Care confounded: the ethnography of intervention into violence

My thanks to Christine Labuski, Julie Livingston and Gethin Rees, who have brought their sharp insights to their reading of my recently published book, The Violence of Care: Rape Victims, Forensic Nurses, and Sexual Assault Intervention. I began this project many years ago as a prelude to research, planning to gain experience as a rape crisis advocate in Baltimore, Maryland and then to depart for the field. Baltimore was the site of my graduate training, and anthropologists, as we all know, must leave home to travel to the field. Over time, my prelude resulted in my deep imbrication in the flawed institutional fabric of intervention. I began to absorb the complex choreography of care as it intersected with Baltimore’s historical, legal, and demographic genealogies, and my original plan of spending time training and practicing as a patient advocate in Baltimore and then going on to other things began to seem less like a method and more a form of abandonment. The layers of the technologies, professional orientations, routines, personalities and genealogies that characterized the approach to sexual assault intervention I witnessed were too compelling to turn away from, so I stayed and laid the groundwork for a study which chose depth over breadth, longitude over sample, while generally adopting an ethic of patience. The clinical location of sexual assault intervention proved a rich and challenging site to interrogate, as many ethnographers and historians have demonstrated in their work and it was the implementation of historically informed ethnography that seemed the only way forward (see, for example, Livingston 2012; Meyers 2013; Saunders 2008).

My orientation to ethnography is to capture excess, and leave some things unexplained rather than imposing an analysis that, while dazzling in its tidiness, leaves no loose ends. Studies of violence challenge ethnographers to cultivate a voice that resists the gravity of sensationalism. A creative approach to analytical categories, drawing broadly on the agencies that structure sexual assault intervention, be they human or non-human, drew me along. I considered the role of DNA, time, emotion, reproduction, visual and documentary techniques, domesticity, compliance, and care. Caring for victims of sexual assault is a process replete with loose ends, unreconciled moments of ethical success and failure, unused or misunderstood data, underpaid and underresourced personnel, and passionate, sustained dedication and successes. These systems, like many other health systems, are curious in their systematicity. They rely on broad diagnostic categories, such as sexual assault, that capture and fix heterogeneous events, plotting them in familiar and actionable rubrics (Mattingly 1994, 1998). Medical anthropologists have successfully traced the narrative features of clinical stories, but my aim was to go beyond this to track patient narratives of sexual assault complaints, and to think of the clinic as a cutting room floor. What patient narratives were rejected by practitioners within the space of the clinic? What futures were deferred? Gethin Rees locates these impulses in a focus on “legal requirements” as “they serve to separate the attack from the rest of the victim’s biography.” I found this mode of therapeutic emplotment particularly puzzling in its manifestation as part of nursing care precisely because U.S. nursing assessment practice incorporates patient advocacy within a holistic framework.

Rees also notes that my emphasis on the text is often on time, although he notes that the text, “spent as much time emphasizing the spatial.” Thus, he notes he was left wondering, “why the temporal was given so much prominence in the introduction.” In many ways, the clinical interactions that informed the research were not prefaced by battles over spatial loci. Rather, space seemed thoroughly colonized by medical practice, by the courtroom, and by criminal justice and epidemiological renderings of the cityscape. Resistance to spatial colonization was present, but the contest over turf was more or less determined before anyone arrived in the clinic. The ways I attended to space were therefore descriptive and, again, by placing spatial rendering within its context. Time, on the other hand, was at issue in the encounter between forensic nurse, patient, and police officer. All these actors, and the institutional structures in which they were located, participated in the struggle to seize, shape, reject and renew time: this struggle was at the heart of the forensic modality as I described it.

Julie Livingston’s discerning comments place the forensic intervention as care in conversation with a broader literature on care. Livingston specifically cites Miriam Ticktin and Lisa Stevenson as she characterizes forensic intervention as “critical care.” I welcome this connection, particularly as Livingston points out the multitudinous ways in which the legal can be thought in relation to the medical. In some ways, we are all haunted by the specter of Foucault, and a most welcome haunting it often is, but I read neither my own project nor Ticktin’s or Stevenson’s as a simple Foucauldian project in which the biopolitical subject is constituted by institutions of care. Rather, while Livingston writes that my work highlights “clinical contexts in which the wellbeing or care of the patient is subsumed under the name of a larger collective – the population (for research or biopolitical purposes),” its “subject is not the legal as a constitutive domain of medicine,” but rather, “medical relationships and technologies used for legal ends in the immediate aftermath of traumatic injury.”

Like Ticktin, I attempt to think about the relationship of sexual violence to poverty. Where Ticktin describes humanitarian intervention and a mode of sexual suffering that supplants poverty and therefore other forms of structural violence, the forensic intervention is perhaps unlike humanitarian aid in that it excludes poverty as the basis for suffering, even as poverty exacerbates sexual violence. Or perhaps this is, in fact, Ticktin’s point in her descriptions of the casualties of care. In both her work and mine, institutions cultivate a care with blind spots, and certain forms of suffering can never be seen, nor given a home. As I thought through the complexities of an un-homed suffering, I found myself turning to the well-trod anthropological ground of domesticity and kinship, domains in which the legal and the medical shape and are shaped by modes of care.

My thanks to Livingston for suggesting, in her gentle way, that I include Margaret Lisa Stevenson’s Life Beside Itself: Imagining Care in the Canadian Arctic as a productive and challenging interlocutor to my work. Stevenson describes an anonymous care that alienates Inuit patients and their supporters, sustaining a form of life that is unrecognizable as life. This anonymity is not what drives the violence within the forensic interventions I describe. Rather, where my work intersects with Stevenson’s is in the consideration of care as not simply a therapeutic project, but a truthmaking process. The truths rendered through the regimes of care that Stevenson and I described are often imperceptible to the subjects of the caregiving regimes themselves. The incommensurability of truth with care and the work of care may sustain an enduring violence. Care, even located within the most well-meaning practices and delivered by “caring” practitioners, results in the unmaking of the subject, her recasting in a form that she barely sees as herself and the positing of a world that resembles only itself and not the world she previously inhabited.

I note here that my response grows long, and I have yet to address the comments of Christine Labuski, who offers me what few readers can, a reaction to my work as both an anthropologist and a former Sexual Assault Nurse Examiner. She begins her response by highlighting the notable absence of a feminist health orientation to the forensic practices I describe, which she accurately reads as reflecting the alignments of the community of nurses with whom I worked. Feminism, or what I call “the ‘F’ word,” was rarely mentioned by the forensic nurses with whom I worked, either by individual nurses, or specifically in the articulated views of local leadership. When it was mentioned, or strategically omitted, feminism was clearly received as a form of advocacy rather than as a way of informing the knowledge practices of nursing. In short, nurses felt their work as truthtellers was compromised rather than enhanced by feminism. The rejection of patient oriented practices, such as a clinician’s communication during pelvic examinations, gave way to silence or distractive talk, restricting knowledge flows within the clinical encounter. In effect, it was not for the victim to know what the nurse perceived, and her requests to share in this knowledge were frequently greeted by silence.

Labuski asserts that resolving the uneasy relationship between nursing care and feminism is not straightforward. Educational resources by way of time and expertise are limited, giving nurses little space to cultivate a feminist sensibility. Meanwhile, the institutional structures that guide forensic nursing interventions are both binary and prescriptive, giving nurses few chances to overcome these structures. To be sure, I try to make the point at several junctures that even a nurse with a very well-defined feminist orientation could find herself on the wrong-side of things so to speak because of the ways in which forensic intervention plays out. If, at times, this seems to over-emphasize the role of structure above and beyond agency, this is deliberate. This might be an over correction on my part as I take this approach as a part of a feminist project that critiques the neo-liberal emphasis in sexual assault interventions themselves, an approach that atomizes and privatizes sexual assault response, depoliticizing the policy debates that inform intervention (Beres, Crow and Gottell 2009). I found the violence of the forensic intervention foundational in its shaping of racialized and gendered subjects (foundational in the sense of Walter Benjamin’s founding), as well as confounding, as the state which was founded by the intervention produced subjects who inconsistently recognized the nurses’ ministrations as care, sometimes branding it as cruelty.

While Rees, Livingston and Labuski have raised many questions and drawn attention to several themes, I have not responded to all of their queries in this short space. I will let their questions and their analyses stand, or rather, I will let other readings of The Violence of the Care supply answers to these questions. It is my hope that encounters with The Violence of Care will generate new questions and critiques of the way that law, violence, care and the state exist in relation to one another.

Sameena Mulla is Assistant Professor of Anthropology in the Department of Social and Cultural Sciences at Marquette University in Milwaukee, WI. Her current project, collaboration with Heather Hlavka, is an interdisciplinary ethnographic study of the sexual assault trial as it engages and produces expert knowledge about evidence, victimization, sex offenders, and carcerality.

 

References

Melanie Beres, Barbara Crow and Lise Gottell. 2009. “The Perils of Institutionalization in Neoliberal Times:Results of a National Survey of Canadian Sexual Assault and Rape Crisis Centres.” Canadian Journal of Sociology. 34(1): 135-63.

Julie Livingston. 2012. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham and London: Duke University Press.

Cheryl Mattingly. 1994. “The Concept of Therapeutic ‘Emplotment’.” Social Science and Medicine. 38(6): 811-22.

–. 1998. “In Search of the Good: Narrative Reasoning in Clinical Practice.” Medical Anthropology Quarterly. 12(3): 273-97.

Todd Meyers. 2013. The Clinic and Elsewhere: Addiction, Adolescents, and the Afterlife of Therapy, Seattle: University of Washington Press

Barry Saunders. 2008. CT Suite: The Work of Diagnosis in the Age of Non-Invasive Cutting. Durham and London: Duke University Press.

Margaret Lisa Stevenson. 2014. Life Beside Itself: Imagining Care in the Canadian Arctic. Berkeley: University of California Press.

Miriam Ticktin. 2011. Casualties of Care: Immigration and the Politics of Humanitarianism in France. Berkeley: University of California Press.