Greg DalyGreg Daly examines the State’s latest report into symphysiotomy
Symphysiotomies were “Ireland’s brutal alternative to Caesarians” reported The Guardian in December 2014.
Describing symphysiotomy as “a controversial operation that was seldom used in the rest of Europe after the mid-20th Century, but which was carried out on an estimated 1,500 women in Ireland between the 1940s and 1980s”, the British newspaper described how the process involved “slicing through the cartilage and ligaments of a pelvic joint (or in extreme cases, called pubiotomy, sawing through the bone of the pelvis itself) to widen it and allow a baby to be delivered unobstructed”.
In distinguishing between symphysiotomy and pubiotomy, albeit by identifying pubiotomy as a type of symphysiotomy, The Guardian did itself some credit. In sharp contrast, for instance, The Irish Times before last month had used the word ‘pubiotomy’ a mere total of eight times over 17 years, but had referred to symphysiotomy over 200 times in that period.
Numerous articles had elided the two procedures, baldly stating that symphysiotomy “involved cutting a pregnant woman’s pubic bone”, “involved sawing through the woman’s pubic bone”, or “involved sawing a pregnant woman’s pubic bone in half”.
Compensation
Despite this, The Surgical Symphysiotomy Ex-Gratia Payment Scheme, a lengthy report – 274 pages without appendices – by Judge Maureen Harding Clark for the Minister for Health into the State’s compensation scheme for women who had experienced symphysiotomies or pubiotimies, is adamant that the two procedures should not be confused.
“Pubiotomy is quite distinct from symphysiotomy,” the report states, continuing, “It involves the sawing through of the pubic bones while symphysiotomy involves cutting through soft fibrous cartilage and does not involve bone or the use of a saw.”
If someone reading this might suspect that the onetime High Court and International Criminal Court judge would be likely to have sceptical view of journalistic shorthand and an all-too-common media preference for that sensationalism that’s believed to sell papers, they’ll find their suspicions confirmed in the report.
“The publicity surrounding the activism for the Government to set up a compensation scheme for symphysiotomy victims was quite intense,” the judge observes, italicising words taken from published articles and continuing, “there can hardly be a person in Ireland who has not been exposed to reports of the procedure described as butchery akin to Nazi medical experimentation; aggravated sexual assault; a form of female genital mutilation causing life long disability, chronic pain, mental suffering and family breakdown and much more.”
Commenting on such colourful writing, she continues, “These reports have been so persistent and frequent that they have created something akin to a knee jerk reaction to the word symphysiotomy. It is viewed as a procedure synonymous with barbarism and pain; but not just barbaric and painful but unnecessary and unwarranted, creating a legacy of countless victims whose lives were permanently ruined.”
Citing Glasgow’s Prof. Oonagh Walsh’s 2013 study Symphysiotomy in Ireland 1944 to 1984, Judge Harding Clark said that although the history of symphysiotomy in Ireland had been “very fully explored” by Prof. Walsh, “to a great extent, her scholarly report has been ignored by sections of the media who appear to prefer the more lurid and unfounded accounts projected by some activists and bloggers”. As a result, she was, she said, “therefore not sanguine that there will be any change in the manner of reporting of the subject”.
That said, it is hard to ignore some of her findings, not least those which reveal that almost a third of the women who sought compensation from the State for symphysiotomies they claimed to have have suffered had never undergone either symphysiotomies or pubiotomies.
In some respects this finding should not be too surprising. It was commonly estimated in 2012 that around 1,500 women had undergone symphysiotomies in Ireland with roughly 350 of these being alive at that point, such that alarm bells must have rung when 590 individuals applied to the State to be compensated for the procedures.
These 590 claimants, who submitted their applications for compensation between November 10, 2014 and January 14, 2015, varied in age from 43 to 96, with most claimants being aged over 75. The judge found that 185 claims were ineligible for compensation, ruling that “almost one out of every three applicants did not undergo symphysiotomy or pubiotomy”.
Perhaps even more astoundingly, in view of how media reports on symphysiotomy have so often described it in terms more appropriate for pubiotomy, “pubiotomy was only established in one case out of 590 claims”.
Given such findings, it is perhaps unsurprising that some have been quick to dismiss the report as a whitewash, but then such cries are all too common when reports don’t tally with received wisdom. A recent obvious example of this was 2013’s McAleese Report into the State’s Magdalen laundries, which even going outside its remit found no evidence to support allegations of systematic torture or criminal ill treatment, with there being evidence indicating that such claims were – in general –unfounded.
Many shouted down that report as a whitewash, but as the Government observed in a July 2015 submission to the United Nations Human Rights Committee: “No individuals claiming to be victims of criminal abuse in Magdalen laundries have made any complaints or requests to the Department of Justice and Equality seeking further inquiries or criminal investigations.”
Predictably, then, the advocacy group ‘Survivors of Symphysiotomy’ have called Judge Harding Murphy’s report an “official whitewash”. With the group calling the scheme – which awarded €34million in compensation – “irrational, adversarial and unjust”, its chairperson Marie O’Connor said, “The scheme refused to take survivor testimony and that made it very difficult for older women to prove their injuries.”
It is difficult to take seriously such objections in light of how the report details efforts made to establish whether symphysiotomies or pubiotomies had taken place.
“Every applicant who expressed doubt about the reliability of the content of her records or who had no records was invited to undergo radiology and medical examination,” the report states, continuing, “The Scheme always paid for those examinations although some applicants preferred to use their own specialists.”
Such examinations could demonstrate beyond any reasonable doubt that symphysiotomies had not taken place. The report describes, for instance, one applicant whose daughter was convinced her mother had had a symphysiotomy.
“As the delivery was in the 1970s, the full hospital chart and records of the birth were available,” the report states, continuing, “Those records made no mention of a symphysiotomy, provided no support for symphysiotomy nor was there any reason why the procedure would be carried out.
“Very surprisingly, an expert report was received where an obvious palpable symphysiotomy scar was described. I requested a second examination as the records contradicted the possibility of symphysiotomy. The applicant’s daughter rejected this opinion. The applicant was subsequently examined by three other gynaecologists but none saw any evidence of any scar in the pubic area.
Claims
Of the 185 claims deemed ineligible, 65 were withdrawn when it was recognised that there was no evidence to support claims that a symphysiotomy had been performed, while in eight cases where there had been “no engagement with the scheme beyond the furnishing of bare application forms without any supporting evidence” repeated efforts to ask applicants either to submit relevant documentation or undergo appropriate medical examination met with silence.
The notion that a refusal to take survivor testimony made it difficult for individuals to prove their injuries is one that simply will not stand up to scrutiny, since the report shows just how questionable subjective evidence provided by applicants could be, even when accompanied by medical reports.
“Non-treating doctors sometimes wrote reports so completely at variance with the contents of treating GP’s notes that I was obliged to make contact with the treating GP to clarify the issues,” the judge writes, continuing, “a notable example was where an applicant was described as a woman so traumatised and damaged by the symphysiotomy which had caused her intractable incontinence, pain and social isolation that she endured it all in silence rather than overcome her pathological fear of doctors and seek medical help.”
Contrast
In contrast, she observed: “Her own doctor’s records depicted an absolutely normal woman who worked outside the home, rode her bicycle to work and attended regularly with her GP for her own and her family’s everyday ailments.”
She cites another case where three different doctors attested to horrors inflicted on their patient by a symphysiotomy that had, in fact, never happened.
While in a small number of cases, she says, doctors had tried to help patients by writing sympathetic reports at variance with their contemporary records, a more common problem was that the procedure had been identified at some point in the past, with older and subsequent complaints being attributed to the operation. “Again,” the report observes, “this phenomenon was observed even where it was ultimately established that symphysiotomy played no role in the applicant’s complaints.”
Judge Harding Clark spends several pages on the question of how a third of applicants can have believed they were entitled to compensation when they had, in fact, never had surgical symphysiotomies or pubiotomies.
She excludes 23 women who had suffered spontaneous or natural symphysiotomies, observing that any women who had known they had experienced symphysiotomies could be forgiven for long afterwards confusing spontaneous ones with surgical ones. But what of the other 162 unsuccessful applicants?
It would be simple to explain these away as simply due to memory problems linked with bad experiences of a first labour, but she ultimately rules out such a straightforward explanation.
“After much thought,” she writes, “I concluded that it is very probable that the combination of a traumatic birth experience and exposure to other women’s stories has created a self convincing confabulation of personal history.
Inference
“Another inference is that the possibility of financial payment has influenced suggestible women and their family members into self-serving adoption and embracing of the experiences described by others or in the media created psychosomatic conditions,” she adds.
Pointing out that most mistaken applicants were “elderly and possibly amenable to suggestion and to emotional contagion”, she notes how “there were certainly some amongst the ineligible applications who were considerably younger and who appeared angry or disappointed when informed that evidence to confirm symphysiotomy was completely absent”.
Contradicting claims that survivor testimony was rejected, Judge Harding Clark notes how personal statements submitted tended to display an “extraordinary similarity”, leading to a “strong suspicion that symptoms described reflected the injuries complained of by the successful plaintiff in the High and Supreme Court judgments of Kearney v McQuillan”.
The report goes on to list 37 phrases that, it says, “appeared regularly in the statements of women who did not undergo symphysiotomy”, starting with, “I will never forget the sound of the saw cutting into me” and “I was told that as a Catholic I would be expected to have 10 children whereas if I had a Caesarean section I would have to limit myself to three children”.
The linking of symphysiotomy to Catholicism has been a common trope since Dr Jacqueline Morrissey, author of a doctoral thesis entitled An examination of the relationship between the Catholic Church and the medical profession in Ireland, first introduced the notion of symphysiotomy to the readers of The Irish Times in September 1999.
Such claims were rejected just weeks later by the then Master of the National Maternity Hospital, Dr Peter Boylan, and Tony Farmer, author of Holles Street 1894-1995, when they wrote to say that Dr Morrissey’s analysis was less complex than the reality.
“The introduction of symphysiotomy was driven not by Catholic teaching but by the medical risks associated with repeated Caesareans,” the two wrote, explaining that doctors of the past had serious concerns about maternal mortality, and that insofar as Catholic teaching factored into doctors’ decisions, “Doctors surely have a duty of care to respect their patients’ beliefs and the population served by Holles Street and the Coombe was largely comprised of working-class Catholic mothers.”
Vatican dogma
Judge Harding Clark’s analysis similarly rejects Dr Morrissey’s thesis, noting among other things that “it seems unlikely that the obstetricians at the Rotunda or the Erinville, both non-Catholic institutions, were motivated by Vatican dogma”.
In commenting on the report last week, Dr Boylan said on RTÉ’s Today with Sean O’Rourke that attempts to cast those doctors who performed symphysiotomies as religious zealots are fundamentally unfair, describing this as “an outrageous allegation to make against professional doctors who were doing their best in very difficult times”.
Explaining that medical advances mean that “procedures come and go”, Dr Boylan said that symphysiotomy was a legitimate practice in its day, adding that it is still an approved technique sometimes used even now in situations when a baby’s head or shoulders are stuck in childbirth. Describing these as “life-saving procedures”, he said “there has been a vast amount of misinformation about this procedure which has done the women a grave disservice”.
As far as Dr Boylan was concerned, the “real scandal” of the symphysiotomy saga is how many women had been wrongly led to believe their problems – probably due to the toll of pregnancy itself – were due to having had symphysiotomies. “That’s one of the saddest things about this whole episode,” he said.
In this he echoed Judge Harding Clark, who observed in her report, “I must confess to a feeling of great sadness for those applicants who somehow believed that they were victims who had survived symphysiotomy only to learn that they were mistaken and that their recollections were based on error.
“Elderly women should not have to face such emotional turmoil,” she continued, “I have no doubt that some of them have spent good money presenting their claims which cannot be recouped. Those who have been active in representing themselves as victims to the media must now retrace their lives and must be understandably upset.”