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Listening to Survivor Moms
by Mickey Sperlich
© 2008 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in Midwifery Today 85, Spring 2008. Learn the background behind the Motherbaby Press book, Survivor Moms: Women's Stories of Birthing, Mothering and Healing after Sexual Abuse]
• Books and Resources on Posttraumatic Stress Disorder
• Web resources
I found out I was pregnant in June of ’94 and suddenly everything was different for me. It was as if I had a gun to my head; I had to get better RIGHT NOW. I was convinced that if I didn’t I was going to be the worst mother on the planet.
—from Shakta’s story
Breaking the Taboo against Talking about Trauma and Childbearing
During the past 20 years talking about the reality that women and children experience abuse and violence in our society and inside their homes has become far less taboo. Breaking the taboo against talking about how intrafamilial abuse and sexual trauma can affect childbearing for some women is taking longer. Research is beginning to show that traumatic experiences in general—from abuse, to disasters, to terrorism—may take a toll on pregnant women and affect their children, too.(1) In addition, more midwives are becoming aware that past traumatic experiences can reappear as posttraumatic stress during the childbearing year. Resources are needed to help these “survivor moms” and their caregivers address trauma-related needs across the childbearing year.
A landmark book that came out a few years ago, When Survivors Give Birth, focuses on helping incest survivors give birth.(2) We are about to “give birth” to a new book that we hope will further help break the silence on the topic of how trauma affects childbearing and mothering for “survivor moms.” This new book, Survivor Moms: Women’s Stories of Birthing, Mothering and Healing after Sexual Abuse, (3) includes excerpts from 81 women’s stories of birthing, mothering and healing after childhood sexual abuse. It is intended to break down the isolation pregnant women and their caregivers often feel—as though they were the only ones having to cope with these challenges. The book is written for lay women and for professionals. It includes some women’s complete narratives, many narrative excerpts, discussion of implications of women’s experiences for their care, suggestions for working together during maternity care and beyond, resources to consult and information from research that is currently available.
Who Is a “Survivor Mom”?
We consider a “survivor mom” to be any woman who senses that experiences she has survived are factors to be reckoned with as she goes through pregnancy and becoming a mother. In this new book, we focused on what sexual abuse survivors had to say, because childhood abuse and sexual trauma are two experiences that occur around the globe and affect about one in three childbearing women. This statistic is derived from two large-scale national studies that show the incidence of childhood sexual abuse to be 27%, with a further 17.6% of women reporting adult rape (attempted or completed), half of whom were also survivors of childhood sexual abuse.(4) These specific traumatic experiences seem to spark posttraumatic stress reactions during pregnancy, prenatal care, labor, breastfeeding and adapting to motherhood. Other traumatic experiences may affect survivors during pregnancy as well, and what midwives learn from the women’s narratives in this book may help them adapt their responses to survivors of other traumatic experiences who are affected while in a midwife’s care. Among the women who contributed their stories, some felt the past trauma played a horrible part in their childbearing, while others counted their passage into motherhood as a time of triumphing over the effects of past violence and abuse. Being a “survivor mom” does not seem easy in any of their stories, but many of the women prized their awareness that their children could grow up mindfully protected by a mother who was actively recovering from any long-term negative effects of her own abuse.
My Midwifery Journey with Survivor Moms
I took several years of practicing midwifery and many pivotal learning opportunities to start developing an awareness and sensitivity to the needs of survivor moms and longer still to realize that a book needed to be written to address their specific needs and concerns. In the beginning of our practice, we did not routinely screen new clients for a history of abuse. We also did not know what to do with any resulting disclosures! While some clients offered this information freely, still many others kept their traumas and their feelings and reactions to themselves. Thus, these uniquely challenging moments offered me the opportunity to learn about how being a survivor informs the process of becoming and being a mother.
I will never forget early in my practice being with a young woman who was fearfully facing her first pelvic exam. She took an hour to be ready to undergo the exam. I remember the long time I spent waiting for her to be ready; with each passing moment I felt another measure of her entrenched terror and at the same time her courage and determined spirit coming to the fore. I learned a lot from her about the importance of being patient and respectful of a woman’s boundaries.
I also distinctly remember another client in advanced labor who, upon becoming fully dilated, expressed fear about pushing her baby out. She stated that she couldn’t push her baby out because she worried that her baby could also be abused. Try as I did to reassure her that everything would be okay, it was her truth of that moment, and she ultimately elected a c-section. I was not aware of her history as a survivor of sexual abuse, as we had not yet begun asking clients about this, so I had missed the opportunity to work with her on this level before she was giving birth. I came away from this birth realizing my ignorance of abuse issues and resolved to learn more. I also began asking clients about their history of violence, and soon realized that we were seeing a sizeable number of women with some history of various types of abuse.
Another client, while I was examining her cervix in labor, helped me learn about how memory is submerged and retrieved. I was humbled by her face, which momentarily showed panic, as she believed that I was no longer her trusted midwife but rather the mother who had abused her as a child. She taught me the importance of being “in the moment” with a survivor; of thinking on one’s feet about how best to comfort and reassure her that the past was in the past and that we were in the present and that she was in control of her own body. Fortunately, we worked through this delicate situation together and she went on to have a positive birth experience.
Coming to Understand PTSD
Along the journey I was very fortunate to meet my friend Julia Seng, a certified nurse-midwife and PhD researcher. Julia also was interested in how childhood sexual abuse affected women’s childbearing and was focusing her research on the sub-group of abused women who develop Posttraumatic Stress Disorder (PTSD). She completed her doctoral thesis on the correlations between women with a diagnosis of PTSD and pregnancy complications and continues to study this phenomenon. We met the day I attended her formal defense of her dissertation, and we have been collaborating ever since, on both our forthcoming book and several research initiatives focused on trauma and childbearing. Her work helped me to see posttraumatic stress as the common thread running through the scenarios I have described with my survivor clients. Whether a woman develops PTSD with its hallmark symptoms of intrusive re-experiencing (“flashbacks,” disturbing dreams, distress), avoidance of reminders of the trauma (including thoughts, feelings, people, places associated with the trauma) and hyper-arousal (sleep disturbances, irritability, exaggerated startle reflex, hyper-vigilance, etc.) depends not only on the magnitude of the trauma but also on the context of the woman’s (or girl’s) life at the time of the trauma exposure. Since some women who have been abused do not seem to suffer the long-term damage and co-morbidities (substance abuse, depression, generalized anxiety, interpersonal sensitivity, for example) evident in other women, PTSD is likely a plausible mediating factor for many women.
The Birth of the “Survivor Moms Speak Out” Project
My experiences working with the survivor moms in our practice sparked me to action. I felt “called” to help create a resource for survivor moms, just as I had been “called” to midwifery. But where would I start? The scientific literature was largely silent on the issue, and guidance from obstetric and midwifery clinical texts was absent. Since my greatest teachers have always been the women I serve, the most sensible course was to start with the survivor moms themselves—to learn through their life stories and wisdom.
In 1998, together with a team of survivors, therapists and midwives, I developed a survey project called “Survivor Moms Speak Out,” which asked basic questions about the ways in which survivors felt that their pregnancies, births, postpartum and mothering had been influenced by their history as survivors. The surveys were distributed at midwifery and birth-related conferences across the country, at doctors’ and midwives’ offices and via a contact address on the Web. The total number of surveys circulated over a two-year period was 1136. A total of 207 surveys were returned, and from this number 81 women completed a narrative or contributed a poem. These narrative accounts have been edited and now form the basis for our forthcoming book. In addition to the narratives, Julia and I have woven our clinical perspectives as midwives into the text, as well as the voices of many other maternity and mental health professionals, together with an accounting of the state of the science as regards survivor issues.
Who are the survivor moms of this project, and what can midwives and maternity professionals learn from them? A lot!
The vast majority of survey respondents were survivors of childhood sexual assault/incest (82%). Many of these women were also later victims of sexual abuse as well (59% during adolescence, 16% during adulthood). The women who responded to this survey were a diverse group of women. The respondents represented a range of current life circumstances, abuse histories, experiences with therapy, substance-abuse programs and self-healing strategies, and a range of descriptions of the negative and positive aspects of survivorship.
Learning from Survivor Moms…
As a midwife, I had expected that survivors would have a lot to say about their birth experiences, and they did. Yet, they had so much more to say, by and large reporting that being a survivor affects your whole life—from being a little girl to being a grandmother. Authors of the narratives offered rich, detailed and heartrending accounts of the many facets of life as a survivor, from the recounting of the trauma itself, to the journey through childbearing, to mothering, healing and beyond. They also had a lot to say about what kind of care would have been helpful to receive from maternity care providers. Each of the time periods below represents a chapter from Survivor Moms: Women’s Stories of Birthing, Mothering and Healing after Sexual Abuse.
…About Life Before Motherhood
From infancy to my early teenage years I was sexually abused by a man. Namely, my father. I can remember being terrified by any male, very early on, because I knew what they were capable of doing to me. When my best friend’s brother came to pick her up from our house I used to shriek and run in terror. I could never concentrate enough in school in a class with a male teacher because I never knew what intentions they had or what they were thinking. I have a hard time giving hugs to my own grandfather, father-in-law or my brother, even though they are good, gentle men in their own rights. Every time I try, my body betrays me. I stiffen, my stomach tightens up and I panic…I tried to tell one of my teachers what was going on at home and she told me to quit making up stories…
—from Kay’s story
Survivors enter pregnancy at various stages of recovery from past traumatic experiences, which has implications for what they will need and how midwives should respond. This reality is illustrated in stories in the first chapter. We also include information from a wide range of professional sources about how adult women are affected by childhood maltreatment and sexual trauma, including an overview of diagnostic criteria for posttraumatic stress disorder, with illustrations of psychiatric terms with the women’s own words about PTSD. Women also discuss issues of disclosure and whether and under what circumstances they were able to tell someone about what had happened to them. These discussions will help midwives to understand the difficulty survivors have with telling someone about their history and how this has implications for the caregiving relationship, in terms of establishing trust. Descriptions of other significant clinical problems, such as women having “out of body” experiences during internal exams or in labor are framed as survival and coping strategies. We provide a list of questions women can take to an initial prenatal appointment or midwives can pull out of their bag to guide a conversation about how a survivor mom is doing and what she might need during prenatal care. This chapter gives women and caregivers a way to bring a focus to what the client is experiencing and what responses from the midwife are likely to be most helpful.
As my body grew and changed, prodded by relentless hormonal surges, I felt like I was being attacked over and over again. Dormant feelings and memories from my abuse not only surfaced, but grabbed me around the neck and threatened to suffocate me…
—from Elaine’s story
Pregnancy is an awesome time in a woman’s life, and for many women it can be quite wonderful. For some survivors, like Elaine, the bodily experiences of being pregnant can trigger memories of abuse and can complicate things. In the second chapter of the book women shared many of the ways in which they felt their experience of pregnancy was complicated by their history as a survivor. Women reported feeling invaded by their growing baby or by the physical changes of the pregnancy and related this loss of control over their body to how they felt when being abused. Some women experienced fear during their pregnancy—for themselves or for their babies. Some struggled with depression or dealt with the surfacing of memories of abuse. Some used drugs or alcohol to self-medicate their distress. While midwives cannot “fix” all these things for their clients, having awareness of pregnancy-specific triggers can help a midwife determine whether to make a necessary referral to trauma-specific mental health services.
Learning about the intricacies of the maternity care relationship is an ongoing process for midwives and clients alike, and this chapter includes recommendations and information about the psycho-dynamics of the midwife-client relationship. Health care professionals, in general, do not have the same kind of training that psychotherapists often have for reflecting on the emotions that are provoked between client and caregiver. When clients with an abuse history have to enter a caregiving relationship where intimate, intrusive contact, pain, fear and vulnerability exist, then stress and emotions can become forces to be considered. It is critically important for midwives to respect the boundaries of the midwife/client relationship. Women who have survived sexual abuse, or any abuse, have had their boundaries irrevocably transgressed. The fencing of their innermost being has been torn asunder and they have then had to establish a makeshift patchwork of intricate coping mechanisms and behaviors in order to keep the chaos of the world outside their inner sanctum. Through birth, we as midwives necessarily stand at the gateway; yet we must help our clients keep their fences intact. Taking the time to establish trust and define boundaries and learning about the psycho-dynamics of the interactions between midwives and clients can go a long way to create a good working relationship.
…About Labor and Birth
When my water broke and the contractions began the pain in my womb felt to me like the pain of forced penetration. It felt like rape. I panicked. I was conscious enough to tell the midwife I was having rape flashbacks, but she was young and inexperienced and could not really offer any help…
—from Katherine’s story
Our decision to birth at home was very important to me from the perspective of a survivor. I knew from helping other women birth that home is where I would feel most safe, most able to control who was present and how I was handled and most able to let down my guard to be vocal and move around as instinct dictated. It was, for me, the place that would most support trust in my own body and abilities.
—from Beth’s story
For survivors, birth can be a huge challenge because they want it to be a safe and positive experience for them and a strong start to their mothering. However, many aspects of birth itself (e.g., pain, being overwhelmed) and many aspects of birth care (e.g., being touched, losing privacy, not being in control, being overpowered by authority figures) are a reminder or reenactment of abuse. In chapter three we focused on what survivors did to cope with these difficulties. The quality of the relationship the woman has with her caregiver and the amount of support she gathers around her during this challenging time are key themes in the narratives. The choice of maternity care provider, place of birth and specific desires for labor and birth are discussed. Survivors’ stories highlighted the importance of finding a match between health care and birth philosophies; and several of our narrative contributors chose to seek midwifery care based on the idea that such care would afford them more control in their birth experience. Chapter four includes specific recommendations for a successful midwife/client relationship, including further discussion on the topic of disclosure, adaptations for optimal care, and suggestions for helping survivor clients to prepare for labor and birth. Survivor moms shared aspects of birth that had been specific triggers for them and what forms of support had made a difference. The chapter concludes with detailed recommendations for optimal birth care from the perspectives of an obstetrician, a midwife and a survivor mom.
…About the Postpartum Period and Breastfeeding
I felt bursting with pride at this incredible thing I’d done, and yet all I could feel when I looked at that perfect little one was grief, grief, grief. I could not understand it. The emotions were so intense that I could not sort them out or make them calm down. I thought the tears would simply never leave me. I thought I’d float away, and he would miss his mama, but he would not be able to find me because it would all have gone blank as soon as I finally wore out my ability to tolerate the intensity of the grieving pain.
—from Claire’s story
In the fifth chapter, survivor moms shared their struggles with postpartum mood disorder and other issues of the immediate postpartum period. Their stories highlight the interplay among postpartum depression, anxiety and posttraumatic stress. We offer a thorough discussion of postpartum mood disorder, along with suggestions for helping survivor moms find appropriate care to recover. Processing birth, particularly aspects that were found to be triggering or traumatic, was an important step in recovery for several of the women narrators, together with finding solid practical support from trustworthy people in their lives. Moms shared their experiences regarding breastfeeding, including making the decision whether or not to breastfeed, dealing with triggers while breastfeeding, getting help, how breastfeeding influenced bonding with their newborns, making adaptations and the positive, healing aspects of breastfeeding. We include recommendations for caregivers seeking to help survivor moms have successful breastfeeding experiences.
This chapter introduces the idea that being the “perfect” mother is not important; women should instead strive to be the “good enough” mother who places her own mental health as a top priority, knowing that nothing is more important to the well-being of the child than his or her mother’s mental health.
…About Mothering and Attachment
As I deal with my problems right now, the people who are most affected by my abuse are my children. I know how important showing affection in the simplest ways is for a child. And I can’t freely show affection. A simple touch of the shoulder or smoothing their hair or a quick squeeze has to be carefully orchestrated and forced. And these are my children. I carried them inside of my body for nine months. Birthed them, nurtured them, and raised them, and yet I can’t hug them, because I don’t want physical contact. How do I deal with the guilt and frustration? It has affected my decisions on how I raise the kids. I am not a normal mother. My security has been shaken. My kids are more sheltered, more protected, more supervised than other kids they know. Every time they go out to play or have a birthday invitation or play date or sleep over or use a public restroom, I always wonder if there is a perpetrator lurking about. Anytime they leave the house without my husband or me we wonder will their caregiver be as vigilant as we are? Will they remember to hold their hands in public or never let them walk more then two steps behind them? Not let them talk to strangers?…
—from Kim’s story
I always thought raising children was all about giving, but already my two-month-old daughter has given me so much. She loves to be touched and cuddled, to the point where she rarely sleeps unless in my company, and by giving her unrestricted affection, I am doing the same to my “inner child” who was neglected and abused. Physical affection feels safe for the first time in my life since I was abused. It seems all the love I shower on my daughter she in turn showers on me, and while she grows, I heal.
—from Elaine’s story
I’ve also stopped thinking quite so much about the abuse and how it has affected me. Maybe this is because I’m busier or because my focus has moved to my children as I try to be a good mother to them. Or maybe it’s because the parts of my body that were violated, that I associate with these memories, were the parts involved in producing, nurturing, birthing and nursing two beautiful children I love more than anything.
—from Melanie’s story
Survivor moms had a lot to share about being a mother and creating attachments to their children. They shared concern about the difficulty of taking on such an awesome task without having the benefit of having been well-parented themselves. They shared their struggles to make healthy attachments to their children and to deal with the intensity of those attachments. They struggled with the twin demands of caring for their mental health and being present for their children. They had issues with the gender of their child, whether girl or boy, and also with the realities of caring intimately for another person’s body. They shared their struggles with setting appropriate boundaries for their children and with exercising appropriate discipline. They worried about how they would keep their children safe from predators and when, if and how to tell their children about the things that had happened to them. They shared worries that they might one day abuse their child, and some moms related the horror of discovering that their child had been abused by someone else.
The good news is that despite their many concerns survivor moms also shared how the process of becoming a mother was enormously healing in and of itself. One of the major messages contributors to this project voiced is that by taking control of their lives, their healing and their mothering, they can break the chain of violence that has been passed down to them as a bitter legacy. Moms are bringing a conscious awareness to their mothering, which makes all the difference for their children.
…About Healing and Survivorship
Healing comes through relationships, not new intellectual knowledge alone.
—from Deborah’s story
Being pregnant and giving birth provides many survivor moms with opportunities to make connections with a variety of people, including childbirth educators, doctors, midwives, doulas, nurses, La Leche League leaders, lactation consultants and parent educators. These relationships can be significant and important, and midwives should know that they have a unique opportunity to make a difference in the life of a survivor mom who perhaps has never felt well-cared for before. Because these relationships have a natural ending point, moms must shift their attention to other connections. The survivor moms in this project went on to form other important connections, which strengthened them in their journey. The final chapter highlights the many ways in which survivor moms sought healing in the context of relationships with intimate partners, therapists of many varieties, faith-based communities and God and in dealing with themselves.
Women related how they struggled to sort out the complicated relationships with their families of origin and to determine which of those relationships are healthy to maintain. They shared the importance of having good friends to support them on their healing journey. They shared the blessings and challenges of relationships with intimate partners. They shared the importance of their spiritual beliefs as integral to their healing process. They shared their efforts at recovery through therapy, from making the decision to enter therapy, to finding the right therapist, to the struggles and triumphs of being in the therapeutic relationship. Many of the narrators found that talk therapy alone was not enough to effect a deep healing that includes the body and the mind. Many used a variety of body-focused or “somatic” healing modalities, among them various types of massage and other bodywork techniques, music therapy, art therapy and eye movement desensitization and reprocessing (EMDR). Some of these healing modalities are highlighted in this chapter through passages written by practitioners of these modalities.
Survivors had a lot to say about what being a survivor means. They weighed in on the terminology of survivorship and their understanding of the power of words to describe the effects on them and their commonalities Several of the contributors went on to become activists for the cause of healing from sexual abuse. They became politically active, formed advocacy groups, became clinic workers, midwives, doctors or teachers. They found the courage to share their stories and minister to others.
Pregnancy is a process of opening up on many levels. I have found in the course of my midwifery practice that women who feel ready to grapple with these issues can make great strides during the course of their pregnancies. Although recovery from sexual abuse is a life-long process, relationships with midwives and other health care practitioners clearly play an important part in the lives of survivor moms. Midwives who are aware of this and make an effort to inform themselves about the needs of their survivor clients and about the trauma-informed mental health services in their communities can make a real difference. We hope that our book may be a resource to facilitate discussions and care-planning between midwives and clients. We invite you to be touched and transformed by the personal and profound accounts of the lives of survivor moms. We invite you to listen.
Being a mother has healed me in more ways than I could ever count. Producing something good from my body, my self, which had been so violated, was restorative to me. I am not evil, and nothing I did made me deserve to be treated as I was.
—from Ann’s story
Having a child didn’t make my life complete. I’m a complete person without having a child. But having a child made my life so incredible. It has been a joy seeing life through a healthy child’s eyes. Watching his wonder of things. I guess that in some aspects I’m experiencing my childhood again in a healthy manner with my son. And that’s amazing.
—from Kathy’s story
I think my life’s experiences have made me a patient mother. I take time to really enjoy my children, my work and my garden. My children are still young—ages 10 and 12. I try to involve my children in our community in ways that make them feel empowered. We have adopted a creek and have joined other families to create a children’s wet meadow. I hope that being with people who care about making the world a better place will balance the pain and violence that also exists and will help them be resilient, purposeful and joyful people.
—from Karin’s story
I have lost my vision of a place of perfect mental health. I have finally realized that I will always be a work-in-progress. I have lost my vision of providing my son with a perfect childhood. If I can teach him to roll with life’s punches in such a way that he can get back on his feet without major injuries, I will have done my job. I try to listen more than talk, praise more than reprimand, and while I don’t always succeed, I improve. I try to take responsibility for my own feelings and give him responsibility for his. And overall, he’s a really special little guy, with the face of an angel and a mind like a steel trap. He’s four now, and I’m no longer frantic about being his mother, although I’m not entirely comfortable with it. I no longer expect that of myself, either.
—from Tamar’s story
I won’t claim to be a perfect mom or person. But what I will say is that I’m the best mom I can be and way better than my parents were. My kids are healthy, happy and safe. I can sometimes be a little overprotective; but who wants to see something bad happen to their kids if it can be prevented?
—from Valerie’s story
Being a great Mom is my ongoing prayer.
Mickey Sperlich is a Certified Professional Midwife with nearly 20 years experience helping women on the journey of pregnancy and birth. She currently coordinates a study on the effects of posttraumatic stress on childbearing at the University of Michigan’s Institute for Research on Women and Gender.
- King S, et al. 2005. Project Ice Storm: Effect of prenatal cortisol levels on obstetric complications. Presented at International Society for Psychoneuroendocrinology Annual Meeting, Montreal, Quebec, Canada; Engel, S.M., et al. 2005. Psychological trauma associated with the World Trade Center attacks and its effect on pregnancy outcome. Paediatr Perinat Epidemiol 19(5): 334–41; Seng, J.S., et al. 2001. Posttraumatic stress disorder and pregnancy complications. Obstet Gynecol 97(1): 17–22.
- Simkin, P., and P. Klaus. 2004. When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women. Seattle, Washington: Classic Day Publishing.
- Sperlich, M., and J.S. Seng. 2008. Survivor Moms: Women’s Stories of Birthing, Mothering and Healing after Sexual Abuse. Eugene, Oregon: Motherbaby Press (www.survivormoms.com/).
- National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, D.C.: National Academy Press; Tjaden, P., and N. Thoennes. 2000. Full Report of the Prevalence, Incidence, and Consequences of Violence against Women: Findings from the National Violence against Women Survey. National Institute of Justice: NCJ 183781. (www.ncjrs.gov/pdffiles1/nij/183781.pdf)
Books and Resources on Posttraumatic Stress Disorder:
Foa, E.B., T.M. Keane and M.J. Friedman, ed. 2000. Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. New York: Guilford.
Herman, J.L. 1992. Trauma and Recovery: The aftermath of violence—from domestic abuse to political terror. New York: BasicBooks.
Rothschild, B. 2000. The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. New York: W.W. Norton & Company.
Schiraldi, G. 2000. The Posttraumatic Stress Disorder Sourcebook: Resources for Healing, Recovery, and Growth. Los Angeles: Lowell House.
Tedeschi, R.G., C.L. Park and L.G. Calhoun, eds. 1998. Posttraumatic Growth: Positive Changes in the Aftermath of Crisis. Mahwah, New Jersey: Lawrence Erlbaum Associates.
van der Kolk, B.A., A.C. McFarlane and L. Weisaeth, eds. 1996. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: Guilford.
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