Pushing Back on Medical Authority with Jennifer Block

Join me for this conversation with journalist Jennifer Block, author of Pushed: The Painful Truth About Childbirth and Modern Maternity Care and Everything Below the Waist: Why Health Care Needs a Feminist Revolution. Jennifer recently found herself at the center of a social media storm over an article she wrote for Scientific American titled “Doctors Are Not Gods.” We talk about why she wrote this article and the controversy it created, as well as the state of women's health in a medical system that is often closed to the alternatives women are seeking.

Aviva: It's wonderful to have you here. Before we dive in to the conversation and the controversies that erupted, can you tell my listeners about your beginnings as a journalist? You've been out front on some pretty big investigative pieces. For example, you rang the warning bell really early on Ensure – I know it's called a contraceptive device, but I feel like it's like a sterility device – that's now been removed from the market in the US. Even prior to that it was banned for use in several European countries. Tell us what you've been doing and what you bring to this conversation as a journalist.

Jennifer Block: I've been a journalist for about 20 years. I began at MS. magazine where I was an intern first and then was hired on as an Assistant Editor and worked my way up to Associate Editor and I kind of – in not a planned way – took over the health beat. When I look back, that’s something that I've always kind of had an intellectual interest in. I've always had feminist leanings and I've always been interested in women's experiences and I have a family full of doctors, but I was never interested in becoming a doctor. So I kind of took over editing the health section and got all the health mail. I stumbled upon a big story about the medicalization of childbirth and what was happening in maternity care in the early 2000s, which was that labor induction was being used more and more. and our C-section rate was going up.

I started to talking to women and hearing these stories of basically their power being undermined in the maternity care scenario. And it led to my first book, to make a long story short, um, which has Pushed which came out in 2007. It’s something that is on lists for trainings for doulas and childbirth educators, it's taught in university courses on the sociology of medicine and reproductive health and reproductive justice. I've just kind of followed this beat at the intersection of medicine and feminism. I've been interested in the controversies around surrogacy and breastfeeding and homebirth, and of course abortion and contraception. My interest in all of those issues led me to my most recent book – Everything Below the Waist: Why Healthcare Needs a Feminist Revolution, in which I go documenting all the ways that the healthcare system in the US is failing women in particular, through a feminist lens and looking back at the unfinished business of the feminist health movement of the 1970s.

Aviva: That to me is a great point that I want to kick off into. What is this unfinished business? But I just want to really emphasize for those of you who are listening, Jennifer has a tremendously respected reputation as a journalist. And I know you as a thoughtful journalist, you don't lean on hyperbole, you don't lean on scare tactics, you don't do take down journalism. It's thoughtful journalism from the perspective of someone who is questioning medical hegemony, questioning what we accept as evidence-based procedures that may actually not be as evidence-based as we think. And really saying that there are alternatives that do have evidence as well and that we might be considering them as we reframe how medicine is practiced. Just for listeners, I really want everyone to understand that the Jennifer is a really well-regarded, not frivolous, not take down type of journalist. And that becomes relevant as we talk about what happened over Thanksgiving.

But before we even get there, like me and I think we're in relatively the same age range generationally, Our Bodies Ourselves was a major inspiration for me. I really attribute that book with my own deep confidence in my body. I got that book when I was 15, hand mirror and all figuring out what was going on there. That sent me on a really important path of honoring women's bodies, honoring women's autonomy over their own health. And like me, I think it's empowered a generation or more of women to take control over their health, to question medical authority, to not be shrinking violets about our vaginas and our reproductive health. And I believe it was the first time I personally had also been visually exposed to an image of the consequence of an illegal abortion, which was the reality for women when the book was published and continues to be for women in many states in the United States, leading to the growing risks of illegal abortion once again. Something was happening at that time, the 1970s, I got ahold of my copy in ‘81 so I was kind of that next generation of women, if you will, who are the first generation benefiting from the generation ahead of me as feminist foremothers.

What do you feel? If you could identify the unfinished business of the feminist health movement of the 1970s, what are those pieces that need attention now or still?

Jennifer Block: So that movement was first of all very skeptical of the experts, right? What was so radical about that movement was that they dared to question the white coats. You know, the men who had been telling them – ‘This is how you give birth, this is what's going on. Don't, don't worry your pretty little head about it. We know the answers.’ They started looking at their own bodies. They took over this medical tool, the speculum, and they got their mirrors and they taught other women how to use it. And they looked at each other as cervices and they talked through their experiences and they started establishing a new literature, which is what Our Bodie, Ourselves represents. I think it's so hard for us in this day and age to imagine a world where there were no images. You know, weren't shelves at the bookstore with information about female anatomy and women's health.

Aviva: Our Bodies Ourselves was really important for me. But actually the book that really showed me what was going on and the variety of women's vulvas was a book called A New View of a Woman's Body, which I bought at the same time. It was sort of like the west coast feminist book in a way, but it was really more images and it was so just earth shaking to me to see these images, incredible, the diversity of women. As a woman's practitioner now, there've been many times over the years where I've just looked at a woman said, you have such a beautiful vulva and she'll start crying, or like ‘have you ever looked down there?’ Women who feel so disconnected from their bodies. For me it was that book that was so important for that.

Jennifer Block: I write about that book in my new book. I agree with you. It was the west coast Our Bodies Ourselves. The illustrations in that book, there was a professional artist who joined the team. Well, I guess she wasn't professional at the time cause she dropped out of art school to go be a feminist health activist. She showed up at the clinic door, this art school dropout and said, I want to help. And she ended up doing all these beautiful illustrations in that book and there's this interesting history. They went back through all these medical texts trying to figure out where is the clitoris, how big is it, where does it begin and where does it end? That book is actually much more accurate than a lot of the medical textbooks at that time because it shows that large grasshopper-like object that now is becoming art – there's the Cliteracy Project from Huffington Post, etc.

This movement was so curious about female anatomy and physiology. It demanded respect for female anatomy and physiology. And it demanded a different idea of who the experts are. So it really challenged this idea that the experts are the MDs and the white coats and we are just these consumers who go and give up our authority at the doctor's office. They challenged that whole model and we can thank this movement for being part of the resurgence of midwifery and home birth and for drug labeling. It was the feminist health activists who stormed the hearings on the oral contraceptive, which at the time was a very high dose estrogen that was causing blood clots. From there we got drug labeling and transparency and this idea that patients deserve to know the risks as well as the benefits and to make decisions. It was a movement that was also skeptical of pharma influence, even in the 70s. I wrote this book coming out of Pushed in which – back to what you were saying before, thank you for, for characterizing my work as being grounded – I was blown away by the fact that a lot of what goes on in maternity wards around the country is not based on evidence.

Aviva: It's really not. Or it's based on a limited range of evidence that's often outdated and based on a small, very homogeneous sample of women in an unnatural setting.

Jennifer Block: Yeah. It blew me away at the time. I was very naive. I was in my 20s. I was like, I was like, oh my God, did you know that most of what's going on in maternity wards is not in the evidence. The evidence says something else. I was so naive and then I of course looked up from Pushed and I realized, oh crap, this is going on across women's lifespans. We don't really have evidence that the Pill treats endometriosis or PMS, but it's being used that way. We're recommending annual pap tests against the recommendations of the United States Preventive Services Task Force, etc., etc. We have this high hysterectomy rate and we're telling women that it's going to have absolutely no impact on their sexual health. We're doing a lot of things across the lifespan for which there is not enough evidence or the evidence actually is contradictory.

And I had this question while I was writing Pushed, and the question persisted: where are the feminist health activists? Why don't we care that almost a third of women giving birth are being cut open and we know that the rate at which cesareans are beneficial is much lower than that. Why don't we care about that? Why aren't we having hearings about the hysterectomy rate? There were congressional hearings in 1993 and before that there was another hearing in the 70s. The rate really hasn't changed, but it just doesn't seem to be something we care about. And then I also was observing when we would have discourse publicly about things like the Pill or epidurals or breastfeeding, I noticed that the feminist response tended to be like a lot of defensiveness of the treatment or product. A lot of defensiveness of formula and a lot of defensiveness of hormonal contraception.

Aviva: Also of cesareans. It's really complicated because as a physician who does women's health and obstetrics, I really want women to understand that the international standard that is acceptable – we know that above actually endangers mom’s and baby’s wellbeing is about 17%. The United States is at twice that rate. And yet, when you’re in labor and your OB says, we have to do this right now or your baby's gonna die, as a mom we're going to do everything we can to protect our baby. That is not a moment where you can usually feel like you can say, ‘Oh, let me hit pause and do my little research on this and see whether what you're saying is true.’ Or how do you interpret, as a mom in labor, a category one, two or three heart tone? And then, when you're on the other side of it, naturally you're going to feel defensive about your choice.

Yet we know from like an insider's perspective that a lot of those fetal heart tracings are misread and err on the side of conservative, meaning going toward a C-section. There's actually a saying in obstetrics, the only cesarean you get sued for is the one you didn't do, right? And 83% of OB’s are already going to experience a lawsuit in their career. So you've got this really complicated situation and if you talk about it, I think a lot of women who have become in a way a victim of that system without knowing it, feel like they're being attacked. And yet we still have to change the system, right? Without women feeling blamed for somehow getting duped into something or having something unnecessary. And like this is a story you're going to remember your whole life, so it's natural also to want to have a revisionist approach to it ourselves to make peace with it internally. Plus you don't know, you don't know if you were one of the women who did or didn't actually need it. Right?

Jennifer Block: I think that’s the key. Exactly. These conversations hold so much complexity and I think we have a problem in our culture, especially right now, with the quote unquote “discourse” that happens, online. We have a problem holding all this complexity, that we can look at a person, we can talk to a person on their individual experience and acknowledge. Like, it sounded like you needed that cesarean in that moment and that might've been hard and I'm sorry that happened. And you can still bond with your baby, you can still recover from that. We're resilient. And we can also have the conversation that across the population, our rate is too high.

We know that a good percentage of those cesareans that are happening are unnecessary. They're causing harm. They're contributing to the crisis of maternal death; they're not the only reason, but they are definitely contributing. We have to be able to hold those two truths – that we have a public health problem and individuals have valid experiences and we don't know which ones were the necessary ones. But I think we can have those conversations if we try. And the same goes for the pill. The pill was revolutionary when it came into use in the 60s. It came into use at a time when abortion was very dangerous and illegal, when you couldn't just go to the corner store and get condoms, when you had to be married to get a diaphragm. All of a sudden women who didn't have a lot of power socially had the power to discretely control their fertility.

Jennifer Block: But we can also talk about the fact that now we know a lot more about how the Pill impacts our bodies and our physiology and that there are a lot of negative impacts. We also live in a different time when we have more choices about how to control our fertility, and hopefully in a time when we've have more power in our relationships. I wanted to have those conversations and I observed other people trying to have those conversations, other authors who had written books that talked about all these negative impacts of hormonal contraception and questioned whether it really deserved to be on the pedestal that we put it on. Like, I couldn't have got my law degree without the Pill, I  couldn't have had my life without the Pill.

Jennifer Block: I saw them get attacked in the feminist blogosphere, in the mainstream media. I saw them attacked as anti-choice. They were assumed to be anti-sex. And I just thought like, wow, what happened here? Because this was a conversation we were capable of in the 70s. The feminist health activists were on the front lines of questioning the safety of the Pill. While they acknowledged that it had all this great promise for women's empowerment and equality, they still were concerned about its impact. I observed that we were really having a hard time having that conversation. You could look at breastfeeding, right? Like we can't have a conversation about the reality of breastfeeding without the worry that we're going to make people feel bad.

Aviva: There's like an inability to have this “yes, and…” conversation and it feels like everything gets polarized. One of the things that I've seen in my own clinical experience, this is in hospitals and clinics and hearing physicians give lectures at conferences, is this sort of inability of the medical model to re-identify itself as not infallible. This belief of doctor as God, this belief of medicine being the answer, and it being above and beyond reproach because it's based on this idea of evidence, which is a very limited concept actually the way it's applied. Yet we see over and over and over – I mean I can name 10 things right off to you just off the cuff…. Right now in the past probably 10 years that we're like, oops, oh well no, we shouldn't have been doing Pap testing on women under 21 cause now we've got all these women who had LEEP procedures who can't maintain a pregnancy because their cervix is damaged or conversely can't birth a baby through their cervix because their cervix is scarred. Or how often we were doing breast exams or I mean just like on and on and on. Pelvic exams, pharmaceuticals that have been dispensed.

Like the Essure. I mean, let's look at the Essure. You would have thought the Dalkon shield would have been a cautionary tale, and then we have the Essure. It's this continual one, idea that medicine has all the answers and that everything outside of that until it's approved by medicine and Columbus if you will, is alternative, but also that women's voices don't count. And what I see over and over and over with the Essure, we saw it with the Dalkon, we see it with all kinds of procedures and pharmaceuticals, women are saying, ‘Hey, this is how I'm feeling and something's not right since I started using this.’ Then the medical answer is, ‘Oh, well that couldn't be like that. That's not a known side effect’ until boom, we've got hundreds or thousands or more women damaged by a procedure. Yet we're still not having this “yes, and…” conversation. Yes, there is a role for the pill and you have a right to know what the true evidence is, right? Yes, there are needs for C-sections, and also here's what you really need to know. We're just not getting true informed consent.

Jennifer Block: This just came up too with the LEEP procedure. There was a great piece in Cosmopolitan [and it got a lot of pushback]. It got so much pushback. I mean, so if your listeners didn't see it, it's by Hannah Smothers. She spent a year reporting it. I really commend her for the piece. I had reporter jealousy. I had done it. I was really interested in it because I had heard the anecdotes, I had heard people, friends, people I'd interviewed tell me that they had had a LEEP procedure and for a year they couldn't have an orgasm or it just didn't feel the same anymore. Or now they were being told their cervix was incompetent while they were pregnant. The piece was titled something like this procedure may prevent you from having an orgasm, and Twitter went crazy. Med Twitter – I didn't know that term until recently, but Med Twitter went crazy and said, this is so dangerous. Women are going to stop getting Pap tests. This isn't happening – we have research that hysterectomy has no relationship to sexual dysfunction, so this couldn't be happening either.

That points to what we mean when people use evidence and wield the science term around. My understanding is that there's very little study of the relationship between hysterectomy and sexual function. The studies that do exist don't follow women very far from their procedure. They ask them really only about like how frequently they have intercourse, not about their actual experience of it. So, you know, there's problems with the research. And when someone says the research doesn't show that well, then the next question is how much research is there on that? And what were the questions asked in the research? But you know, people don't usually go that far and we listen to our doctors.

The piece was about anecdotal reports. It did not claim that there is a definitive percentage risk. It just asked the question. It's women having this experience and there are researchers who are mapping out the nerves of the cervix. And so we need to pay attention to this. Women need to know that this is a possibility. Doctors should know that this is a possibility, and should maybe like, ‘let's think about this and what does it mean that the nerves are there and how should we be doing these procedures’? That was the point of the article and it was attacked.

Aviva: Here’s the thing. Back in, I'm going to guess ’97, I remember having a conversation at one of our local midwifery meetings about women who had had LEEP procedures or cone biopsies, and we were noticing amongst us as midwives, a pattern of women who were having trouble dilating in labor. So we were transferring women to the hospital from home birth who were unable to get past two centimeters if that, or weren't even going into labor effectively and were ending up needing inductions, cervical dilatation mechanically, and often C-sections and we're like, wait a minute, are you noticing a pattern here that all of these women had had a cervical procedure?  This is 22 years ago now. And at that time OB’s and gynecologists were saying there is zero connection.

At this time we were still doing Pap smears on women under 21 because we were checking for cervical dysplasia and early HPV testing. And what was discovered, if you will, or finally determined not that long ago in the last decade, was that we should never be doing Paps under the age of 21 because they lead to over-diagnosis of cervical problems that will usually clear on their own, over-diagnosis of HPV which will almost always clear on its own in a woman under 21, and it was leading to procedures that are now well-documented and proven to cause the problems that we were describing back then. Difficulty with dilatation because of cervical scarring. And as you mentioned, what used to be called incompetent cervix – the language that's used is so incredible – but a woman's cervix inability to stay close during a pregnancy. So her either having a mid-pregnancy miscarriage or needing a procedure called a cerclage to literally tie the cervix, stitch the cervix closed until she'd go into labor. These are things that we've been told over and over, ‘no, those couldn't be the side effects.’

I want to switch gears just a little bit here. Along comes this OB-GYN, Jen Gunter who, as you and I both know, didn't exist in the social media world until a couple of few years ago. She had a meteoric professional career rise, which started out as a very trendy goop and Gwyneth Paltrow take-down approach and has extended into a take-down of most natural therapies, which in my worldview completely misses the point as to why women are seeking them. She emphasizes modern medicine as pretty much always right in contrast to what she's actually disparaged as old wives’ tales. She's used that term disparagingly, which is a classic term to disparage traditional knowledge and women's experiences almost entirely. Yet because she is a pro-abortion, self-identified feminist MD who's comfortable saying vagina on Twitter and this whole GP take-down, she has literally become an almost instant celebrity.

So, I saw this mug today on Instagram. It was from a different celebrity, OB-GYN and the mug said, please don't confuse your Instagram search with my medical degree. And I feel that that kind of like says so much. It's reinforcing this doctor as God and insults patients’ ability to do research and discern research. It's not stupid to question medical authority. Doctors make errors. Medicine as we just talked about is full of woopsies and it's really important to search for information when we're not going to necessarily be handed that clear informed consent information from our physicians. This is also at a time that women's experiences of what's going on in their bodies are dismissed and missed by conventional medicine. We know that it takes like nine years for a woman to get an endometriosis diagnosis. We know that a woman is more likely to die of a heart attack because her symptoms are going to be dismissed as stress or anxiety. This is exactly why women are searching for alternatives anywhere they can find them. On the other hand, you know, I do agree with a portion of what Jennifer Gunter says, like there is a lot of green halo and just BS happening in the women's wellness movement at a very high price.

So, I want to know what inspired you in the first place to write that article that day. You woke up one day and you're like, ‘I'm going to write this article.’ It's really about doctors not listening to women, right? This role of doctor as God.

Tell me what inspired you and then tell us what happened.

Jennifer Block: She’s kind of taken on, she's become emblematic of an attitude that to me is like the old school attitude that I thought we had gotten over – the attitude of the paternalistic doctor who tells you what to do and you listen and you don't ask too many questions, and they kind of take their degree and hit you over the head with it, and say ‘I'm the one who studied, I'm the one who knows best.’ Because I see medicine evolving in other respects – I see more integrative medical doctors speaking up and physicians taking on medical reversals and fighting overdiagnosis and overtreatment and trying to raise awareness about that and trying to bring medicine back into a more evidence-based place, or bring it to an evidence-based place.

I've been following Gunter for awhile and I very much appreciate her being out front about having provided abortions and the way that she's willing to get down in the mud with people to smack down these totally inaccurate descriptions of procedures. There's a lot of misinformation and myth coming from the anti-abortion movement, and she's one of the people who's willing to be out there – and that's brave. That's really brave in this culture and I commend her for that. And also we need doctors to clarify that vaginas don't need annual checking and that they're self-cleaning, that cutting the labia (doing labiaplasty) and vaginal rejuvenation could have potentially harmful consequences. She's been out there doing that myth debunking, which I think is really important.

On the other hand, she does seem to have this very black and white view of what is medicine and what is myth. From what I've seen, anything that might fall under the banner of natural or “Big Wellness” gets thrown into that bucket of myth for her. I've observed her on Twitter being very dismissive of people who find that yogurt helps them when they have a yeast problem or people who are choosing do vaginal steaming as a therapeutic healing process. Or even people who are using Jade eggs, the yoni eggs that goop was famous for that they won't sell anymore. I've observed it for a while.

I thought about writing something, but it really wasn't until I learned that Gunter was kind of grouping Our Bodies Ourselves into that category of misinformation and goop and pseudoscience and harmful mythologies. In her recent media tour for her book and show and everything, she had been talking about Our Bodies Ourselves a lot, and they wrote her a letter – they CC'd me. At that point I was like, this is now interesting as a story and also I just wrote this book that is through this lens of the feminist health movement which gave us Our Bodies Ourselves. I know this history and it's not fair to group Our Bodies Ourselves with goop just because Our Bodies Ourselves mentioned yogurt as something that has helped some of us. That's how they phrase it in all the editions – some of us have found relief using yogurt. It doesn't say that yogurt is an evidence based treatment for yeast or anything like that. The Our Bodies Ourselves tradition includes the experiences of women.

Aviva: Can I just interject one thought right there. I want to hit pause on one thing, which is what is evidence-based medicine. We tend to think of evidence-based medicine as randomized controlled double blind placebo crossover – all these abbreviations of what is a good study. But evidence-based medicine, which first showed its face in medicine in the 1800s actually and then kind of disappeared as a concept, was established by a gentleman who passed away a few years ago named David Sackett. He was a Canadian researcher and his entire life was dedicated to this concept of evidence-based medicine. He defined evidence- based medicine not in this very sort of narrow way that it's just the randomized controlled trial. It was actually a three-legged stool that you could sit on to make your decisions about best care. Either a patient could use it or a physician could use it or a hospital risk management team could use it. But the three legs of evidence based medicine are best available evidence, the best consensus from the professional group, and patient preference – those three things together.

There aren't a lot of physicians who are probably using yogurt on their vulva or in their vagina. So, the best professional evidence in that case would actually be women using it. And if women prefer to try yogurt before they try Nystatin or something else, there's no evidence of harm from it. We're so quick to attack something really quite harmless when we can always still go and use the conventional intervention if we need to. But I just wanted to say that about evidence – it's not just this lack of a randomized controlled trial. We have to look at the whole picture when we talk about it.

Jennifer Block: Thank you. Maybe you'll write something about it, maybe I'll write something about it. I think that there is a lot of misunderstanding about what this term means, and there's a lot of misuse of science, and what's science-based and what's anti-science and what pseudo-science.

I had a few big points with my piece. One point was, like you said, these things, yogurt, even Jade eggs, there's no evidence of harm of Jade eggs. Vaginal steaming, I guess there's a risk that you could get a burn, but so is there with anything you do with hot water or cooking or hot coffee or hot tea. My point is like, people are not finding the answers. They're not there. They come out of childbirth having issues with sex. They're not getting answers. They're getting, you know, just relax. They're getting the advice to go see a psychiatrist, or they're just getting Diflucan, or go to the drug store. And those treatments for many people don't work effectively or they work temporarily.

I'm hearing a lot about people, and maybe you can talk about a cycling back and forth between BV and yeast and kind of not getting a balance… People aren't getting what they need from conventional medicine. Of course they're looking elsewhere and some people are actually finding some relief. So one of my points was, let's listen to them if they're finding relief. First of all, let's listen to them and acknowledge their experience. Why would we shame them? Why would we publicly shame them and associate them with anti-science and pseudoscience when what they're doing is something for themselves. This has no bearing on the public health. This is not the same as questions of climate and immunizations. This is someone's personal health, personal decision, and this is really what like the feminist health movement stood for.

Aviva: This divisiveness and this insulting anything that is not medically proven as hokey or again, like old wives’ tales, this is a tactic that has gone back hundreds of years in our history. It was the tactic that was used with the Flexner Report in 1912 to close down almost every single medical school that trained women, African Americans and Native Americans in medicine, and singlehandedly excluded whole populations from getting medical training until essentially the 1970s when still only 9% of medical classes where doctors were women. I feel like I'm watching a woman doctor be emblematic of a very long history of… it's almost like I'm watching the worst of patriarchy coming out in this situation. And yet it's confusing because a lot of what is being said is also true. So how do you distill those grains of truth without losing the ability to feel confident looking at what the alternatives are.

Jennifer Block: That's what I was seeing too. There is a long history of medicine with a capital M maintaining its authority by smearing other practitioners and modalities. The history of medicine in the United States, North America is that it established its authority by putting midwives out of business.

Aviva: You look at things like 22 years ago midwives saying, well, I'm not too sure about these LEEP procedures on these young women, or let's look at delayed cord cutting or using honey for coughs instead of codeine or all of these. I mean, there are just dozens, if not hundreds of examples we can give of things that have come from outside of conventional medicine, born out of need for people looking for a safer option when they couldn't find it. And then lo and behold, 5,10, 15, 20 years later now actually being part of mainstream medicine because they were found to be actually effective.

Jennifer Block: The stuff we're talking about may be placebo, it may just be, as someone said to me, if you put a Yoni egg in your vagina, you're directing energy and intention and thought toward that part of the body and maybe that helps. I don't know if these things are having an effect. I don't know if it's placebo if they are, I have no idea. But I think that the point is that people are having an individual experience with them that they find as positive, and we're not talking about sticking razors, up your vagina, we’re not talking about bleach… We’re not talking about things that are like overtly risky and harmful. So why are we focusing, why are we spending time on that? That was my other big point.

Jennifer Block: We have major problems in women's health right now. We have a maternal death rate that's rising. We have people complaining of obstetric violence aside from that – just being bullied in the maternity ward, not being listened to, getting exams they don't want, getting procedures they don't want. We have crises with vaginal mash and we had the Essure disaster. We've got big problems, and if you have a big platform, are you gonna use it to talk about yogurt or are we going to really address the bigger problems?

Aviva: That's what I really wanted to ask you. What do you think is happening here? In my notes for our talk today, I have this whole thing about – okay, we've got a 34% c-section rate, the hysterectomy rate has come down by about 40% over the past decade however it's still at least twice as high as it's supposed to be. And big studies have now shown that women are not being informed of, I'm not talking about alternative medicine, but I'm talking about nonsurgical medical alternatives. We have one of the worst maternal mortality rates in the Western world and it's going up. So why is somebody who is clearly intelligent and educated going after goop? It seems like such a red herring. I mean, first of all, it seems like a cheap and easy target, but I mean honestly, how many women in the United States are really buying Jade eggs compared to how many are, I mean, 60% of women over 50 currently will have a hysterectomy in her lifetime and at least half of those are unnecessary. So, why is she doing this?

Jennifer Block: Well, I think in terms of brand and, and getting followers, those are easy targets. like you said. It's easy to criticize goop. I called Gwyneth Paltrow a salad of low hanging fruit, a line I really liked from my piece, because it's so easy to make fun of her. It's so easy to Jade eggs. It turns out they have no ancient origin story, so it's easy. It’s also easy to slam the anti-choice movement. Those are easy targets. I think what's much more difficult, the more complex conversation is all the other stuff in the middle between those two ends of the continuum. It's all the gaps in care…

Aviva: … which is where I live in my work and trying to really think about how in 2020 this podcast is going to transform so that we can really start addressing these issues together in a bigger way.

Jennifer Block: Right. I mean, women are they're not getting help with endometriosis. I'm seeing that on Twitter now. There's a large community on social media of women who are really pissed off because they've gone years without a diagnosis and all they're being offered are drugs and surgery, and it's hard to even find a surgeon who does the proper excision surgery. And they're also battling the disagreement over what their disease is and what the proper treatment is with their own physician. We've got that kind of area of like hormonal dysfunction and these diseases endometriosis and PCOS that are being more understood as these like systemic diseases that have other processes that, you know, even if you take the Pill and get rid of some symptoms that you still have this disease that's in the background putting you at more risk for heart disease and infertility and maybe even cancer, etc. And we've got this epidemic of chronic pain and pelvic pain.

Maternity care. My first book is unfortunately still pretty relevant because we still have this problem that the vast majority of labor protocol in hospitals is counter-productive. It's causing women and babies harm. It's resulting in our high cesarean rate. It's resulting in routine everyday kind of obstetric violence in that this is a case where we are not treating pregnant people as we would treat any other patient in the hospital in that we would get consent to enter their bodies. It's like they're in another class. I mean, every day women are told, well, you have a breech baby, you can't have a vaginal birth.

Aviva: There are a lot of rules that we’re treated as if we're children around. And we definitely seem to become the second priority around childbirth. Of course none of us as pregnant mamas wouldn't put our healthy baby as the first priority. But I think our definition of a healthy mom is really limited to surviving childbirth with minimum damage as opposed to actually the experience itself being an important part of your memory bank and your emotional experience and how that shifts your experience of being a mom, too.

Jennifer Block: So the choice that some women are making to quote unquote “free birth” on the one hand looks like an irresponsible, reckless decision. But on the other hand they see it as life and death. They know if they've got certain characteristics, if they go to the hospital, they're going to get a c-section whether they like it or not.

Aviva: …or if they're even fortunate enough to have a hospital in their county or within hours of where they live. And yet they're denied. Like in Georgia where I used to live and practice midwifery still, even from when I started there in 1985 to now, has one of the highest infant mortality rates in the country. Yet there are counties with no hospital access. Yet home birth midwifery, unless you're a certified nurse midwife, continues to be not legal. So women are literally denied access to safe providers or any providers.

Jennifer Block: Right. I'm reading about a midwife in Georgia right now who is suing. And in New York we don't recognize the Certified Professional Midwife credential. We have a midwife upstate who's being charged with a bunch of felonies. I’ve actually written a piece for Longreads that's going to be out in January about the history in New York. I think what this brings up is that what we're dealing with is the tension over authority. Medical doctors have sat at the top of this hierarchy of authoritative knowledge and that has to do with the history that we talked about and how medicine established itself. And it's a disservice to all of us because they don't know everything. Maybe as someone who went through medical training and midwifery training, you can speak to this too, but many medical doctors absolutely have an expertise.

They don't know everything. They're a piece of the puzzle; they're not the entire puzzle. There are other practitioners who have expertise and authority, and they've had to fight for that recognition. They've had to fight for the license to practice, and they still don't have it in many states, like for the Certified Professional Midwives. It’s a disservice to us as people, as consumers, as patients because if I'm in Georgia and I want to have a physiological birth, I want support, I want expertise, I want someone who has the expertise of supporting that process. I don't want to be in a hospital. I can't choose that because that authority hasn't been recognized.

Aviva: It's also driving the exact situation that then in a way becomes a self-fulfilling prophecy from the medical model to this sort of outside the box model in that because so many states are refusing to recognize the provenance of midwives or other practitioners, there's no way for the consume if you will, for the woman who is pregnant, or the woman who's looking for an alternative to an antibiotic for an ear infection in her kid rather than just getting the standard, you need an antibiotic rather than the actual evidence which is there's a wide range of wait and watch to give an antibiotic for that… Then the people who are practicing some of these professions become increasingly wild west and unregulated so that you as a consumer don't know the difference between someone who's a Certified Professional Midwife or somebody who woke up one day, had a calling, went to their niece’s birth and are suddenly putting themselves out as a midwife.

You have no way to really get to the bottom of that. I've seen complicated situations happen that way too. To me the answer is, unless medicine expands its definition of who's acceptable, what's acceptable, or stops trying to regulate everything and allows for more, I don't even want to use the word allows cause it still sounds like it's at the top of the… Starts to move over a little bit and expand partnerships. That's the answer, right? You have to be able to have a smooth transport from a home birth, particularly in a state that's not legal or women are going to stay home and midwives are going to stay home past the point that it's safe. It's the medical model that's even generating some of this lack of safety that might exist. It's the medical model that's creating the vacuum in which a consumer-driven business like goop can start to become sort of a health care space for women.

Jennifer Block: That’s right. It's fascinating that goop, a person, an actor, doesn't have the same ethical responsibilities as even a chiropractic doctor or acupuncturist or a midwife. Right? So someone like Gwyneth can get some products, put them on a website and say things about them, and that's perfectly in our capitalist society. That's totally kosher. She did say too much about Jade eggs; I know there was a lawsuit about that.

Aviva: But let's still counterpoint that to somebody goes online, they know what goop is. They go to goop. They see a Jade egg or they see an herbal this or they see a supplement that, and they make a decision about, yeah, you know, I really don't want to spend 80 bucks on that, or yeah, maybe I'll try that, and we want to criticize that. But what about when you sit down to watch Grey's Anatomy or Billions or whatever, Game of Thrones, whatever shows are on, and we're one out of two countries that allow direct to consumer, totally capitalist-driven marketing of drugs that can actually kill you compared to a Jade egg. So I feel like even still like, yes, we can criticize that capitalism, but let's get real. Even still how many women are going to go to goop versus how many women are going to see that pharmaceutical advertised on television for their rheumatoid arthritis and are going to go ask their doctor for it – statistically a lot. And that does have risk. I still don't have time to kind of come out on goop about it. You know what I mean?

Jennifer Block: That's such a good point. That is such a good point. Yeah.

Aviva: Can we swing back to what happened when you wrote this article? iIt came out right before Thanksgiving. A bunch of us were pretty excited. My social media followers loved it. People really felt like it expressed something that they couldn't quite put their finger on but were frustrated about. And next thing you know, you're at the center of this storm and Scientific American pulls the article down.

Jennifer Block: Yeah. I haven't been very active on Twitter and I experienced…I got trolled. I was in the center of a Twitter war over Thanksgiving, had never experienced that before and had to get up to speed really quickly on how to deal with it. There were a lot of phone calls, finding mentors who generally were younger than me and who know Twitter better as millennials. I noticed a couple things about it. I did not let it take over my life for Thanksgiving. I think I did a pretty good job of checking in with Twitter for a minute, but then going offline and enjoying my family and having a nice meal, seeing friends.

But there were a few things that I noticed about what was going on on Twitter. One was that the people who were attacking me, there was some reasoned  criticism, which I take. There were a couple of errors that could have easily been corrected. I pointed to a study on yogurt that it turns out was in a sketchy journal; I could have pointed to another study. But my point in that was not to prove anything about yogurt. It was just to say, look, there is some research on it. Some people have been interested in it enough to actually do randomized controlled trials on it, so there is scientific interest in it. But I wasn't citing that study to like prove anything about yogurt.

There was another little error about case reports about tea tree oil. I thought there was only one; it turns out there are a few case reports. It doesn't change any of my big points. But I noticed that like the unreasonable criticism was that I was somehow going against science, that I'm anti-science and that I should be grouped with people who deny climate change is happening. And that I must be anti-medicine or anti doctor and that's it. I'm still kind of trying to make sense of who those people are on Twitter and what their agenda is because it seems to be this kind of old school agenda of trying to smear alternative medicine. I noticed that there like a lot of the kind of fighting that went on, some in my stead or whatever, was between integrative medical doctors and these skeptic people. And that this is bigger than Jen Gunter. This is bigger than vaginal steaming. This is really this historic argument that has come up again and again about evidence and who gets to have authority, who gets to have authority over health and the body. I think that that's what I saw playing out.

Yes, Scientific American pulled the piece. I still don't really have a good answer from them. And The Daily Beast has written about it. Slate wrote about it. Um, there's another outlet that I thought was working on something like IMediaEthics. They all went to Scientific American and asked for an explanation and, and there was no comment.

So, I don't have a great answer about why it was taken down ultimately, except that I think that they became convinced that it represented something anti scientific that they didn't want to be associated with. Because Gunter screen-shotted emails that she was writing to SciAm in which she was claiming that I mischaracterized her, that she does not bully people online, that she only  dismisses the anti-choice trolls with “I'm the fucking expert” [a quote that she has]. She's sort of known for saying that and known for saying, ’I'm the expert, I get to say that.’ But plenty of people have now posted exchanges from her Twitter history in which she has been very dismissive of people who are not trolls, who are not anti-choice trolls, who are just people who have fought with her about endometriosis or fought with her about Leep or fought with her about yogurt.

Other journalists have come to my defense to say that she was weird about their reporting and kind of trolled them. There's a lot of example now of her behavior and now there's also the record of how she behaved in the days after my piece came out because she retweeted a lot of nasty stuff. She called me a weird stalker. She called me a misogynist. She called me a liar. She tweeted at my part-time employer. She spent a lot of time on Twitter in those days that the piece was up. I can't speak for Scientific American. I don't know why they took the piece down, but I think it had something to do with this smear campaign that it was anti-science and I don't think that that's my perspective.

I try to critique medicine from a place that's very grounded in science and evidence. That's the place that I was trying to critique her from. I don't know that I made the best choice in focusing the piece so much on her because, you know, I think that again, she represents something that's much bigger. She's emblematic of a problem that's much bigger than her, and it might've served the argument better if I had made it a broader piece and not focused it so much on her.

Aviva: On the other hand, she really has become quite a celebrity. She really is emblematic of exactly what we're talking about because she has chosen to focus on taking down so much of what women are looking toward for answers and information. It makes sense that that would kind of be an example that you might use. I see why it went that way. I think a lot of us feel that way. We see this New York Times column and it's got the same medical rhetoric as going to any gynecologist or any textbook would have in terms of what treatments are available with a sort of take-down of anything else that a woman might try if she doesn't just want a pharmaceutical answer. And as if the pharmaceutical answer is the only rational answer and everything else is as that mommy blogger said, ‘stupid or you're even stupid for asking the question.’

Jennifer Block: Right. And it's really disempowering to people, which is not in my mind, a feminist response.

Aviva: I have to say. One of the things that I find troubling about this whole picture as a feminist response is that I personally don't consider it feminist to take down other women publicly. I know that in your piece, you were not doing that. I don't consider it feminist for Jen Gunter to have taken down Gwyneth Paltrow and to have attacked her personally. I guess I personally prefer educating people, offering a better option – women are trying the best they can to fill this void. And this is where we need the answers. We need conventional medicine to look at why women are turning to those resources. And those resources need to look at what they can learn from conventional medicine. But you know, you stand in the middle of the road, you're going to get hit by a car and it's kind of what happened. But I do actually feel like that's where the answer truly is. It's not in this take down, back and forth lobbing. It's what are women asking for and what's missing and looking at the actual true definition of evidence which is broader than what we're talking about.

If thousands of women have had an experience that putting yogurt on their vulva helps, we're not talking about treating their child's meningitis with yogurt. We're talking about a benign, relatively benign condition, unless perhaps you're pregnant or have HIV, then it's different. But for most women, this is benign and see if it works. And if it doesn't….

We need to be de-prescribing. We're already prescribing too many antifungals, antibiotics and other pharmaceuticals. So to me there's this whole other reframe that needs to happen.

So I have a question for you. I think one of the critiques I've read from a number of different places, I think I've read this in Daily Beast, and some people's comments on your Twitter feed, or that you and Jen Gunter are actually closer or have more similarities than you have differences. I'm not actually sure that that's true because I think the intention and desire to help women is actually the same, but I think philosophically you're coming from completely different models. I lean toward the model that you're coming from, which is that the operational model in the medical model is still patriarchal and based on decades, centuries of racism and sexism. We need to really look at that and completely see things differently. But is there anything, is there anything that we need to think about? We're coming into an election year. We all know what the situation is. How do we all get, or can we all get, as women’s health, feminist-oriented practitioners, journalists, etc., on the same side of the aisle. Because I feel like this division is only going to feed the problems that we're all collectively facing.

Jennifer Block: Right, right. I mean, to your first question, I do think you're right that I think we are coming from different places philosophically. I think it comes down to authority and I think I'm on the side of people having authority over their bodies. I mean that in a very broad sense. I think a lot of this comes down to people want providers, medical providers, to be on their team and to listen to them and I think they want providers who are humble, who can admit when they don't know something, when they get to a place where like, you know what, we don't have good treatments for this. Here's what some other people have tried. I can't, you know, it's not standard protocol. It's not standard of care. It's not quote unquote “evidence,” evidence-based. But it is evidence-based in the sense of like, people are… That's the best we've got. I think people really crave that. Like if you find that provider who's honest and willing to be on a journey with you, then I think that's gold. Those are the people who love their doctors. At least who I want in a provider. I want someone who is going to be honest with me about what they know and what they don't know. And who's going to listen and I'm going to be able to say to, ‘you know what, actually I tried to vaginal steam and it was kinda nice. And maybe they shrug and they go, okay, but I don't want someone who's gonna shame me or tell me that it's wrong when I know that there's no evidence to say it's wrong. I want someone who's going to ultimately say like, well, it's your body. It's up to you. Even if you're, wanting to do something that I think isn't best. You know, I'm speaking for the physician.

Aviva: Hopefully you have a physician that you trust enough that when they can say to you, this is why I think it's not the best, you actually trust them as a person. They're just shutting you down because it sounds hokey, natural or different and they don't know about it.

Jennifer Block: Right. Right. I don't trust someone who says, well, I've gone to medical school and I have a degree. That's why you should listen to me. That's so infantilizing. That's like when I tell my son because I said so. That works cause he's six, but I don't want to hear that from my providers. I think that's what people really want and that's what women are craving and what we haven't been getting from physicians because historically that has not been the model. It's been very authoritative and authoritarian and disrespectful of our autonomy and authority and it still is in a lot of ways. I think that that's going to be how it evolves. If it evolves, it's going to recognize the autonomy and authority of the patient, and really put them at the center, not just the lip service of patient-centered care and informed decision-making and all that.

Aviva: I just literally said that on another podcast I was on it. That was what they use as the quote. I said, true patient care is putting the patient at the center of the universe. And we have to be able to do that, and listen to what women want.

Jennifer Block: Right, right. And I think women need to take that back because, I think we've given it away in a lot of senses. In childbirth we're so vulnerable because we've got this person, cause we've got this, we've got this baby, right?

Aviva: I don't know if we give it away as much as we've been taught not to take it. And we've been taught not to take our own power. I have patients who cannot call me Aviva and they will only call me Dr. Romm. I do not own a white coat. I left my white coat on the back of the residency door. And in fact, when I was on The Dr. Oz show, one of the times I was on, they brought a white coat to me and they said they wanted me to wear it on the show to look more like a doctor. And I'm like, ‘I am what a doctor looks like because I am a doctor and no, I won't wear the coat.’ I said if it's a matter of not being on the show or wearing the coat, I won't be on the show.

I wrote a whole blog about why I don't own a white coat. It's really important to me to have folks understand not only are they germ breeders, but they really do represent this idea that we're differentiating ourselves in white, which is like historically a Judeo-Christian color of purity and religiosity. These are not unintentional symbols  in medicine. These are very deliberate symbols that are  so inculcated in our brains that we don't feel like we can question authority. And then particularly as women, we're taught not to make waves, not to cause trouble and not to speak up. And then, as you said, we don't usually go into the doctor's office cause we're feeling great. We usually go in because we're scared about something and we don't have information. We're trusting someone else to give us that information.

Jennifer Block: I don’t know, are we giving it away or are we not taking it? But I do think… with the Essure piece, I talked to a lot of women who got that device and they were told, ‘Oh, this is like the new way that we can do, it's instead of tubal ligation, it's an alternative, it's quick and easy, it's this natural material, and they did it. And the ones who had the complications, one of the first things they said when they looked back on the experience was, I wish I had done more research. I wish I had asked more questions. I wish I had listened to that little voice in my head. They were angry with their doctors, but the person they were most angry with was themselves that they had given away their authority, I think. That they had like trusted the expert.

Aviva: But like, I built a house a few years ago, right. And I think about this a lot. I mean, I had to have electricians, I had to have plumbers, I had to have people who could put in insulation. And I think particularly about the electricians, right? If your electrical wiring is not done, your house can burn down and you can be in it and you and your family can die. Like this is a big deal, right? You have to have electrical wiring that's done safely. I did not have to learn about electrical wiring and switches and codes and research everything on the Internet to know that my house was wired properly. I was able to hire a licensed electrician who is insured and trust that they were going to do what they were supposed to do. If my house had burned down because of faulty wiring, I wouldn't blame myself. I would be like, wow, that electrician really fucked up. You know, that was a bad electrician. They lied about their knowledge, whatever, whatever. But I would never blame myself and think, Oh, I should have learned everything there was to learn about electrical wiring before I let that person in my house.

Jennifer Block: That's why we need experts, right? Like we want experts.

Aviva: But as women, if we go and get a procedure, we should be able to trust that licensed, insured, certified provider who was trained in something to do it properly, we shouldn't have to have the burden of making sure everything they say to us is true and accurate and safe and honest. I think that's like a double burden on top of, I mean the Essure maybe is a different case only because it's  an elective thing and you could choose something else, but still like there's so much burden on us to make sure that that c-section really is needed when you're in the throes of it or that hysterectomy really is needed when your doctor tells you that your endometrial lining too thick and you could develop endometrial cancer. All these things that we're told and we then blame ourselves for the “aha” retrospect that we should have not had to even question. We should have been given real reliable, honest information. And that kind of feeds into women. We tend to blame ourselves for things like that.

Jennifer Block: I completely agree with you. It is a burden. It is a burden and not everyone has the time, resources, funds to do the all that work.

Aviva: Or to be able to read through medical statistics. I went through seven years of medical training, five years of that included intensive study in statistics, and I still read studies and I'm like, hmm, yeah, well I don't know if this confidence interval or this P value or the Chi square or the reverse regression…. If I went through all that training and still can't interpret a study sometimes, how is somebody else supposed to interpret studies that may be published in medical journals when that study was actually paid for by the device company, cherry picked by the pharmaceutical company. How do we sort through that? We have to be able to trust the people who are representing that information.

Jennifer Block: I agree with so much of what you're saying. We want experts. We can't possibly carry the burden of reading all the studies and knowing everything there is to know.

Aviva: Jennifer, thank you for the article that you wrote. It's unfortunate that more women listening can't read it, but I do appreciate your taking the time to revisit what happened. Tell folks how they can find you.

Jennifer Block: You can find me on Twitter, @writingblock. My website is jenniferblock.com and I post a little bit on Instagram, @jenniferblockauthor. And people can find the article. It’s in the web archives, so that link has been shared around. I won't share it because I want to respect the editorial process, but it is out there and I'm working on something new about all this. Hopefully that'll be out soon.

Aviva: Very exciting. Well, when you get that link, I know you'll let me know and I'll share it. And listeners, thank you so much for joining me. Not only has this been an amazing episode with Jennifer Block, but this has been an amazing year and this episode closes out our 2019 season. I'm really looking forward to bringing more content like this to you, but also more solutions that you can rely on from a physician who I hope you feel is listening, who also happens to be a midwife and herbalist, so maybe can help provide some answers in those gaps that we have talked about today are out there. I wish all of you a healthy, happy holiday season. I'll see you in the new year. And thank you again, Jennifer, for joining me.