Abstract

In this essay, we explore possible affinities between disability studies and trauma studies. We suggest that a fruitful engagement between these fields should start with the meanings of trauma and disability in their embodiment. We offer theoretical provocations alongside a comparative cultural analysis of traumatic brain injury and obstetric fistula. Ironically, while many disability studies scholars have worked to dislodge definitions of "abnormal" from the body, a conceptual focus on stigma still keeps the disabled body partially in view. Yet wounds, impairment, and pain are erased, and in many framings, the object of analysis is an individual being, whose now-disabled body is socially constructed, and whose agency is posited as being in struggle and resistance against the normative culture. We suggest that the body itself provides a link between disability studies and critical trauma studies, arguing both for the significance of representations as well a materialist understanding of breach, for a notion of the organic, fleshy body as it is damaged, sometimes profoundly, in its operations of life.

 



"Frida Kahlo died in 1954…of complications due to a severe bus accident, when she was eighteen, in which a metal handrail entered her lower body, broke her spinal column and pelvis, and exited through her vagina. This accident, combined with an earlier bout with polio and a possible congenital spinal deformation, left her physically disabled on a number of levels for the rest of her life." (Greeley 2004, 216)

"Between the ages of fifteen and twenty, I suffered two major traumas— first polio and then four years later an automobile accident. Each resulted in a year's confinement and each was severely debilitating." (Zola 1982, 2)

"We all have bodies. This is not a truism. It is not an exercise in the obvious. It is a fact—and a fact of a special kind. It is an incontestable fact. Everything we do, we do as or by means of our body. We cannot get beyond the fact that we are bodies. The body is, simply put, where everything in human culture begins and ends." (Siebers 2010, 136)

Introduction

Numerous memoirs and biographies of people living with disabilities have explored the intersection of trauma—specifically illness-related or accident-induced traumas—with subsequent experiences of disability (e.g., Linton 2006; Zola 1982). That is, scholars and writers have represented their own and others' physical disabilities in a causal context of trauma, suffering, illness, accidents, and/or other disruptions to their bodies and lives. Lucy Grealy's Autobiography of a Face (1994), for example, offers one such tale in which trauma and disability, and socio-medical responses to these, exist viscerally side-by-side. Frida Kahlo's lush, haunting corpus showcases her own embattled body in arresting tableaux, while her life and art have been frequently narrated in terms of trauma and disability (e.g., Drakulic 2008; Levine and Jaycox 2009).

Yet taken as a whole, disability studies and its "cultural locations" (Snyder and Mitchell 2006) have been remarkably silent on matters of the traumatic origins of many disabilities, and on the ongoing relationship between shocking events, their abrupt and chronic impacts, and experiences of disability. (A notable exception is David Serlin's [2004] Replaceable You, which locates the post-War, re-engineered human body firmly within the geopolitical trauma of armed conflict.) Siebers, interrogating the "realities" of the disabled body, writes, "rare is the theoretical account where physical suffering remains harmful for very long" (2006: 177). Berger (2004) suggests that while trauma studies has focused on trauma as a metaphor, as a starting point for poetics and the creation of meanings, disability studies has erased the moment(s) of trauma in service to a social constructionist framework. In disability studies, he argues, trauma is not understood metaphorically, but rather practically and politically. Thus, while both trauma studies and disability studies focus on the body and its harms, each field has its own premises, goals, and limitations. There is, according to Berger, no shared conceptual vocabulary.

We propose that this disconnect stems, at least in part, from the fact that disability studies has done an exceptional job of moving disability beyond the body to the broader social, political, and cultural contexts in which bodies are located and which give them meaning. That is, the field has worked diligently to (re)locate disability from embodied function and/or difference to the social structures and meanings that name such (dys)function and difference (see, e.g., Shakespeare 2006). At the same time, important political and intellectual work has been done in disability studies to recast disability as something more than inherently traumatic and traumatizing. Peering at disability through a trauma studies lens would, on the surface, seem to amplify precisely those embodied disruptions that disability scholars often seek to minimize or contextualize. To refocus attention on the physical acts of disabling—the signal moments of bodily breach and psychic tear—feels dangerous.

And yet, we argue, it is precisely within these moments of wounding and their aftermath that human bodies become the ideal corporeal screen upon which are inscribed notions of the normal and the pathological (Canguilhem [1966] 1991). Just as disability studies has illuminated processes and categories of normalization (Davis 2010; Casper and Talley 2007), so too has critical trauma studies theorized disruptions, breaks, shocks, and ruptures that mark deviation from situations perceived as normal or mundane. As Stevens (2011:171) notes, "beginning with 'marks' like bloodied bodies, ruptured minds, incomplete narratives, or riddled archives, Trauma Studies provides explanatory narratives that, by offering one telling of how the subject achieved its ruination, support fantasies of an originary time before the fall; a time of whole, coherent, innocent selfhood and uncorrupted, clean and proper subjectivity."

These delineations of normal and pathological are most obviously cultural operations saturated with meaning (Kaplan 2005; Miller and Tougow 2002). But they are profoundly historical, structural, and political operations, too, replete with advances and resistances (Fassin and Rechtman 2009; Foucault [1963] 1994). What/who we have come to know as "the disabled" is produced by and within norms of ability, while what/who we have come to know as "the traumatized" is produced by and within discursive and institutional conventions of the traumatic (Stevens 2011). The body is central to these operations as both trope and material, and indeed, "trauma" and "disability" may be fruitfully conceptualized as embodied manifestations of social classification systems. As such, like Stevens (2011), we draw a distinction in our work between "trauma" as a marker and critical trauma studies as a reflexive analytical perspective. Such a distinction is similar to that drawn between "disability" as an indicator and the critical focus of disability studies. This interpretive stance requires attention to our own epistemological politics while also subjecting to critical analysis non-reflexive studies of trauma and disability, such as those from psychiatry and biomedicine.

In provoking a dialogue between disability studies and critical trauma studies, then, our approach is necessarily interdisciplinary. As qualitative medical sociologists deeply invested in comprehending the "vital politics" of human bodies (Rose 2006) and the mechanisms by which societies produce both life and "premature death" (Scheper-Hughes 1993), we draw on our expertise in cultural analysis to explore meanings and representations of "trauma" and "disability" embodied in two health-related conditions: traumatic brain injury (TBI) and obstetric fistula. We show that the traumatic "shocks" of TBI and obstetric fistula, and the disabling effects they produce, are not, as they appear on the surface, merely about physical harms to the body. Both TBI and obstetric fistula are deeply shaped by and embedded in social structures, institutional forms, cultural meanings, shifting geopolitics, and the transmigrations of biomedical and military technologies. Thus, the injured body serves a pedagogical function, pointing to something else; the identity of this "something else" is subject to investigation.

Of course, we certainly do not intend this article to be the last word on intersections of disability studies and critical trauma studies, nor on the impacts of TBI and obstetric fistula. As sociologists investigating "trauma" and "disability"—kith and kin to medical sociological categories of "morbidity" and "mortality"—we offer this account as an invitation to scholars in many fields to explore possible conceptual and empirical junctures between critical trauma studies and disability studies. We are heartened by Siebers' (2010) recent contribution analyzing modern art to theorize trauma studies alongside disability studies. He writes, "I want to insist that disability studies include trauma within its definition of disability, but it is equally important to insist that trauma studies accept disability as a key concept…[A] merger between disability studies and trauma studies will allow us to conceive of wounds as disability representations on a par with those typically considered in disability studies…" (2010, 103).

A Shock to the System

Consider these statistical representations of wounding: "at least 5.3 million Americans, 2% of the U.S. population, currently live with disabilities resulting from TBI" (Brain Trauma Foundation 2011). In one study of 10,239 TBI patients, 53% sustained their injury in a vehicular accident, 23% through a fall, 13% through violence, and 11% from other causes (Traumatic Brain Injury National Data and Statistical Center 2011). According to the Defense and Veterans Brain Injury Center (DVBIC), the incidence of TBI among wounded service members might be as high as 22%. Men are about one and a half times more likely than women to suffer TBI, although some TBI symptoms are consistent with those of PTSD, and women are more likely to suffer from PTSD (Nayback 2008). While numeric data capture to some degree the scope of wounding, these statistics offer no insight into suffering, war, the politics of diagnosis, or lived experiences. They do, however, contribute to the production of TBI as a diagnostic category.

Taking our cue from cultural and historical accounts of post-traumatic stress disorder (e.g., Young 1997; Fassin and Rechtman 2009), we attend here to the ongoing configuration of TBI as a constellation of bodies, knowledge, statistics, diagnoses, psychiatric technologies, cultural meanings, and popular depictions. Although TBI is typically narrated in the shorthand of its acronym, the term itself encompasses a multitude of recognized causes and embodied consequences. We are particularly interested in traumatic brain injuries to U.S. service members as the result of war. These injuries are most commonly produced by blast injuries from bombs, rocket-propelled grenades, and improvised explosive devices (IEDs), the latter a "signature" technology of so-called insurgents (Defense Update 2004). 1 Statistics concerning the extent of TBI in soldiers, insurgents, civilians, and contractors are, unsurprisingly, vague. (One imagines that the U.S. government is not eager to measure and disclose the full human impact of war.)

TBI and other "closed-brain" injuries are not new to warfare. Inasmuch as bombs, bullets, falls, and other strikes to the head and neck have long been a fact of war, so have injuries to the brain. What is new about TBI is its etiological and political classification as a signature wound or injury for our time, one that is the center of increasing public attention along with a focus on other health issues facing veterans of the Iraq and Afghanistan conflicts (Benjamin 2006). Cultural studies scholar Jennifer Terry (2009, 221) notes, "The increasingly common usage of [TBI] suggests an interesting move toward marking wars through a historiography of wounds; that is, as a means through which to construct a history of armed combat that foregrounds the wounding capacities of new weapons systems and the damage they can do." This new marking strategy also foregrounds the bodies of those affected, often through visual media and in terms of suffering, disablement, and other combat-related disruptions (Siebers 2010).

As a biomedical work object (Casper 1998), TBI is commonly characterized within health care settings and psychiatric facilities as mild, moderate, or severe. Brain injuries can result in loss of consciousness for a minute or for days, and the effects of TBI can be short-lived or permanent. Biomedicine positions TBI in its moderate and severe forms as causal of degeneration in neural connections throughout the brain—connections that might be supplemented by other neural connections, but that rarely return (Mac Donald et al., 2011). Depending upon the location of these connections within the brain, as revealed through brain imaging technologies (Grady 2011), service members with TBI experience a variety of behavioral changes, many of which are consistent with that other signature injury of war, PTSD. Diagnostic categories are fluid, and their use may say as much about embodied phenomena as about history, politics, culture, and institutions (Jutel and Nettleton 2011). Connections between PTSD, TBI, and a more diffuse "combat stress" (historically known as "shell shock") are complex and ambiguous—it is often unclear where one condition ends and the next begins.

Media coverage of TBI has been of two kinds: the first has focused on the use of IEDs by Iraqi and Afghan insurgents and their impact on U.S. troops, and the second has featured personal stories of veterans heroically facing recovery after injury. The stories of recovery typically stop when patients return to active duty, begin accepting military disability payments, or retire from military service. Yet journalists (and scholars) who have tracked veterans of the Iraq and Afghanistan wars report that suicide and other violence may follow a return to the U.S. for many soldiers (Alvarez and Frosch 2009; Benjamin and de Yoanna 2009a). In addition to the poignant and disturbing narratives of TBI and associated behavioral (irritability, aggression) and psychological (anxiety, depression) symptoms, there is another, institutional level at which these events occur. As has been well documented (e.g., the Washington Post's comprehensive reporting on Walter Reed), 2 many veterans receive inadequate health care for mental and physical wounds received during their time at war—an issue to which we shall return.

The New England Journal of Medicine reported in 2005 that a TBI event may last from a few minutes to a few days, but the trauma of brain injury, including related disabilities, is chronic and continues long after the event that caused it (Okie 2005). Wartime TBI is often the result of blast injuries, in which the detonation of an explosive changes the air pressure around the blast site such that a shock wave crashes into the body. These blasts can be accompanied by fragments of the explosive device, as well as sequelae including falls and strikes of the body to blunt objects such as vehicles and buildings. Other results of such blasts can include intense heat, burns, and environmental impacts (Force Health Protection and Readiness 2010). Any of these events can lead to TBI (plus other injuries), with symptoms varying widely. According to the U.S. Operational Medicine and Force Readiness Office, service members diagnosed with TBI experience short- and long-term physical symptoms, including headache, dizziness, balance problems, and sleep disturbance. Cognitive problems include short-term memory, poor concentration, attention difficulties, and trouble making decisions. People with TBI also suffer mood changes, such as increased irritability, depression, lack of motivation, and anxiety (Force Health Protection and Readiness 2010).

Like many disabilities, especially psychological and/or intellectual disabilities, TBIs are often invisible to the naked eye, which implicates the narratives produced about them. The visual cues so common to physical disabilities are absent, making TBI seem more like mental illness-as-disability rather than an acute bodily injury—despite the harrowing materiality of the initial incidents and the cascading nature of brain damage and degeneration. Yet Wein and his colleagues (2009) reported that only 22% of veterans at risk for PTSD were evaluated for mental health problems, and less than 40% of service members diagnosed with PTSD received needed care. They state, "We found that 35 percent of soldiers and marines who deploy to Iraq will ultimately suffer from P.T.S.D.—about 300,000 people, with 20,000 new sufferers for each year the war lasts" (2009, A23). Media coverage and Department of Defense programs have highlighted the importance of eliminating stigma from help-seeking for both PTSD and TBI (RealWarriors.net 2011). However, the vexed dynamics of diagnosing and treating TBI (and PTSD) extend beyond individual help-seeking behavior to encompass institutional barriers, such as the military's need to keep troop levels up.

Compared to previous armed conflicts, the degree to which today's service members are surviving combat-related injuries is unprecedented, leading to increased rates of conditions diagnosed as TBI. For example, Okie (2005) reports that 12 to 14 percent of wounded soldiers in the Vietnam War sustained some form of closed-head injury. According to Bellamy, author of Textbook of Military Surgery, mortality from brain injuries to U.S. soldiers in Vietnam was 75 percent or higher (Okie 2005). Thus, soldiers with brain injuries were rarely treated in hospitals then—they died on the battlefield or shortly thereafter. In contrast, Okie found that 22 percent of wounded soldiers from the current Iraq and Afghanistan wars who passed through Landstuhl Medical Center in Germany had injuries to the head, face, or neck, and were likely to have received some form of brain trauma or injury.

According to the U.S. Operational Medicine and Medical Force Readiness Office, advances in diagnosing and treating brain trauma during the Vietnam War led to improvements in trauma care in U.S. hospitals. These innovations are positioned, practically and rhetorically, as solutions for improving TBI treatment in the nation's ongoing conflicts. Some advances are technological: Kevlar body armor and helmets are relatively new additions to a service member's armament. They also serve as one reason offered for the higher rates of TBIs: soldiers are now partially shielded from bullets and flying debris, improving survival rates after injury. Kevlar helmets have reduced the number of injuries sustained from penetrative head wounds, where bullets, shrapnel, or fragments of objects such as vehicles enter the skull. Yet helmets and armor cannot completely protect a soldier's vulnerable face, head, and neck—and they cannot prevent closed brain injuries produced by bomb blasts from IEDs, land mines, and other explosive weapons.

Soldiers are also more likely to survive blast injuries in the Iraq and Afghanistan wars due to improvements in battlefield medicine (or combat casualty care) and the availability of new biomedical technologies for acute injuries. Current treatments for TBI include immediate care in the field and transport to combat support hospitals, which are equipped with brain imaging equipment. Service members may also be evaluated quickly by neurosurgeons. Standard treatment includes removal of foreign materials, control of bleeding, and craniectomy to relieve pressure from the swelling brain (Okie 2005). 3 Eventually, all combat-related TBI patients are evaluated at one of eight Defense and Veterans Brain Injury Centers in the U.S. These centers illustrate the biomedical/military complex, a significant outlay of capital that has been built up around traumatic brain injuries. It is worth noting that dead soldiers are autopsied and their bodies CT scanned when they transit back to the U.S., suggesting unlimited efforts to understand the nature of war injuries (Grady 2009a).

In order to "Get the Right Patient to the Right Hospital in the Right Amount of Time", the motto of the U.S. Central Command Joint Theater Trauma Systems (JTTS) team, the military has been forced to re-think its processes for handling service members who suffer blast injuries but may not show immediate signs of brain injury (Jenkins et al. n.d.). In addition to developing a Joint Theater Trauma System in order to improve survival rates for troops injured during combat, the U.S. military developed the Joint Theater Trauma Registry, a massive database that chronicles the "vital statistics" of war injury (Eastridge et al. 2006). Currently, the JTTS team is developing new assays for an objective test for brain cell damage. Advocates suggest that if such a test can be deployed in the field, then perhaps the most severely injured soldiers can receive treatment more quickly. Further, according to the Army, novel therapeutic agents have shown excellent results in lessening the impact of brain injury, and these agents are now in clinical trial to determine their effectiveness in mild to severe TBI (U.S. Army Posture Statement 2010).

The World Split Open

We turn now to another signature wound, that of obstetric fistula. But rather than marking contemporary military conflicts, obstetric fistula serves as a signature injury of "stratified reproduction" (Colen 1986), or the procreation of our species in a profoundly unequal world. An injury typically caused by unattended obstructed labor and almost unheard of in the contemporary West, obstetric fistula marks astonishingly high maternal morbidity and mortality rates in developing nations (WHO et al. 2010). Fistulas are tears in the body's organs, but they also represent gaping holes in social support, justice, and health care. 4 They are disabling and traumatic at many levels.

Severe tissue damage and fetal death often result from prolonged labor, but this is largely preventable where adequate health care is more readily available. In developing nations, particularly among poor, rural women, obstructed labor can cause a fissure to develop between the vagina and bladder (known as vesicovaginal fistula) or between the vagina and rectum (known as rectovaginal fistula), or both. After a case of prolonged labor, the fetus or baby usually dies (likely increasing infant death rates, although fetal deaths are not counted in most Infant Mortality schedules). The woman, if she does not die, is left chronically incontinent of urine, feces, or both. Statistically insignificant (but no less tragic) in wealthy nations, in the developing world there are up to 100,000 new cases of obstetric fistula annually (WHO 2010).

Ahmed and Holtz (2007, S10) describe obstetric fistula as "an abnormal communication between the vagina and the genito-urinary system and/or the rectum." This is a fascinating metaphor, as it signals other kinds of communication difficulties, such as that between developed and developing nations, men and women, health care providers and patients, and between women perceived as disabled and their families. The abnormality here is not that women's bodies are damaged in childbirth and that babies die, although these are indeed catastrophic (and also "normal") occurrences in the "third world." No, the abnormality is that obstetric fistula is both preventable and treatable where health care services are available. That is, the pathology reflects the lack of vital health care services for the world's most vulnerable people: "poor, young, illiterate girls and women in remote regions" (de Bernis 2007). These gaps in care are also failures of communication: between resource-rich and resource-poor nations, between technologies and bodies, and between providers and the women who need their help. These women should not be disabled by childbirth—a "natural" condition of human life—nor should their babies die, and yet they are and they do. As Ahmed and Holtz (2007, S14) state, "having a fistula changes a woman's quality of life forever."

The bodily impairments of fistula may include a crushed pelvis, damaged internal organs, and chronic leakage of human waste. Social disablement immediately ensues. Women suffer from bodily odors deemed offensive, and are considered to be unclean. Because the genitals are implicated, family and community members may erroneously believe the women to have a sexually transmitted disease. Women are prevented from fulfilling their culturally defined roles as wives and mothers, and are cruelly ostracized. Women whose babies die in birth are grief-stricken at the loss. Ahmed and Holtz (2007; quoting Harrison [1983]) write, "The consequences are devastating: the girl is initially kept hidden; subsequently, she finds it difficult to maintain decent standards of personal hygiene because water for washing is generally scarce; divorce becomes inevitable and destitution follows, the girl being forced to beg for her livelihood." Women with obstetric fistula may be banished from their communities and isolated in separate living spaces such as confinement huts or compounds, evoking the historical treatment and colonization of people with leprosy.

The media have begun to pay attention. Grady (2009b), reporting in the New York Times, describes Ward 2 of a regional hospital in Dodoma, Tanzania:

All [the women] had suffered from obstructed labor…One of the most striking things about the women in Ward 2 was how small they were. Many stood barely five feet tall, with slight frames and narrow hips, which may have contributed to their problems…The women wore kangas, bolts of cloth wrapped into skirts, in bright prints that stood out against the ward's drab, chipping paint. Under the skirts, some had kangas bunched between their legs to absorb urine.

Grady's article goes on to describe surgical treatment for fistula, a complex undertaking in a poor nation:

An air conditioner put our more noise than air. Flies circled, sometimes lighting on the patients. A mouse scurried alongside the wall…Midway through the first operation the power failed, and the lights went out. Dr. Wilkinson put on a battery-powered headlamp and kept on working…At the end of the week in Dodoma, the surgeons said that of the 20 operations, some were straightforward and easy, and a few seemed likely to fail.

New York Times columnist Nicholas Kristof, who comments often (and sometimes controversially) on women's health issues, used the issue of obstetric fistula to criticize President Bush's 2007 cuts in spending on global maternal and child health programs. He described the case of Simeesh Segaye, a 21-year old Ethiopian woman whose baby died after four days of prolonged labor, two of these days spent on a bus attempting to reach the nearest hospital. When her parents later paid for a public bus to transport her to another hospital for fistula repair, passengers complained about her odor and she was ordered to disembark. Kristof writes,

Mortified, Ms. Simeesh was crushed again when her husband left her. Her parents built a separate hut for her because of her smell…In that hut, she stayed, alone, ashamed, helpless, bewildered. She barely ate, because the more she ate or drank, the more wastes trickled down her leg. 'I just curled up,' she said. 'For two years' (2007).

Maternal health experts have reported that up to 90% of obstetric fistulas can be surgically repaired. A growing movement comprised of medical providers, donors, governments, and transnational NGOs is targeting this condition, in part because of the suffering of the women and in part because improved maternal morbidity and mortality rates are enshrined in the United Nations Millennium Development Goals (2010). Clinics are being established in regions across the developing world, and trained practitioners are traveling to these regions to help with repairs. Alongside health services, social support networks are being implemented to help counsel women and their families, and to reintegrate women into their communities.

However, obstetric fistula must also be prevented, which will require structural changes and economic investments in obstetrical care in the developing world, family planning services (including provision of contraception and abortion, which are related to incidence of maternal death), and major policy changes. The United Nations Population Fund has initiated the Campaign to End Fistula, emphasizing prevention (including eradicating poverty), treatment, and education to destigmatize. Yet Ahmed and Holtz (2007, S10, quoting Browning and Patel [2004]) note, "'At the world's current capacity to repair fistula, it would take at least 400 years to clear the backlog of patients, provided that there are no more new cases'; and by this estimate, the unmet need for surgical treatment could be as high as 99%."

As a signature wound of maternal health in the developing world, obstetric fistula as "disability" and "trauma" can be read as a marker of global poverty and inequality. If, as Terry argues (2009, 206), "each modern war has its signature injuries," then obstetric fistula serves as visceral proof that the global war on poverty is stalled. Untreated horrific wounds, in the example of obstetric fistula, lead to waste out of place, a kind of transnational "return of the repressed" to borrow Freud's conceptualization. Fistula thus offers stark and shameful evidence that the promise of biomedicine remains deeply stratified across time and place. While much of the West has marched brashly into the 21st century with genetic technologies, plastic surgeries, nanotech, and neuroscience innovations, the developing world is, bodily speaking, still mired in the 19th century. Women who suffer from obstetric fistula have been left behind by modernity.

Embattled Home Fronts

We wish to highlight two additional, related themes emerging from our inquiry, both of which deepen our account of "disability" and "trauma." First, the theme of home binds these two sites of exploration. In both instances, the disabling effects of the conditions are linked to the lack of control over something deemed external to the domestic and tranquil. Home thus becomes a site of "normalization" against which pathology is defined. Yet, at the same time, damaged bodies starkly confront these definitions of home, thus changing them and disrupting notions of the tranquil. Injured soldiers who leave active duty, as a result of TBI or not, often return home with damage that extends the temporal and existential reach of the traumatic event and may be physically and socially disabling. The "trauma" of TBI is ongoing: both in how the brain is understood to react organically to an original blast or impact, and in how events associated with TBI are carried through a veteran's everyday life following the event and are deemed traumatic.

At Fort Carson, Colorado, for example, nine current or former members of the Fourth Brigade Combat Team killed someone or were accused of killing someone between 2005 and 2008, in a widely reported and dissected case (Smith 2009). During the same period, the incidence of violence against women, including sexual assaults and domestic violence, increased. The Fort Carson home front may not be the safe haven one would hope for. Reporting in the New York Times, Alvarez and Frosch (2009) write that Fort Carson soldiers were charged with 57 cases of domestic violence in 2006. By mid-December 2008, that number had nearly tripled to 145, allegedly due to TBI, which is linked to "inappropriate aggression" in the biomedical and popular literature. In Fort Carson, this aggression was directed towards wives, girlfriends, and other women in the area. Rape and sexual assault cases tripled between 2006 and 2008.

Female partners, and women in general, are subjected to consequences of TBI-induced changes in behavior in the mostly-male victims of TBI—a kind of bimodal gendered suffering that builds on and contributes to legacies of militarized violence (Enloe 1988, 2000). 5 Thus, women are often secondary or "collateral" victims of violence passed through their partner's combat experiences and related injuries. The behavior of men who suffer TBI and then go on to commit acts of violence brings together trauma, violence, health, and gender. Medical sociologists and feminists have long investigated the social sources of disparity in women's health and illness relative to men's (Doyal 1995), and have also understood the role of male violence in causing female injuries and death. 6 The case of TBI and violence against women brings to the fore notions of both intimate and geopolitical trauma. We want to highlight here the extent to which, while brain injuries are inflicted in combat upon a particular (usually male) body, their disabling effects are spread throughout the community in hierarchical ways. While the embodied aspects of TBI may live in and through a man's disrupted body, women disproportionately experience negative social consequences in their vulnerable roles as wives, partners, girlfriends, and acquaintances.

While it is unclear how many soldiers charged with domestic violence and rape suffer from TBI, all the men in the cases noted above had served in theaters of combat, specifically Afghanistan and Iraq, and many had deployed multiple times. With each deployment, with each combat or patrol mission, the greater the opportunity for combat stress, TBI, and later-onset PTSD (La Bash et al., 2009). One therapist who treats Fort Carson soldiers said, regarding combat stress, "'It got to the point I stopped asking if they have deployed, and started asking how many times they have deployed'" (Alvarez and Frosch 2009). Clearly, a major contextual factor is the number of deployments that have been required of U.S. soldiers in the long-running series of conflicts, and the Bush administration's policy of "stop-loss" which extended tours of duty from 12 to 15 or more months for many service members. 7 In addition, leave times were shortened, so that service members would often spend less than a year at home between deployments to Iraq or Afghanistan. Thus, each soldier's likelihood of TBI and other injuries including PTSD is directly related to the overall number of U.S. service members available for any given conflict and on the bruising cycle of deployment and rest.

In comparison to men who return home (and then perhaps harm those who have welcomed them home), for women with obstetric fistula home is often relentlessly denied. Women are expelled from their homes when their (gendered) bodies "fail", and they become isolated or quarantined with other sufferers. They are abject. Even women who undergo reparative surgery may continue to experience stigma and social isolation stemming from their fistula, and the lingering implications of sexually transmitted disease and reproductive failure. Severed from their families, husbands, and villages or communities, grieving the loss of a baby, many of these women continue to suffer from malnutrition and poverty, regardless of the degree to which surgical intervention is successful.

Deficits in provision of health care also bind these cases, and reveal institutional disavowals of corporeal damage. It has been well documented that screening for traumatic brain injury and related PTSD has been inconsistent. For example, Army physicians were reportedly pressured not to diagnose cases of PTSD, in large part to reduce benefits entitled to injured soldiers thereby saving the military money (Benjamin and de Yoanna 2009b; de Yoanna and Benjamin 2009). Physicians were allegedly advised to diagnosis "adjustment disorder", a condition for which disability payments are not provided. According to David Rudd (quoted in de Yoanna and Benjamin 2009), former Army psychologist and chairman of Texas Tech's psychology department,

Each diagnosis is an acknowledgement that psychiatric casualties are a huge price tag of this war…It is easiest to dismiss these casualties because you can't see the wounds. If they change the diagnosis they can dismiss you at a substantially decreased rate.

In addition, because many injured soldiers were not being screened for TBI or diagnosed accurately, fewer cases were recorded. Even when cases of TBI were reported and soldiers began treatment, few resources awaited them; this was especially the case in the early years of the current conflicts in Afghanistan and Iraq. Their treatment (or lack thereof) is part of an overall deficiency in veterans care in the United States, recently documented in news media such as Dana Priest's Pulitzer Prize-winning coverage in the Washington Post and in Salon throughout 2007.

As noted above, women with obstetric fistula may lose their babies in childbirth and suffer social isolation, malnutrition, and ongoing pain due to a lack of basic medical care. Indeed, these very consequences are also risk factors for fistula, suggesting a brutal cycle of structural violence against women's bodies. Thus, a fundamental cause of such fistulas, and of continued violence exhibited by those with mental health symptoms of TBI, is a yawning gap in reliable health care. We do not want to conflate the immense challenges faced by "third world" women with obstetric fistula to those of more privileged Western men without access to long-term psychological treatment following TBI—yet both conditions are heavily stigmatized (Benjamin and de Yoanna 2009a) and both reveal a disheartening lack of social support.

Gender plays an important role here, shaping divergent meanings of stigma (Goffman 1963). The female body disrupted by fistula violates gender norms of maternity, purity, and cleanliness, and women are "disabled" and shunned. TBI, particularly its psychological consequences, is stigmatized for "tough guys" in the military, many of who never consider seeking care. A major component of stigma for health conditions connects these issues to heteronormative notions of masculinity and femininity. For example, at Fort Carson, a mock Army document asked soldiers who were seeking mental health treatment related to TBI, PTSD, and other conditions to pick an explanation for their "Hurt Feelings": "I am a pussy," "I am a queer," and "I want my mommy" were among the choices offered (Benjamin and de Yoanna 2009a). Together with mental health problems, being (seen as) gay or lesbian and/or being a woman in the military may be defined and experienced as stigmatizing and demasculinizing.

Recognizing the constructed nature of "illness," "disability," and "trauma," we pose this question: how do we simultaneously take care of brain-injured soldiers, both men and women, repair women and girls who are assaulted by combat veterans, and protect all women and children from violence perpetrated by men? How might disability studies, with its focus on environmental accommodations that remove obstacles to mobility, deal with such embodied mental health conditions as TBI and material consequences for those who suffer? The "trauma" of TBI and obstetric fistula extends through time in a way that is commonly overlooked in both trauma studies and disability studies—the "event" is multiple, and lasts longer than the "disabling" or "traumatic" incident itself. The impact of trauma, then, can be both personally stigmatizing and socially dangerous. Traumatic events, such as brain injuries, are inscribed and re-inscribed upon the body, changing (some) bodies and lives, as an original trauma takes on new meanings in different contexts and at different levels of analysis. Thus, the intersection of critical trauma studies and disability studies moves us beyond stigma and its necessary amelioration and beyond curb cuts to a broader recognition of the temporal and socio-historical aspects (e.g., geopolitics, social suffering, lack of adequate health care, social and economic injustice) that are instantiated through the categories of disability and trauma and the classifications of people into these categories.

Conclusions

We have attempted to show here that critical trauma studies and disability studies might usefully engage one another. Beginning with the not-unproblematic notion that traumatic events may cause disability and that disabilities are often perceived as traumatic, we suggest that a helpful starting place might be cultural meanings of and made by trauma and disability. While both critical trauma studies and disability studies attend to context and social structure, much of the work in disability studies has been to use context to explain the stigmatized meanings of disability, particular the body configured as "pathological." Ironically, while the field has worked to expunge definitions of abnormal from the body, a conceptual focus on stigma still keeps the disabled body in view in order to question the assumptions of the normal body. It is in this way that disability studies also functions as a normalizing discourse or, at the very least, engages in theoretical gestures that may reinscribe a norm. Yet in these framings, the wounds, impairment, and pain are conceptually erased, and the object of analysis is an individual being, whose now-disabled body is socially constructed (not material) and whose agency is posited as being in struggle and resistance against the normative culture.

We propose, in contrast, that the body itself is a link between the categories of "disability" and "trauma" and the fields of inquiry we name here. By refocusing our lens on wounding, as in TBI and obstetric fistula, we are not arguing for an inherent, "natural" meaning of the disrupted body. Meanings of breach and disruption are always contextual. We are arguing for a materialist understanding of breach, for a notion of the organic, fleshy body as it is damaged, sometimes profoundly, in its operations of life. We are interested not just in disability, or how disabled bodies accrue meaning, or how disabled people navigate unhelpful environments; we are also, perhaps primarily, interested in the larger social forces that produce "trauma", that damage bodies, and that continue to shape what the traumatized body read as "disabled" can be and do. That is, we are interested in the politics, cultures, histories, economies, policies, and conflicts that "traumatize" and "disable" human beings at the level of the body, through lived experiences, and in social settings.

Thus, we want to argue that while a focus on the individual body, such as the veteran with TBI or the poor woman with obstetric fistula, may advance our thinking about disability in context, a focus on the collective allows us to reframe these individual harms in terms of social and cultural trauma. War, infant death, maternal morbidity and mortality, sexual violence, poverty, hunger—these are all social traumas, in which individual, embodied suffering represents massive collective failures. The "traumatized" soldier is the distressed military is the embattled (rather than victorious) nation; the "disabled" woman is the fractured family is the nation in severe geopolitical decline, the so-called failed state. In advancing this argument, we are actually advocating for a more intensive look at wounds and wounding, not to lodge our explanatory frameworks in the body, but rather to use these "signature wounds" to tell stories about the social conditions that produce them. These wounds, and the wounded bodies they generate, are marked—sometimes horrifically, sometimes invisibly—and they can be examined for clues about the nature of social wounding (Seltzer 1997).

We also want to note a temporal dimension to this wounding, and to the ways in which we may read wounds across various iterations. While disability studies often posits disability as an acute, singular thing, static in time and place, critical trauma studies allows us to examine both pre- and post-wounding conditions and all points in between. For example, TBI and obstetric fistula have a "before" and "after" that are as significant as the wounding event, and perhaps more so. Just as symbolic interactionists theorized notions of careers and trajectories to refer to patients' illnesses and death (Glaser and Strauss 1967), we suggest that the categories of trauma and disability may also be conceived in terms of a trajectory model. The cumulative, fluid nature of traumatic injury and consequent disability indicates that notions of "traumatized" and "disabled" are emergent, changeable across time, and inevitably contested. Examining any point on the trajectory may tell a different yet related story about injured bodies in space and time, and about structural causes and effects.

Finally, we want to offer a prognostic note to accompany our critical analysis of diagnosis. Reduction of stigma, curb cuts, increased accessibility, universal design, the U.S. Americans with Disabilities Act, and other changes resulting from social movements are hugely valuable and have advanced the cause of disability rights. However, we want to ask: What are the curb cuts for social traumas such as war, poverty, and pandemic violence against women? Repairing individual bodies, or working to reduce stigma for bodies that have been injured and/or disabled, does not necessarily create lasting social change. The trauma of wounding, and subsequent physical and social disablement, continues to mark and affect human bodies in devastating ways. Certain types of social traumas—bloody conflicts, empire-building, unattended childbirth, dead babies, broken families, global stratification, gender inequity, hunger, genocide—are not acute, one-time ordeals. These traumas—as illustrated in our analysis of TBI and obstetric fistula—mark and scar certain types of bodies over and over again, deepening structural inequalities. Fixing a woman's torn genitals and reproductive organs will not invariably restore her dignity, her family, her dead child, or even her hope. Repairing the bodily and psychic effects of TBI does nothing to stop war or to end militarized violence against women. In understanding these enduring traumas that are written on and in turn harm the body, we must consider the structural, historical, and geopolitical arrangements that shape human affairs at their most intimate and global levels.

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Endnotes

  1. IEDs are typically 'homemade' of various materials and are used in unconventional warfare, such as the urban fighting that is typical of the Iraq War. Often placed on roads, they target vehicles and pedestrians. Defense Update states, "IEDs can be prepared almost everywhere, with materials that can be acquired from agricultural and medical supplies. The preparation does not require highly technical knowledge."


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  2. See the series archived at http://www.washingtonpost.com/wp-srv/nation/walter-reed/index.html.


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  3. A craniectomy removes a portion of the skull bone in order to allow the brain to swell, limiting further damage.


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  4. Fistula can also result from violent rape, in which the vaginal canal is ruptured by penetration. Peterman and Johnson (2008, 971, emphasis in the original) assert, "Although obstetric fistula has begun to receive attention on the international public health agenda, less attention has been given to traumatic fistula...Women with traumatic fistula may be victims of brutal rape and exposed to a number of other dangers including unwanted pregnancy, sexually transmitted infections (STIs) and psychological hardship." We are profoundly disturbed by these cases as well as intrigued by the framing of rape-induced fistula as traumatic, which certainly is relevant to our argument; however, we limit our discussion here to obstetric fistula for reasons of space. We intend to explore traumatic fistula in other work.


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  5. Of course, the incidence of rape in the military is staggeringly high, with servicewomen at considerable risk from their male comrades (Gibbs 2010; Sadler et al. 2003).


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  6. See Bureau of Justice for statistics on violent crimes against women: http://www.ojp.usdoj.gov/bjs/ibrs.htm.


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  7. The policy began to be phased out in 2009 (Shanker 2009).


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Copyright (c) 2012 Daniel R. Morrison, Monica J. Casper



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