Language as Violence, or Peace?

“Violence is not simply an action or a practice; it has many dimensions. Violence is a perception. It is an expression. A way to be seen or heard. A form of domination. A mode of discrimination. A lack, absence or decline of communication […]. Language acts as a map that mediates reality through everyday communications, so violence becomes instilled in reality”1 —UNESCO “I am trying to get the violence out of my language,” said Sr. Angela Murdaugh, CNM, as the lively conversation about the effects of rap lyrics and MTV on teens and society continued around the dinner table. That comment replayed in my head many times in the following months. A physician said to a nurse caring for a laboring woman, “Get aggressive with that pushing or she's getting cut.” A staff member smiled as she hung up from talking to her teenage child who had finally remembered to call and check in, “Sometimes I just want to kill that kid.” I heard Sr. Angela's comment in my head a few seconds after I said to a staff member, “Touch this stack of charts and I am gonna hurt you.” It replayed again as I watched the evening news: violence in everyday language. Is this a result of the violence around us? Or could it contribute to the violence in our world—or at least reflect our tacit acceptance of violence in our daily lives? Violence and language became a serious project for me the night I said to a young woman in labor, “Let's break your water and see if that won't speed your labor.” My intent was good—stimulate a stalled labor and avoid oxytocin—but the woman's face showed the fear she felt at my statement. She said in a shaking voice, “What are you going to break? Is it going to hurt my baby and me?” Her tone let me know she was terrified. My language with her was violent—and that is what she heard. What impact was my language having on the women I cared for? A quick Internet search turned up many books and articles by sociologists and anthropologists that address the relationship between language and violence. In 2003, the United Nations initiated a year-long project called Language as Violence in a worldwide effort to address the violence that youth experience in language and life. The first paragraph in the preface to the report, which is quoted above, makes it clear that violence is much more than a violent act. Violent language is a form of domination in communication that can become instilled in reality. Does our workplace language put us at particular risk for violence in our care of women and their families? Our professional literature uses demeaning and discriminatory language to describe women and ultimately to control women's experiences in childbearing. Textbooks picture female anatomy as if it were the whole woman. It is interesting to note that chart forms for burn victims and standard chart forms for dermatologists show whole people—not body parts. What is it about women's health care that separates women into breasts, pelvis, and perineum? Our workplace language reflects this mindset. We speak of women by their condition: “the previa in room 6”or the “gestational diabetics in Tuesday's clinic.” Yet we also know from the articles in this issue that women who have experienced abuse have more physical symptoms2 and seek health care services more often than women who are not abused.3 The study by Seng et al.4 makes it clear that women who have experienced abuse have risk factors associated with poor perinatal outcomes and are more likely to use substances in pregnancy that are associated with poor perinatal outcomes. Despite these relationships between abuse and poor health outcomes, we continue to complain of barriers in screening for abuse.5 Violent language in the workplace needs to be recognized as one of these barriers because women who need us most may be those who are the least able to trust our care. In women's health care, violence begins in office visits. We “scrape the cervix” for a Pap smear, or do “punch biopsies where we take tiny bites of the cervix.” If that doesn't work, the cervix is “frozen” or lesions “burned off.” Personally, I think any procedure that uses an instrument called a Kevorkian biopsy forceps can be nothing but violent. In labor, we “pop her bag,” “crack the sack,” and use similar terms if the woman did not arrive “ruptured.” From this point she is “pitted,” “blocked” when speaking of a pudendal or epidural, “put to sleep” or “knocked out” if given a general anesthetic, or just “sectioned.” We roll her over or “flip her” periodically in labor. We may “sit on her” if we are not clear on the course of action, a term that can be easily misunderstood by persons not familiar with American idioms. Birth is facilitated by “pushing” with many forms of violent encouragement. Phrases such as “Get mad at that baby and push him out,” or “If you don't push harder we are going to yank him out with the forceps” are used to encourage a woman's efforts. My personal favorite is “You know you don't want to be pregnant anymore, so just poop that baby out.” If the woman fails to comply with these requests, she is “pitted out,” “pulled with forceps,” the baby is “sucked out with the vacuum,” or she is “sectioned.” During these births, comments such as “Hand me the scissors, I need some room to work” or “If you don't hurry and push, you'll get cut” or “Make me section you” are violent threats to women. The placenta is “expelled.” I remember the stunned look on a teen mom's face when the nurse asked me to call out when the placenta was expelled. The young mom did not see “expulsion” as a good thing—having been expelled from her high school recently. She asked me, “Who has to kick out the placenta?” She clearly thought that “expelling” was not something she wanted to do. The cervix in particular inspires demeaning language. A woman's cervix can be floppy, rigid, unfavorable, or incompetent. Why is it that a woman has cervical incompetence but a man needing Viagra does not have penile incompetence—he has erectile dysfunction? The latest term for the cervical problem is cervical insufficiency, but I find that not much better than incompetent. Women's bodies can be hostile—particularly where men are most intimate. Cervical mucous can be “hostile” and “hostile to sperm.” A newer term is “spermicidal mucous”—a small improvement. Women can “fail” in many aspects of their physiology: ovarian failure, failure to progress, failure to descend, failed homebirth, failed VBAC. Women can fail to relax, fail to cooperate, fail to comply, and fail to attend childbirth education classes. One failure may be the provider's failure: failed induction. However, the failed induction is on the woman's chart as her diagnosis, not consistently attributed to the provider who scheduled the induction. The opportunity for women's bodies to fail continues throughout labor. Women can have an inadequate pelvis, inadequate contractions, inadequate pushing effort, inadequate fetal growth, and intrauterine growth retardation. Is intrauterine growth restriction any better? Birth is not the woman's last chance to fail. She can fail at breastfeeding, fail to bond, and contribute to her infant's failure to thrive. All this failure on the part of the woman means the provider must take over to correct and control the process, leading to provider domination. Our language to each other supports a violent tone. We “treat 'em and street 'em” in the emergency room or triage area. We “rack 'em and stack 'em” in clinics or busy units. We put the “high rolling” multipara in an area where we can watch her because the baby will “crash” when she “ruptures” (membranes). The “rookie”—aka primigravid—woman is the “old maid card” nobody wants because she will take too long in labor. We ask each other what we are doing about that labor with the clear suggestion that we should “do something” to get things moving. I submit that our language encourages us to take a more aggressive than patient approach to care. Our language says we are in control and compelled to make something happen—no matter what it takes. Certainly emergencies require direct and decisive action but even then, violence can be avoided. A wonderful article titled, “You'll feel me touching you, sweetie: Vaginal examination during second stage of labor”6 reminds all of us of our behavior and language. I cringe when I read the article— hearing myself in so many of those phrases. Why do we use the demeaning language? Does it reflect how we feel—that we dominate our patients or need to put them in a dependent role? Does this domination lead to the violence in our delivery of care? Violent language creates the perception of violence and stops communication. As providers, we use professional slang as a source of humor and probably a stress reliever. We all laugh at the books and movies like M*A*S*H and Hospital where our slang is rampant. I remember going to see the movie M*A*S*H with my father. I was laughing until I was crying, but my father was not—he was appalled that medical people “thought of patients like that.” Try as I could, I could not explain to this brilliant man that we talked like that but really didn't mean anything demeaning about the patients. The gap between our words and the ability of the people in our care to believe that we “don't mean anything negative” cannot be bridged with simple explanations. If you aren't “one of us in the medical community,” then the sense of fear, humiliation, and insult is bound to result from our language. We must change our language if we are to remove the demeaning and sometimes abusive impressions it leaves and the contribution it makes to our actions. Language can also change our role from dominator to expert companion and champion of the woman. Describing a Pap smear as lifting some cells from the surface of the cervix is less violent than the previous terms. Instead of “rupturing membranes,” we can ask the women for permission to “open the water bag to assess the fluid before birth” or whatever our reason for amniotomy may be. Pushing can be described as helping bring the baby out. Most of us subscribe to “laboring down,” which is both nonviolent and physiologic. Encouraging a woman to go with the pressure she feels as the pushing sensations begin is far more empowering and less violent than “Push! Push! Push!” Our language needs to convey respect for the woman so she can maintain her dignity. When we believe that violence has no place in our care and in the care of women, only then can our language change. When we hear ourselves say something that we recognize as violent or that we see engenders an anxious response from the woman or her family, we need to stop immediately and address the communication. When I decided to change my language, I felt that I spent as much time correcting myself with the woman as I did in communicating in the first place. With awareness comes skill, however. Now, with the support of others in my environment, we are working together to change our language. My observations of women and language convince me that violent language is easily misunderstood (or clearly understood), frightening, and tension-producing to the woman and her family. It affects the way we provide direct care to women. A colleague has a bumper sticker that says: Peace on earth begins at birth. Violent language in the workplace supports violent delivery of care that shatters the setting we believe is essential for health. Does peaceful nonviolent woman's care contribute to a world with less violence? I propose that we join in a commitment to find out—by eliminating the violence in our language and care. The Chinese proverb says every long journey begins with a first step. May we be the people who take the first step to eliminate the violence in the language and care of women. Thank you, Sr. Angela.