norm for intersexed children.  Interestingly, Turner (1999:461) explains that 90% of children diagnosed as intersexed - whether they possess the gonads of a male, female, or both – are assigned a female sex.  The treatment that they undergo are a series of surgeries and procedures which remove or reduce an “enlarged clitoris”, and create a vaginal canal if there is not already one.  Dreger (1998:28) explains that this means that many children who are true males with a micropenis, potentially able to have sexual relations and children with women, are surgically reassigned a female gender.  Dreger also speculates that physicians appear to place much more emphasis on assigning female sex to intersexed children because their criteria for a “successful” penis are higher than for a vagina.  The penis is required to be capable of erection, able to urinate and ejaculate from the same hole which is expected to be located at the tip of the penis, and “’believably’ shaped and coloured” (p.29). Unfortunately for intersexed children assigned to the female sex, the vagina is only required to be a hole which permits the penetration of a penis – sensitivity, self-lubrication, and clitoral integrity are not considered as important as their male counterparts and are therefore missing in most surgical vaginal constructions (p.29).  Clearly, as Dreger (1998:29) and Turner (1999:461) have both noted, this not only devalues the body and sexual potential for the intersexed individual, but also that of females more generally.  This is particularly notable since it moves in line with more typical feminist critiques of the devaluation of women’s bodies and sexualities. 

            There are important reproductive consequences to reconstructive surgery as well.  Some intersexed people are born potentially fertile, and the removal of gonad tissue that does not match the assigned sex may render them permanently infertile.  One must speculate at what these babies would choose for themselves should they have understood the potential consequences.  MacKenzie et al. (2009:1780) noted in their small study that none of the participants would have chosen surgery had they been given the option. Kessler’s survey of non-intersexed men and women found they almost exclusively indicated they would wish not to have clitoral reducing surgery if their clitorises had been too large/penises had been too small; and in the case of the men, all but one indicated they would not wish to have their micropenis removed even if there were valid health reasons to do so (Dreger 1998:33).   This is in line with others who have found that a great many intersexed individuals who were unaltered through childhood do not wish to have reconstructive surgery on their genitals when approached with the possibility in adulthood (Gough et al. 2008:495; Chase 2003).  Indeed, many who discover their medical histories express a sense of loss for their former bodies and sexualities unexplored and may seek out gender reassignment  (MacKenzie et al. 2009:1780; Hird 2003:1083-1084). Chase (2003) and others have connected the acts done to intersexed people in much the same ways others in the West have condemned female genital cutting.  Much like female genital cutting, reconstructive genital surgery is “non-consensual and cosmetic” (Hird 2003:1083-1084).

            An ulterior motive may be subtly at work here as well, which plays its tune at altering the child’s genitals to match its perceived future sexuality so that it may grow up to become heterosexual.  Holmes (2008:170-171) explains that heteronormative frameworks assume that the appearance of the genitals will portray sexual preferences.  The “heterosexual matrix”, as Dreger (1998:29) describes it, “does not allow for other sexual practices or sexualities.”  Hird (2003:1083-1084) confirms that inducing “opposite gender desire” is a “major concern for clinicians”.  Real (2007:540) explains explicitly that sex assignment surgery has repeatedly been justified as a homosexual preventative. Thus, we see the cycle of heteronormativity reach its peak – the intersexed body challenges the ideas that males couple only with females to such a degree that anyone whose genitals at birth may suggest a potential for another type of sexuality is subject to alteration in order to conform with the principles of heterosexism (Fausto-Sterling 2003:170).

Sexuality

            There are many rumours and thoughts about what sexuality might look like in a person without a clear sex.  Reis (2007:537) notes that just the word intersex has been thought to be associated directly with sexuality, and explains that some parents have difficulty separating thoughts of their child’s sexuality from their “anatomical condition”.  Butler (1995, in Turner 1999:468) discusses how the heteronormative framework must rest upon the assumption that a hermaphroditic body, being neither male nor female and therefore incapable of “normal” heterosexual relations, is rendered “incapable of desire”.  The idea of a person who, as Fausto-Sterling (2003:170) describes it, possesses female organs and menstruates, but also has a clitoris large enough to penetrate a vagina, challenges “traditional beliefs about sexual difference”.  It will inevitably make many people squirm in their seats and question all that they understood about “normal” sexuality.  But what is normal for those who are born this way?  Is the removal of the enlarged clitoris an instigator of normal, or a stripping away of a “very special form of sexuality, arousal, and all of that which is uniquely hermaphroditic” (Intersex Society of North America 1996)?  Is the untouched hermaphrodite capable of satisfying intimate relationships?

            The answer, of course, is absolutely.  This is not to say that intersexed people are without challenges.  Their unique anatomies (used in plural to convey the wide variation between individuals) do leave them with challenges and opportunities for variation and creativity.  MacKenzie et al. (2009:1779) notes that concern over “body rejection” may cause some to avoid intimacy, but their participants have nonetheless participated in intimate relationships and found them to be positive. Intersexed people may also exhibit a tendency toward sexual dysfunction.  This is not to say that intersexed people are all sexually dysfunctional, but that they have higher likelihood of challenges.  Minto et al. (2003:1256) notes that, while the 7% of the general population reports never being able to reach orgasm ever, 39% of their sample of intersexed people who had received clitoral surgery made this same report.  Minto also noted that those who had undergone clitoral surgery had greater difficulties with “sensuality,” “communication difficulties,” and “avoidance” (p.1256).   Interestingly, their intersexed controls who had not received clitoral surgery did not report these same effects.  They were, however, sure to note that both groups still indicated overall difficulties reaching orgasm (p.1256).

 As one might have guessed by this point, sexuality is not a clear category in which one easily fits into.  This is true to the multiples with intersexed people.  There is a very wide variation in the preferences and practices of intersexed people.  It appears that males with a micropenis, whose parents were well informed and chose not to surgically alter them, are “more confident and better adjusted”, but do not generally practice ‘typical’ heterosexual contact (Shober and Woodhouse, in Dreger 1998:30).  Indeed,

“The group was characterized by an experimental attitude to sexual positions and methods....the group appears to form close and long-lasting relationships.  They often attribute partner sexual satisfaction and the stability of their relationships [with women partners] to their need to make extra effort including non-penetrating techniques” (Shober and Woodhouse, in Dreger 1998:30)

As noted, the concern to eliminate “homosexuality” in intersexed people may be one of the greatest motivators for clinicians to advise surgery.  Several sources have noted that intersexed people identify as lesbian or gay, particularly those who have undergone feminizing gender assignment surgery (Turner 1999:461; Hird 2003:1083-1084; MacKenzie et al. 2009:1780). The ability, then, to predict the future sexuality of the child has not been reached.  The varieties in practices, preferences, and the way intersexed people will identify sexually is practically limitless.  Turner (1999:474) describes an unaltered intersexed individual raised as a girl who identifies as heterosexual because she has relations with both males and females, and not other intersexuals.  Certainly the variety in ways of identifying sexually might be particularly dependent on the gender that the intersexed person relates to in adulthood, which may or may not align with the appearance of their genitals.

Conclusion

The challenges that intersexed people, their parents, and health care providers meet are clearly unique to their conditions and the social arenas which are affected by them.  The effective erasure of hermaphroditism from the wider spectrum of understanding has contributed to the stigma that intersexed people and their parents face when dealing with medical decisions and day to day life.  Although the surgical restoration of the genitals of intersexed people is the preferred norm of specialists today, a closer look at the lived experiences of these children in adulthood leads one to question whether or not this is the best course of action.  The current understanding of the psychological and sexual outcomes from genital reconstruction surgery that I have reduced here leads to the conclusion that other alternatives should be explored.  Further qualitative research and speculation into the outcomes of genital reconstruction surgery would contribute greatly to the understanding of clinicians and the parents of intersexed children who are faced a decision that no parent should have to make.  

References

Chase, C.
2003 Hermaphrodites with Attitude: Mapping the Emergence of Intersex Political Activism. In Constructing Sexualities: Readings in Sexuality, Gender, and Culture. S. Lafont, ed. Pp. 172-187. Upper Saddle River, NJ: Prentice Hall.

Dreger, A. D.
1998 "Ambiguous Sex" --- Or Ambivalent Medicine? The Hastings Center Report 28(3):24-35-http://www.isna.org/articles/ambivalent_medicine.

Fausto-Sterling, A.
2003 The Five Sexes: Why Male and Female are Not enough. In Constructing Sexualities: Readings in Sexuality, Gender, and Culture. S. Lafont, ed. Pp. 166-171. Upper Saddle River, NJ: Prentice Hall.

Gough, B., N. Weyman, J. Alderson, G. Butler, and M. Stoner
2008 "They did not have a Word": The Parental Quest to Locate a 'True Sex' for their Intersex Children. Psychology and Health 23(4):493-507.

Hird, M. J.
2003 Considerations for a Psychoanalytic Theory of Gender Identity and Sexual Desire: The Case of Intersex. Signs: Journal of Women in Culture and Society 28(4):1067-1092.

Holmes, M. M.
2008 Mind the Gaps: Intersex and (Re)Productive Spaces in Disability Studies and Bioethics. Bioethical Iniquiry 5:169-181.

Intersex Society of North America
1996 Hermaphrodites Speak (video). Intersex Society of North America Ann Arbor, MI.

MacKenzie, D., A. Huntington, and J. A. Gilmour
2009 The Experiences of People with an Intersex Condition: A Journey from Silence to Voice. Journal of Clinical Nursing 18:1775-1783.

Minto, C. L., L. M. Liao, C. R. J. Woodhouse, P. G. Ransley, and S. M. Creighton
2003 The Effect of Clitoral Surgery on Sexual Outcome in Individuals Who have Intersex Conditions with Ambiguous Genitalia: A Cross-Sectional Study. The Lancet 361:1252-1257.

Reis, E.
2007 Divergence Or Disorder? the Politics of Naming Intersex. Perspectives in Biology and Medicine 50(4):535-543.

Sax, L.
2002 How Common is Intersex? A Response to Anne Fausto-Sterling. The Journal of Sex Research 39(3):174-178.

Turner, S. S.
1999 Intersex Identities: Locating New Intersections of Sex and Gender. Gender and Society 13(4):457-479.

A little about myself and how I got where I am

I've had some questions lately wondering a few things about me and my relationship with midwifery and schooling.  I thought I might answer them here since I'm sure for every person that asks a question, many more are thinking them.  My main purpose of starting this blog was to help prospective students (and eventually students) to understand what the lived experience of the midwifery education program is like, but I never really did give myself a backgrounder!

My first thought of midwifery was when I was 19, and newly pregnant with my first daughter.  I even called Ryerson and had their MEP information package sent to me, but after longingly reaading through it, I put it down and forgot about it.  I was sure that I would never be able to do it, for a number of reasons.  Mostly because we were poor.  But also because of a secret that I sometimes try to keep hidden (although I'm not really sure why) - due to a tumultuous and emotional adolesence, I dropped out of high school at 17 and never went back.  Seriously, who could possibly get into an amazing program like that with no high school diploma? 

Then, my daughter was born.  Struggling to heal from a very difficult birth (emotionally), I confided to my doula that I was interested in supporting birth.  Mostly, to try and help women to avoid unwanted c-section, since that was so close to home for me.  Luckily, she just happens to be a doula trainer, so I attended one of her trainings and also eventually started running a c-section/VBAC support group online and through in person meetings.  Ever since my daughter was born, I've been very passionate about VBACs, and I found myself attending quite a few.  Many of these which were attended by OBs (ok not just VBACs) frustrated me to no ends.  Why can a woman not ask to sit in a different position?  To have a few more hours time when the baby is doing well?  Why does she not deserve a better connection with her care provider, more respect, more information? 

Well, of course she deserves it.  She just doesn't have a midwife!  Absolutely, many OB/nurse attended births I went to were lovely, and women were well informed and choices were made together - but overwhelmingly, most were not.  And as the doula, with no real rights in the birthing room, there was little I could do about it aside from help her to feel better about it.  It was through this process that I revisited the idea of being a midwife.  I had probably been to 10 or 15 births by the time I started working on the prerequisites for the program:
- Gr 12 University level english
- Gr 12 University level social science
- Gr 12 University level chemistry or biology

I also got my high school equivalency. And I passed everything with flying colours.  This really helped me to develop my writing and understanding skills.  I was part way through getting these courses when I gave birth to my son.  This was rather monumental for me, because I was aware of the potential for my motivations to completely change depending on how his birth turned out.  I was so, so devoted to VBAC (homebirth, actually).  And I didn't know if I would still be as committed to birth if I got the "birth of my dreams".  Or whether it would be too difficult for me to revisit if I didn't.  So I left myself open to suggestion.  Thankfully, once the acute memory of the pain of feeling him coming out, the overwhelming sense that I needed to continue on this mission came over me.  I started going back to births much sooner than I expected after he wass born (8 months maybe) and LOVED it.  FAR more than I had before I had Robin - - - because my demons were gone.  I can't restate this enough - birth professionals who have their own personal birth baggage from their own births are really at risk of carrying this around with them to other women.  Lucky for me (and the women I was working with) this baggage got carried away when I got the "birth of my dreams" and I knew I was ready. 

I applied to the MEP at Ryerson in Toronto when my second was 12 months old  (and I, only 24).  The waiting process was excruciating.  I'm a great writer, and I wasn't worried about the letter I wrote, but the time after the interviews was back breaking.  And then I got the heart breaking news that I was wait listed.  I took it completely as a failure, and I signed up for 5 courses at Athabasca University (online) that I knew would qualify as transfer credits, so that next year my load would be lighter.  Well, no sooner had they arrived in the mail when I got the call that I was accepted!!!!  What a wonderful feeling! 

 Managing the program itself, with two small children and a one-way 2.5 hour commute (yup, 5 hours a day) is a challenge, but I am by no means the only one doing it.  Although I sent many of those Athabasca courses back, I did one through that summer, and am doing another three currently, during this summer approaching second year.  This has been tremendously helpful in reducing my commute down to only three days a week (except for first semester).  I'm one of the rare few who doesn't have a university degree already (and even rarer that never finished high school), so taking these courses helped to lighten the very heavy courseload for those who didn't come in with a ton of transfer credits. 

So, there's the long story short (or not so short)!  Voila, Melissa, the former-doula-soonish-to-be-midwife.  I'm sure the story will get MUCH more interesting when placement starts in January.  I'm so scared!

HIV and Voudou in Haiti

Okay, this post is completely unrelated to midwifery and my personal life, but rather another essay that I recently wrote.  Even though its unrelated directly to midwifery, anyone interested in differing cultures might appreciate some of the info in here for general knowledge.  I wrote this essay for my Human Sexualities course - which, after a slow and somewhat boring start, has turned into a really interesting learning experience about  not only different sexualities but also different cultures.  I'm happy to be able to say I was able to take an anthropology course that doubled as one of my social science electives!  Although the course load is a little heavy (3 8-10 page essays, two "quizzes", and an exam) its worth it for the info that can very often be applied to midwifery. 

So, without further ado: HIV and Voudou in Haiti, by Melissa J Nowell
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Long before its ravaging earthquake that brought global attention hit it, Haiti was the focus of a health crisis. AIDS is a continuing epidemic in Haiti, and its prevalence has become so high that it now represents 67% of all reported cases in the Caribbean  (Martel and Mueller 2007:107).  In 2009, approximately 7,100 AIDS-related deaths were reported in Haiti, and currently 1.9% of the total population is infected with HIV (AVERT.org 2010:1).  Although these are rough estimates which are debated by locals and the international community abroad (Treichler 1999:103, 113), these numbers represent a significant risk to the population.  Haiti presents many unique challenges to the international efforts at reducing the prevalence of AIDS.  Its adherence to both Catholicism and voudou practices present a framework of beliefs that is often contradictory to the prevention of HIV, and the intense stigmatization that those suffering AIDS face presents barriers to the reception of effective health care.  In this paper, I will discuss the role that voudou has played in the AIDS crisis in Haiti, and discuss both the failures and successes in overcoming the many barriers to AIDS prevention and care that this group of people faces.

AIDS in Haiti

Much like AIDS in other Third World countries, in Haiti, HIV is spread primarily through heterosexual transmission (Martel and Mueller 2007:107). Multiple partner sexual relationships are also common (Devieux et al. 2004:110).  Education about HIV is not standardized in Haiti, and access to communication through various media outlets is limited (Martel and Mueller 2007:107).  Perhaps partially as a result of this, there are many misconceptions in Haiti about the validity and stigma in regards to the AIDS crisis.  Denial that AIDS presents a problem to Haiti is common.  Prostitutes and community leaders alike are often under the distinct impression that AIDS is an American conspiracy, and/or that it doesn’t actually exist (Treichler 1999:103; Fitzgerald and Simon 2001:302).  Some have even gone so far as to call it “le Syndrome Imaginaire pour Decourager les Amoureux”, or the Imaginary Syndrome to Discourage Lovers (Fitzgerald and Simon 2001:302).  Accompanying this denial is an intense stigmatization of those who do suffer from AIDS-related illnesses.  Because of many prevalent beliefs about the perpetuation of disease in Haiti, those who suffer AIDS are often “shunned by the community” and “denied their status as humans”; forced to suffer a vicious cycle of deterioration, neglect, and resulting further deterioration (Fitzgerald and Simon 2001:303).  Further, because of both stigmatization about STDs and suspicions about colonialist motives in regards to efforts from the medical community, many of the hospital-based education initiatives that have been attempted have been met with “denial, passivity, and rumors” (Devieux et al. 2004:111).  Fitzgerald and Simon (2001) summarize the AIDS problem in Haiti by asking,

“How does a community fight a disease whose existence it denies, whose victims it shuns, when the community is seemingly powerless to fight the disease on its own but mistrustful of any outside help?” (p.305)

This situation has posed many problems for both the prevention and the widespread understanding of AIDS.  Much of these barriers are due to cultural differences between those attempting to educate the masses, and the framework of understanding that the masses hold about disease and the world around them.

Voudou in Haiti

Voudou is a way of living that is woven into most aspects of life for Haitians, whether they declare themselves Catholic or not.  In Brown and Beck’s (2009) description of its “purple” worldview, voudou is classed within a group of worldviews that follows traditions of “superstition, allegiance, obedience, and kinship” (p.7).  Under this framework, belief in supernatural occurrences such as curses, spirits, and other things magical are characteristic and very common (Brown and Beck 2009:7).  Voudou is often poorly understood by the global community and foreigners within Haiti.  Yet, its principles and many of its fundamental beliefs exist within most aspects of life in Haiti – including even Haitian Catholics.  Many have adapted a belief system that has incorporated aspects of both Catholicism and voudou, which they conclude are compatible with one another – which has unfortunately only further stacked the odds against prevention and treatment of HIV/AIDS in Haiti (Martel and Mueller 2007:107).  And yet, because voudou is incorporated into so much of the fabric of Haitian society (Devieux et al. 2004:110), problematic beliefs and practices about AIDS continue to persist.

 The Relationship Between Voudou and AIDS

                Voudou practitioners hold a variety of beliefs and superstitions about AIDS, most of which have proven to be quite challenging to those attempting to prevent AIDS and alleviate the suffering of those diagnosed with it.  Because of its superstitious nature, traditional cures and diagnoses by voudou doctors, priests, or leaders follow a different system of logic than in Western thought.  Most believe that the onset and development of AIDS has supernatural or magical roots, which may manifest in a variety of imaginative scenarios: as a punishment from the Gods, a curse from another individual (Martel and Mueller 2007:107), or as a result of a person’s soul being stolen from them (Fitzgerald and Simon 2001:303).  Each of these beliefs transmits the potential that the sufferer brought the disease upon themselves by malicious acts.  Because these beliefs do not take responsibility for the technical aspects of transmission, they often stand in the way of education efforts to help with the very fundaments of the problem – the spread of a viral infection through sexual intercourse.

In regards to curing AIDS, another host of problematic beliefs emerge. Many Haitian voudou followers believe that sex with a young virgin can protect them from, or cure them of AIDS – and the younger the virgin, the more effective the cure (Brown and Beck 2009:8).  Many also believe that protection from AIDS can be obtained through various charms or protection spells (Fitzgerald and Simon 2001:302). These beliefs and values, coupled with the Catholic custom to refuse condoms and birth control (Martel and Mueller 2007:107), breed a dangerous mix for those at risk of HIV.

The social and physiological consequences of these stigmas towards AIDS are great.  Those who suffer from AIDS are often presumed to have brought it upon themselves and are gradually ostracized from family and friends, neglected, and shamed, sometimes causing the premature advancement of their illness and untimely death (Fitzgerald and Simon 2001:303). Those who believe that they have protection from AIDS may continue high-risk behaviour under the false impression that they are protected by charms or spells - increasing both their own risk of contracting the virus, as well as the risk of their sexual partner(s) (Fitzgerald and Simon 2001:302).

Voudou and the Medical Community

                Many efforts have been made to enhance communication between the health care community and voudou leaders.  Unfortunately, much of the health care that is delivered has not addressed the “tremendous social stigma and isolation” that people with AIDS face in Haiti (Fitzgerald and Simon 2001:302).  Because many of the approaches have been through generic, international, hospital-based means that taught the “facts” about AIDS , the unique worldview that voudou practitioners hold has not often been taken into account (Fitzgerald and Simon 2001:302).  As a result, many people in Haiti (particularly voudou practitioners) have become suspicious of the motives behind medical community’s efforts, with those who follow Catholic beliefs suspecting a “family planning conspiracy,” and voudou followers fearing a “murderous trap”  (Fitzgerald and Simon 2001:304). Some voudou doctors have also become weary that the promotion of AIDS prevention and treatment is an attempt to steal their “patients” (Fitzgerald and Simon 2001:303). Unfortunately, many of the attempts to meet with voudou leaders directly led to suspicions of conspiracy or attack (well warranted given the colonial history in Haiti), and very little feedback or true exchange between voudou leaders and members of the medical community resulted from it (Fitzgerald and Simon 2001:301-309).

Building Bridges

Some experts have made suggestions for approaches that may be more culturally sensitive, and therefore more effective, for future efforts. In addressing those who practice voudou and similar worldviews, Brown and Beck (2009:7-8) assert that HIV/AIDS communication should focus on their understandings of the supernatural, as well as appealing to their deep sense of respect for elders and authority figures.  This translates into linking references with magic and spirit beings; honouring, respecting, and appealing to the elders and leaders of the community; and using storytelling and other familiar methods of expression, rather than the written word, to convey ideas about HIV prevention and treatment (p.7-8). Martel (2007) suggests that practices voudou practitioners traditionally use, such as the use of herbal medicines, are potential launching pads for “culturally appropriate” intervention (p.115-116).

Despite the obstacles to effective care delivery, some groups have made positive steps toward healing relations between the health care workers and the voudou leaders that are so influential upon the population. Treichler (1999:10) reports a case where voudou leaders were able to “overcome men’s traditional resistance” to condom use by describing AIDS “as the work of an evil spirit who uses sexual desire and the virus as secret weapons”, whereby condoms were seen as the means to trick the spirits out of transmitting the curse.  Yet Treichler does not discuss the enormous and often overwhelming challengeof  getting past the suspicions of the voudou leaders and gaining their trust and respect enough for them to develop their own, culturally-based and very influential beliefs like the condom-trick example.   Fitzgerald and Simon( 2001:301-309) discuss a fascinating account of their failures and successes at a rural community hospital in Haiti at length. After many poorly received attempts at making contact with voudou leaders (and the rest of the community) to “educate” them about the AIDS, their hospital workers reached out to community members for feedback.  The consensus of the locals was that hands-on involvement and care for those suffering from the final stages of AIDS would be the greatest learning tool, which was implemented with so much success that those who participated were eager to teach the rest of the community. This hands-on approach taught them about the realities of the disease, the potential for preventing transmission, and the ability to alleviate suffering.  Although the initial participants were not specifically voudou practitioners, their contribution eventually encouraged some to attend the subsequent seminars, which used a curriculum based on the narratives of people suffering from AIDS. Into this program came a building cascade of influential leaders from surrounding communities that increasingly included voudou leaders. Fitzgerald and Simon (2001:301-307) report that over 1000 individuals, primarily influential community leaders, took place in the workshops, 311 of whomo were voudou leaders. 

The most positive gains from this program, in regards to the voudou community, were the results that were seen following the training.  All of those who were interviewed post-training had returned to their communities to discuss AIDS.  Most voudou leaders reported discussing it during ceremonies, where they reported that the voudou spirits “told stories about people with AIDS during the ceremony and warned people to protect themselves from AIDS” (Fitzgerald and Simon 2001:307).  By far the greatest success was that several of them had chosen to buy condoms and distribute them to their followers, as well as referring patients with AIDS to the community hospital for treatment (Fitzgerald and Simon 2001:307).  Given the great resistance, doubt, and suspicion that existed prior to this program, the measures that these voudou leaders took is an enormous step both out of their old comfort zones and into a completely new way of thinking – or at the very least, a step into some very unknown (and previously untrusted) territory.   It is also an enormous success that this information was able to reach the voudou leaders in an effective way in the first place. This Haitian AIDS success story, however, was only successful because it was almost exclusively activated, perpetuated, run, and taught by the community leaders and their followers, rather than the hospital (Fitzgerald and Simon2001:305).  This bypassed the stigma and suspicion that was held towards the hospital and the medical community in general, and used an approach that focused on something locally important – the respect and esteem that locals held for their authority figures.  Its strategy of teaching also utilized only the community centres that were most respected and which most of the population used (listed as schools, churches, and “voodoo societies”) which furthered its respectability, as well as the proportion of the local population to feel its effects (Fitzgerald and Simon 2001:305).

                The AIDS crisis continues in Haiti today.  Many positive steps have been taken, but many more need to be taken.  Its 2010 earthquake and the resulting breakdown of infrastructure have taken the focus off of AIDS while the country recovers, but the 1.9% prevalence rate of AIDS in Haiti from 2009 (AVERT.org 2010:1) is not likely to have gotten better.  Culturally appropriate approaches are clearly more effective than generic information campaigns that may be successful in other places, particularly given the complexities that voudoun beliefs present to Western thought.  Most importantly, though, I feel it important that preserving these spiritual beliefs is an important aspect of culturally appropriate education, as they are a spiritual outlet that can be used to alleviate psychological and mental suffering for many.  Clearly, as Fitzgerald and Simon demonstrated, there are ways of reaching out to the public and voudou leaders and teaching them in ways that help to reduce the impact of the illness while still respecting cultural beliefs.  More research and efforts in this direction will be of great benefit not only for those in Haiti, but surely for many other international contexts as well.

References

AVERT.org
2010 Caribbean HIV & AIDS statistics. Electronic document, http://www.avert.org/caribbean.htm, accessed July 14, 2011.

Brown, B. C., and D. E. Beck
2009 How to tailor public communications about HIV/AIDS to different worldviews. Electronic document, http://richardslaughter.com.au/wp-content/uploads/2010/02/Barrett-Brown_D…-Worldviews.pdf, accessed July 12, 2011.

Devieux, J. G., R. M. Malow, M. M. Jean-Gilles, D. M. Samuels, M. M. Deschamps, M. Ascenio, L. Jean-Baptiste, and J. W. Pape
2004 Reducing Health Dispairities through Culturally Sensitive Treatment for HIV+ Adults in Haiti. The Association of Black Nursing Faculty Journal 15(6):109-115.

Fitzgerald, D. W., and T. B. Simon
2001 Telling the Stories of People with AIDS in Rural Haiti. AIDS Patient Care and STDs 15(6):301-309.

Martel, L. D., and C. W. Mueller
2007 HIV/AIDS Teaching Behaviors of Educators in Haiti. Journal of HIV/AIDS Prevention in Children and Youth 7(2):105-118.

Treichler, P. A.
1999 AIDS and HIV Infection in the Third World: A First World Chronicle. In How to have a Theory in an Epidemic: Cultural Chronicles of AIDS. Pp. 99-126. Durham, NC.: Duke University Press.

In my blogging absence...

I guess I took a bit of a period of absence from blogging!  I've been far too busy lately to jot down thoughts on here but things are definitely going very well.  The boom that Robin's birth story got was absolutely incredible - I think I got over 1000 hits in the first day it was online!  Very encouraging feedback.  I love to share that story everywhere I can, so that people can understand that it CAN be done - and it can still be empowering, even if its really, really hard!

I've been working away on three courses through this summer, but have also had the opportunity to spend a ton of time with the kiddos.  One course is completely done, one is about halfway there and the other is a third or so - so I'm pretty well on track and they're all going well! 

We have been working very hard (actually, my partner Jamie has been) on night weaning our litlte guy.  Yes, at 2.5 he is still nursing - but not through the night anymore!  Jamie has been sleeping with him each night and he adjusted to it surprisingly well.  Unfortunately, when Mommy is in the bed he doesn't think that the same rules apply.  And doubly unfortunately, Jamie leaves this Thursday for 5 days/4 nights to sell drums at the London Sunfest.  Wish me luck people!  Night-time parenting of both kids who do not sleep through the night (despite being 2 and almost 6) is not my favourite of jobs!

More to come, hopefully a lot sooner than last time!

My HBAC Story

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My daughter, Willow, was born by cesarean section after a much wanted attempt at a home birth.  Shortly after she was born, when I asked my doctor if I would be able to have another baby, he assured me I could have a vaginal birth after cesarean (VBAC); but heavens, don't try to do it at home! In my new-found reverence for him, after a long and trying labor and birth, there was no question in my mind that I would ever consider a home birth again. 


It didn't take long before that changed.

When Willow was still a babe in arms, I attended a c-section/VBAC support group where I first shared my story amongst those who shared similar feelings towards their birth histories.  My desires to become more involved with birth were also first articulated there.  A couple of months later I became a doula and got myself good and informed about VBAC.  Clients planning VBACs often went to me for support, and I ended up taking over the support group and adding it to the large umbrella of ICAN Canada Through this group and many other means, I found myself attending almost a majority of my clients in VBAC plans.  This really helped me to understand technical dynamics of VBAC in the hospital, as well as the emotional needs that women who've had a cesarean section have.  


When I got pregnant the second time, I worried about who my care providers would be.  Would I be hung up on a repeat of the first time if I had the same midwives?  I didnt know if they would even help with a home birth, so I contacted them (and almost every other practice in the province) to find out who would "allow" me an out of hospital VBAC.  Response was low, let me tell you.  My previous midwives, Caring Hands Midwifery Services in Alliston; and Midwives Nottawasaga in Collingwood were, however, both happy to accomodate me.  The decision to move to Midwives Nottawasaga was so hard for me. It's not that I didn't like my first midwives; they were lovely.  But they were in a state of transition - their senior midwife was retiring and a new one was coming on near the end of my prengancy and I worried about not knowing someone who may be influential in my care.  I also worried that having the same faces would set me into a spiral in a direction that I didn't want to go again.  Lynne-Marie and Diane had just started up their practice and I just loved them.  I can't say enough about them, really!  I could go on and on.  They were so supportive, so honest.  They pulled out their guidelines to tell me that they didn't have to 'make' me consult an OB for VBAC when I was already very well informed.  They treated my pregnancy as though they would have treated any other second time mother.  Normally!  



Me - 40 weeks with baby #2, surrounded by
affirmations given to me at my blessingway

 At my own request, I started having stretch and sweeps (among other measures to self-induce) around 38 weeks.  I loved being pregnant, but Willow was 9lb 5oz and her cesarean section was for failure to...erm...push.  So I had a little hope in the back of my brain that this baby might come a little sooner, and maybe be a bit smaller.  Alas, I was 41 weeks before contractions started first thing in the morning 5-7 minutes apart as I laid in bed, Willow still asleep.  They weren't long, or strong - just there, and consistent.  Within an hour, I realized that parenting was not an option at this point. My patience was pretty much nonexistant.  I called my mom to ask her to pick up Willow, who was very confused that Mommy was "in labor" since actually Mommy was "in the house"! Despite all the preparation we did for her, her 3 year old brain conceived of labor as a place!  I think later on, I could agree with that.  Laborland is a very interesting place.


My mom and step father came to pick Willow up mid-morning and Jamie and I sauntered through our day in early labor.  Such lovely memories we have from this time.  I was 3-4cm dilated before I went into labor and I hadn't felt too much change in my cervix when I checked, but I knew we were approaching the real thing and just enjoying our (rare) time alone together while we waited.  We went on a couple of beautiful slow winter walks about the lovely forest we call home, pausing for contractions along the way. We ate three big meals that day, knowing at some point there'd be no time or interest in food. We even played cribbage, while I sat through contractions.  By the evening, I couldn't sit through the games and chit chat anymore. I decided to lay down in bed and try to get some sleep because I knew it was going to kick into high gear soon.  We kept in touch witih my mom through the day and she sounded worried that the midwives weren't there yet; but we had close contact with the midwives and our doula.  We just didn't need any help at this point.  

But once I laid down in bed, instead of letting up, the contractions intensified.  I even started to get a bit shaky.  There was clearly a change and I was ready for someone to be there, so I asked Jamie to do the honors.  Doing his best to remember what he had learned from all of my birth talk, he told Melissa (our doula) that he thought I was in transition (because of the shakes).  I heard it just as he got off the phone and I told him I was definitely NOT in transition, so he called her back so that she didn't panic and run out in the snow in her slippers!  Then we called Di, our midwife.  Melissa arrived first, and around 10:30pm Di arrived.

When Di checked my cervix, I was 3-4cm and 75% effaced. I had guessed I was around there (although of course I hoped I was further), since the contractions hadn't really lengthened or increased in frequency, only intensity.We decided to start taking caulophyllum and cimicifuga (sp?) alternately every 15 minutes to try and help establish a closer contraction pattern and get well established into active labor - which came soon after.I am quite sure active labor would have come at this time, anyway, though - I could feel the change in intensity.



Our midwife, Diane, checking heart tones.
Note the slippers. And the lack of modesty.
It only gets better.



I had been laying on my side for the first little while, and as things got stronger, my contractions moved into the back of my legs, closer to my butt. The butt pain actually got much worse than the contractions themselves.  I didnt like that I wasn't relaxing through my contractions as I had done so well with during my first labor. I was discouraged  because the contractions weren't coming frequently enough, weren't strong enough, that I wasn't handling them the way I wanted them to be.  In short - my doula brain got in my way a bit.



My hand was always trying to put pressure on the butt pain

 Over the next few hours, I was so busy trying to analyze my progress (and not believing I was making any!) to realize that I was in transition!  When I was checked again around 2 or 3am, I was 7cm, and baby's head was level with my spines - lower than Willow had ever gotten.  But oooh the butt pain.





The stomping - complete with
heart tones and fan!

When I got up to go to the washroom,out of desperation to relieve the butt pain, I lifted my leg high and stomped it down on the floor.  A millisecond of relief!  And so, for the next few hours, I stomped, kicked, and danced my way through every contraction, rather rhythmically so I'm told.  Let me tell you, I felt so much more powerful standing and stomping so late in labor than I had before laying down!  I didn't need help getting up to eat/drink/go to the washroom.  I was in control of what was around me, because I was vertical.  That is such a nice memory (although I was much too distracted to appreciate it at the time).

Then I noticed myself grunting at the peak of my contractions.  At my last check, I was 7cm. That's when the blocks started coming up in my head. When I was in labor with Willow, my progress stalled twice - the first time, when I was 7cm and had pushing urges.  As soon as the feelings came, I became worried that they were in my head - that I was making them up.  Or that worse, I wasn't fully dilated again.  The feeling of needing to push ~SO~ bad and not being able to is a feeling to dread, indeed.  Enduring it for as many hours as I did with Willow is about the worst pain I have yet faced in this life. So since I had been 7cm at my last check, and I was feeling these pushing urges, I got worried. I was so worried that I was unconciously sabotaging myself...that I would have to go back to the hospital for the same reasons as last time.  From all of my work with VBAC Moms, I knew to expect these fears - but they were so real.  My contractions spaced out; eased up.  I knew this was often a sign that women reached full dilation but I was afraid because I didn't *know*.  I kneeled on the floor with my head on the bed, and Di asked me if I was alright.  I told her I was worried, because I was feeling pushy and I was worried that I wasn't fully dilated. 

Even though they encouraged me to push if I needed to, I just couldn't do it without knowing.  So I asked Di to check me again.  When she checked, she said I was fully dilated but for a lip of cervix, and my waters were bulging but still intact.  I asked (actually, I demanded) that she break them.  I was really, really happy that I was fully dilated and I wanted to be done as soon as possible.  I was about to encounter my next road block though - the second time my first labor stopped progressing with Willow (pushing).

Once my waters were broken I flipped onto my hands and knees and started pushing with all my might.  I had always imagined I'd give birth in this position.  At some point, our second midwife, Lynne Marie, joined us.  After a while (half an hour or so) with no progress, I needed to flip things up.  I hated pushing.  I was so done with labor.  The butt pain was steady, relentless.  The only thing that kept me going was Melissa's voice in my ears saying - "The butt pain will go away when you get the baby out".  And oh, I would do anything to get rid of that butt pain, so I kept on pushing!

Jamie was behind me, and I flipped onto my right side and put my head in his lap.  I pushed with every grain in me.  I was still convinced it wasn't going to work; that I was going to find myself in the hospital with another c-section.  But I was pushing beyond pushing.  Pushing my brain into another dimension.  Pushing until I had red spots and swelling all over my face.  Pushing until my eyes were bloodshot.  And at some point in this position, I figured out HOW to push.  I never figured that out with Willow, because I was numb when I was actually allowed to push. It was a hard spot to get into, but I felt an awful burning feeling, and they told me that I "got it".  It was hard to get into in that position though, so I moved onto my back.  Melissa tossed me her rebozo and held on to one end while I pulled on the other end, for leverage.  Amazingly, she managed to take photos while she was pulling; I don't know how, because I don't think I've hauled on anything else in my entire life the way I hauled on that rebozo.  It is a wonder it is still in one piece.  Despite the effort, I still thought I wasn't making any progress.



Boy, am I sure glad I was wrong on that one!

When they pulled up a mirror and showed me my baby's head, I couldn't believe it.  I looked around at everyone and said "Am I actually going to do this??!" and htey hollered back "Yes!!".  Really??!  I was in disbelief!  I had renewed energy.  Then I asked them if I could get the baby out on the next push, and they said yes!!!  And on the next push, his head came out.

Almost there! Still beyond words in my efforts. (and scaring the crap out of Jamie with the look on my face!)

About 20 second elapsed after his head was born; I can remember them well because I wanted to rest sooooooo badly but I knew the clock was ticking.  I heaved like never before, and then, at 6:26am on January 4, 2009 - the greatest moment of my life - my warm sticky baby came out and onto my tummy.

Relief!!!

Jamie and I were in pieces.  I think we both cried, sobbed, for an hour.  I just could not believe I had done it!!  I was ***SO*** happy.  I looked up at my midwives and doula, with tears streaming down my face, and said "I have this beautiful baby and nobody cut it out of me!". 

After a couple of minutes, we thought to find out if we had a son or a daughter.  I lifted up the towel that was over us to find we have a son - who promptly emptied the contents of his bowels upon introduction to cold air.  But really, I was covered up and down with blood and amniotic fluid anyway, and NOTHING was killing my birth high!!  We just sat together and cried, and cried.

I was so overwhelmed with relief, emotion, I was just completely dazed.  Now I understand the "hormone bath" phenomenon of natural birth!  WOW!  Our baby boy - whom we quickly named Robin - stayed on my chest for a couple of hours, and didn't come off until *I* decided to let Dad have a turn so I could get cleaned up.

Lo and behold, our "little" Robin was 9lb 5oz!  The same size as his sister - who was "too big" to fit through my pelvis! 
 Robin's birth was absolutely amazing.  I rode on the confidence I gained from his birth for a long time.  Although I wouldn't have told you in the minutes and hours after he was born (for at that time I was sure I'd never want to be reminded of that pain again), I quickly came to understand that his birth brought me the healing I needed to be fully present with the women that I support, instead of fearing that their outcomes might look like my own. 
Willow's birth laid the stone work for the path I now walk on, and Robin's carved the stone so there would not be a shadow of doubt. 

Could I get any more lucky?!

The big little guy, on his big day.

Willow (almost 6) and Robin (2.5) this weekend.

Lazy days of spring

Aahh the sweet smells and sights of real spring!  Has it finally arrived?  We have really enjoyed this long weekend.  I think the key to happy times is LOTS of time outside!  Especially for my little kangaroo (er, I mean son) who has all the excess energy.  Being outside is where everybody is happiest!

Tell a boy to strike a pose, and this is what you get!  Isn't that smile too cute for words?

This is what she says June will look like.

I've really been enjoying the pace that I can work at as well.  3ish days a week of working on assignments means I'm going to be able to finish each of my distance ed courses in roughly 5 weeks.  No commuting, no rushing out the door first thing in the morning, no schedules or deadlines.  Unfortunately, no wonderful classmates, either, but I can take comfort in the fact that I'll get to see them again in the fall.  In the meantime, I'm working on a Womens Health Issues course, where I get to write fascinating mini essays about menstruation, menopause, abortion, and now a final essay that I chose to write about HIV and the childbearing year.  Absolutely fascinating!  Another topic I'm starting to get super-interested in.  Good thing I've got 10 pages to write about it! 


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Unassisted Childbirth

Ryerson's students received their final grades today.  I had some pleasant surprises and an overall sense of satisfaction for a year well done!  Now, on to a lovely selection of Women's Studies and Social Science electives for the summer, through distance education with the flexible Athabasca University!  More to come, I'm sure!

And with the final grades, came feedback for the big, gigantic paper.  And finally, it is ready to be shared.  I had thought I'd be editing it a lot before it came out but it turns out that my teacher only had a couple of small points in suggesting how I could have improved the essay!  All in all I'm so happy that I wrote it and will be considering publishing it (in a shortened version) in the near future.  Beware that its a big long, but when you factor in the references list, the long appendix, and the fact that its double-spaced, its not actually that bad!  So snuggle up with a blanket and a hot chocolate (or whatever tickles your fancy) and prepare to learn about Unassisted Childbirth and midwifery in a way that you probably didn't expect to...

Unassisted Childbirth and Midwifery: A Philosophical Juxtaposition. 

                                                         Photo taken from www.unassistedbirth.com/uc/


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