Knowledge Controversies and the Sociology of Postpartum Depression

Reposted from the Pacific Postpartum Support Society blog.

This week’s article is by Rebecca Scott Yoshizawa, a researcher and academic specializing in reproductive politics. Rebecca believes in writing honestly about her experiences as a sociologist and mother, who struggles with those seemingly irreconcilable identities. This post continues a series by Rebecca that will explore motherhood, postpartum depression, and reproductive politics.

I am a sociologist specializing in the analysis of the relationships between science, medicine, and society. I am interested in the ways in which social structures and social processes impact how medicine is practiced, as well as how they impact the course of scientific discovery. I am also a feminist, which to me means that I work to overcome inequality along the lines of gender, sex, sexuality, race, class, gender, and ability. I am writing this blog series on postpartum depression from these perspectives, and not as a medical or psychological expert. I am also writing this series as a mother who experienced mental health difficulties postpartum.

Oftentimes, people are puzzled by the idea that there could be a “sociology of science” or a “sociology of medicine.” In this post, I’d like to start a sketch of what the sociology of science and medicine looks like. In this series, I’ll be exploring how the sociology of science and medicine can inform people who are interested in PPD, as sufferers or carers.

The Canadian Mental Health Association defines PPD as “depression that may start during pregnancy or at any time up to a year after the birth of a child. Depression is a mental illness that affects a person’s mood—the way a person feels.” Postpartum depression is also sometimes called a psychological or mood disorder or a disease.

“Disorder,” “illness,” and “disease” are interpretive terms that doctors use to make sense of their observations of their patients. However, they are not experiential terms, or words that come from the everyday life experiences of people. When we don’t feel well, we usually use experiential terms to describe the problem: “my stomach hurts,” “I’m sad,” et cetera. In medicine, these experiential terms are called “symptoms.” Symptoms are considered to be the subjective experience of the patient. They must be interpreted through medical understandings of the body. Symptoms may be interpreted as indications of disorder, disease, or illness. These interpretive medical terms characterize the significance of signs and symptoms as “disturbed” or “abnormal.”

Sometimes it’s very clear when something is disturbed or disordered. For example, if a person’s skin yellows, doctors can perform a simple blood test to establish a disease of the liver called jaundice. In this case, the sign of the yellow skin and the confirmation blood test clearly establish jaundice. Other times, it’s not clear whether a physical or psychological state is disordered. In that case, the scientific and medical community work to establish a consensus as to what is “normal” and what is “abnormal.” They do studies, and gather evidence, and establish a standard of diagnosis and treatment.

“Consensus,” though, is not static. The scientific and medical community is constantly negotiating the significance and meaning of signs, symptoms, diseases, and disorders. They will do studies, write articles and editorials, hold meetings, debate, and mobilize publics and governments in order to create a resolution. Often, determining the meaning and significance of a disease can get extremely contentious.

I borrow a term from the geographer Sarah Whatmore to make sense of this by saying that diseases constitute “knowledge controversies”(1).  A knowledge controversy is defined by discord among experts as to what counts as knowledge, and good knowledge, about some issue.

Knowledge controversies are both problematic, and productive. Whatmore suggests that knowledge controversies “unsettle public trust in scientific expertise and its relationship to public policy-making.” What she means is that, although we tend to think that science is a truth-finding endeavour, scientists argue about what is true. When they do this, our faith in the capacity of the scientific method to uncover truths can become shaken. When the public lacks trust in science, they are incited to participate in the controversy. As such knowledge controversies provide the opportunity for new voices to be heard.

Therefore, knowledge controversies slow down decision-making and highlight discordances in society, while also empowering those at the margins of health discussions to participate in defining the meaning and significance of ill-health. In that sense, knowledge controversies can be positive, because they are transformative of social relations of power.

However, and in the meantime, experiences of ill-health are heavily impacted by knowledge controversies. Diagnosis could be difficult; treatments could be denied or delayed. As such, we need to pay close attention to the debates in science and medicine to ensure that the needs of patients are served as best as possible. I think PPD constitutes a knowledge controversy that we must pay close attention to.

For example, we can look at the history of PPD in the DSM to get a glimpse of the ongoing knowledge controversy. The DSM, or the Diagnostic and Statistical Manual of Mental Disorders, complied by the American Psychiatric Association (APA), is something akin to the psychiatric bible. It describes diagnostic criteria and classification of mental disorders according to a consensus of the psychiatric research and clinical communities. There have been several versions of the DSM, which means that some disorders have been added, some dropped, and some criteria have been refined and changed. For example, what were once described as four separate disorders are now included in the DSM-5 as “autism spectrum disorder.”

PPD was not included in the DSM until 1994 (2). PPD was added to the DSM as a result of advocacy for women who experienced depression in the postpartum period. It’s addition was so important for people who experience PPD, because the DSM is a powerful document. It determines what symptoms and signs are recognizable and therefore actionable on the part of healthcare providers, policymakers, and everyday sufferers. The inclusion of PPD in the DSM gave validity to specific presentations of postpartum depression, and therefore justified research, treatment, and funding attention.

However, the first definition of PPD in the DSM also set the tone of the healthcare approach to PPD for the next two decades. The first definition of PPD was as a modifier to generalized depression, rather than its own disorder. Rebecca Godderis (3) wrote a very fascinating and important article outlining how PPD came to be included in the DSM. She describes how what counted as knowledge, and good knowledge, about PPD was up for debate:

instead of discovering evidence for a clearly defined psychiatric object known as “postpartum depression” which could then be easily classified in the DSM… there was disagreement in the psychiatric literature about the nature and definition of PPD. Moreover, the kind of evidence that had been produced in relation to the illness was not well suited for meeting the DSM classification requirements. In other words, evidence about PPD was deemed… the “wrong kind” of evidence, resulting in the classification of PPD as a course modifier rather than a distinct disorder.

This was controversial for two reasons: 1) some scientists and clinicians argued it should be considered its own disorder, and 2) not being its own disorder, women’s groups argued that PPD would receive less attention and funding than was required to address it.

And PPD is still a knowledge controversy. The current and fifth version of the DSM was published in 2013. In the DSM-5, PPD is still classified as a modifier to Major Depressive Disorder. The DSM-5 says (American Psychiatric Association DSM-5, under “Major Depressive Disorders”):

Depression with peripartum onset: This specifier can be applied to the current or, if full criteria are not currently met for a major depressive episode, most recent episode of major depression if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery.

It’s important to note the time specificity of this modifier: symptoms must appear in the four weeks following delivery. However, there are many stories of women and men who experience depression with onset after four weeks. Under the current DSM, this would not be considered PPD.

This is a major point of contention. An article from Postpartum Support International indicates that many PPD advocates and healthcare practitioners were shocked that the APA had not really changed anything about the definition of PPD with the new DSM-5. Authors write:

in October 2010, at the biennial meeting of the Marcé Society and PSI annual conference held in Pittsburgh, we heard a panel presentation on the DSM5 revisions in which it was revealed that the postpartum onset specifier would not be extended, and that the committee did not find persuasive evidence to indicate that postpartum depression is distinct from other existing depressive disorders. There was a palpable reaction in the audience and during the opportunity for Q&A, lines quickly developed behind the microphones. PSI members bravely walked to the microphone and in front of a large audience of perinatal researchers, professionals, and PSI members, made the concise argument that the conclusions of the workgroup seemed a disservice to many women.

When different experts disagree as to the symptoms, signs, and definitions of a disorder, indeed, we have a knowledge controversy on our hands. The sociology of science and medicine helps us to identify these knowledge controversies, and how they come about.

So while a controversy is underway, what are we to do in the meantime?

I think the key to making sense of knowledge controversies while also experiencing health and mental health-related problems is to acknowledge that the production of any kind of knowledge requires a reduction of complexity. There is no one study, no one scientist or doctor, and no one discipline that has the tools necessary to fully comprehend PPD. I find it empowering to look at studies, discourses, articles, and advices about PPD and ask myself, what’s missing? What doesn’t count? When I talk about PPD to my healthcare providers, friends, and family, or in my writing, I bring those things up. When I do that, I know that I am demanding a share in the power over deciding the meaning and significance of PPD.

It’s empowering to think critically about science and medicine. Likewise, because society is something that can and does change based on the efforts of people trying to make a difference and make things better, this means that as a society, we could actually do things to lessen the experience and burdens of PPD. That might mean continually interrogating the definitions of diseases, and asking questions about who gets to make them.

 

References

  1. Whatmore, S. J. (2009). Mapping knowledge controversies: science, democracy and the redistribution of expertise. Prog Hum Geogr, 33(5), 587-598.
  2. Godderis, R. (2013), A Tricky Object to Classify: Evidence, Postpartum Depression and the DSM-IV. J. Hist. Behav. Sci., 49: 123–141. doi: 10.1002/jhbs.21590
  3. Godderis, R. (2013), A Tricky Object to Classify: Evidence, Postpartum Depression and the DSM-IV. J. Hist. Behav. Sci., 49: 123–141. doi: 10.1002/jhbs.21590

Ways of Healing: Reproductive Political Activism in the Postpartum Support Group

Reposted from the Pacific Postpartum Support Society Blog.

 

This week’s article is by Rebecca Scott Yoshizawa a researcher and academic specializing in reproductive politics. Rebecca believes in writing honestly about her experiences as a sociologist and mother, who struggles with those seemingly irreconcilable identities. This will be the first in a series of articles by Rebecca that will explore motherhood, postpartum depression, and reproductive politics.

 

I am a sociologist specializing in the politics of reproduction. I am also a teacher. I am also a wife, a sister, a daughter, and a friend. And I’m a mom to a 10-month-old baby.

But sometimes I feel like I’m a mom only. And I’m not okay with that. It’s very hard to admit that, because it is associated with deep feelings of shame, failure, and guilt.

I had only just earned my PhD months before he was born. I had spent a decade and a half to finally earn that PhD. After I had my son, I felt like Rebecca was gone. Dr. Yoshizawa, PhD, wasn’t required to change diapers, make bottles, snuggle, or hold a crying baby for hours. For the first several months, I felt reduced to a shell of myself.

Many told me it was only a phase and would pass. Now that my son is 10 months, I can say that they were right; it was a phase that passed. But it passed because I worked hard to grow, change, and heal in my new role as a mother.

After I had my son, it became clear to me that being a mother to a baby stimulated some parts of myself, but other parts that I hold dear were not expressed at all. I know that this is inevitable. A newborn baby has a specialized set of needs that must be met, which requires a huge lifestyle change for caregivers. In time, the baby grows and changes and can be more easily cared for. We get better at it as time goes by. I am sure many women strongly and confidently weather that storm without worry, but I really believed that I would be gone forever.

I started to work again part time as a teaching assistant when my son was only three weeks old. Part of the reason was economic; I have always been tenuously employed and must constantly seek teaching or research contracts to keep afloat. But another reason was that I was trying to create a life preserver associated with my “former self” to cling to during such a transcendently demanding time.

Then I designed and submitted a proposal to teach a class in Gender, Sexuality, and Women’s Studies at Simon Fraser University on the politics of reproduction from a feminist perspective. I received a bachelor’s degree from the very same department, which was fundamental in shaping the person I am. But the biggest gift GSWS at SFU gave me was the opportunity to teach that course, because it facilitated a personal transformation.

Reproductive politics refers to ongoing struggles over who/what has the power to define, constrain, medicalize, technologize, spur, and/or prevent reproduction. In particular, there are many pressures of being a mom associated with socially constructed notions of good mothering. For example, good mothers are expected to selflessly and seamlessly give all of themselves to their children, while still giving their all to other spheres, including the keeping their home well and, increasingly, the workforce. One of the key course concepts is the notion that around reproduction swirls a number of contradictions and tensions that are not easily resolved by individual women. Instead, mothers live through and with dualities, or competing pressures. Competing pressures can tear you apart.

Teaching the course was therapeutic, but crisis provoking at the same time. I felt like a failed mom since I wasn’t able to embrace motherhood ‘naturally’ the way that I was supposed to. But I was also a failed sociologist, since as a sociologist, shouldn’t I more or less be able to cut through all the BS expectations society places on mothers and just be a strong, self-assured working mom?

I had enough of daily rock bottom moments. A quick Google search brought me to the Pacific Post Partum Support Society. Since I am talkative and know that I work through issues by talking about them with others, I decided to join one of their support groups.

I was nervous to attend at first, especially because I was ashamed that I needed to go in the first place, since it felt like publicly admitting all my failures. But my fears were quickly allayed. The women and facilitator were so real, so courageous, and so supportive. I found myself in a place where I could resolve problems intersecting sociology, politics, and personal experience with kind women who could somehow understand that two completely opposite feelings can be felt simultaneously. Group is a place where you can vocalize and explore the very contradictions and dualities of motherhood that I lectured about in my course on reproductive politics. It’s a place to feel comfortable saying, “my son is so darling and sweet AND it feels like he abuses me constantly”; “my daughter is the light of my life AND I feel like I’ve lost my zest for life”; “my son is the most important thing to me AND I just want to do anything else but play with him all day long”; “I want to go to work so badly AND I miss my daughter terribly when I’m there.” All of those things make sense in group. There are very few other sites where such contradictions are so patently and poignantly sensible. And when the sessions were over and I drove away, I felt renewed power to live through, embrace, or reject those contradictions.

The postpartum support group rejects the pressures society places on women to be perfect mothers, instead emphasizing realities and identifying avenues for healing. It therefore gives power back to mothers, who in turn empower each other. I therefore understand the postpartum support group not as a place to wallow in personal failure, but as a site of reproductive political activism. Group enabled me to understand myself as a good mom, PhD. That’s what my healing looked like.

GSWS 318: Man’s Best Friend: Feminisms Engaging with Nonhumans (SFU Gender, Sexuality and Women’s Studies course)

I am very excited to be given the opportunity to teach another course at SFU in the Gender, Sexuality, and Women’s Studies department this upcoming Spring semester. The course, GSWS 318, is a special topic entitled Man’s Best Friend: Feminisms Engaging with Nonhumans. Here is the course statement:

Feminists are increasingly examining how the power structures that produce unjust oppressions for women and other marginalized Others extend to the nonhuman world. This course explores how feminists have theorized, advocated for, and fostered relations with nonhumans, including animals, organic and inorganic matter, machines, and cyborgs. Informed by feminist ethics, science studies, and philosophy, we ask: How do understandings of animals relate to conceptualizations of sex and gender? Are there feminist obligations to animals, plants, bacteria, viruses, fungi, and protists? How does feminism inform and support animal and ecological advocacy? Can nonhumans teach us about ethics, care, and equality? Specific topics include evolutionary biology, environmentalism, cyborgs, artificial intelligence, animal research ethics, microbes, ‘gut feminism,’ and homo- and trans-sexuality in animals. Recognizing the timely and controversial nature of these topics as well as the role of GSWS in transforming students into critical advocates for change, assignments encourage engagement in public dialogues on human/nonhuman relationships.

Assignments include an opinion editorial, film review, and collaborative advocacy project. The prerequisites are 30 units, including 3 units in GSWS or WS or GDST.

Here is the syllabus. If you are a prospective student and have any questions, please email me at rebecca_yoshizawa@sfu.ca.

New Position: Postdoctoral Researcher, GeNA Lab, Communication, SFU

I am pleased to report that I’ll be serving as a postdoctoral researcher in the GeNA Lab in the School of Communication at Simon Fraser University starting this month.

About the lab:

The GeNA Lab investigates the social and organizational impacts of information technologies and communication networks and the turn to big data in a number of sectors including genomics and health, social media, and NBA basketball. We aim to disseminate scholarly outputs and policy work to an interdisciplinary community and engage broader communities and partners who are innovating digital technologies.

I’ll be working in a collaborative manner on genetics, network, and society research. I’m excited to extend my expertise in science studies and biology to new topics in bioethics, surveillance, and health research!

#gsws320sfu Twitter feed: What’s going on in the politics of reproduction today?

I regularly tweet articles/news/blogs/etc. that are relevant to the course I am teaching on reproductive politics in Gender, Sexuality, and Women’s Studies at SFU (my alma mater! #gsws4life). I had the idea to do this as one of the assignments is an op-ed about a contemporary issue in reproductive politics, and I wanted to direct the students to the twitter feed to help them come up with topics. I’m also delighted that my students are joining in on the twitter conversation!

The thesis of our course is that reproduction is not merely ‘natural’; ethical and political issues attend every facet of the instantiation of new human beings in this world. If the twitter feed is any indication of the significance of reproduction today, it relates profound and ongoing struggles over who gets to reproduce with whom, when, where, and how.

GSWS 320: A Womb of One’s Own?: Feminisms Engaging with Reproduction (SFU Gender, Sexuality and Women’s Studies course)

I am very excited to be given the opportunity to teach a course at SFU in the Gender, Sexuality, and Women’s Studies department this summer. The course, GSWS 320, is a special topic building on my research on reproduction and reproductive politics. It is entitled A Womb of One’s Own?: Feminisms Engaging with Reproduction. Here is the course statement:

In this course, we develop tools to analyze narratives, issues, practices, and arguments regarding reproduction. We define reproduction not simply as a biological fact of life, but a ‘naturalcultural’ phenomenon where biology and culture collide in the continuance and dynamism of humans through generations. Students learn how to think critically about a wide range of issues in reproduction using tools provided by feminist theorists and researchers. Recognizing the topical and controversial nature of debates on reproduction as well as the role of GSWS in transforming students into critical advocates for social change, assignments encourage students to engage in public dialogues on reproduction. Topics include biomedicine, reproductive politics, reproductive technologies, and gendered, racialized, and sexed roles.

Assignments include an opinion editorial, film review, and collaborative multimedia project. The prerequisite is 15 credits.

Here is the syllabus. If you are a prospective student and have any questions, please email me at rebecca_yoshizawa@sfu.ca.