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Inclusive Classes: Maintaining a safe space for the survivors of sexual abuse.

Guest post by Ngozi D. Tibbs BS, CD, LCCE, IBCLC

Some days I find it hard to watch the news. We are bombarded by stories of child neglect and abuse. The stories that are particularly disturbing involve sexual abuse.  It causes one to wonder, is sexual abuse occurring more often, or is it the reporting of sexual abuse that has increased? Whatever the reasons, the stories appear to be everywhere.  I, who like you, care about families, am disturbed by the reality that children are not being protected. We have heard recently in the media where coaches, teachers, trusted neighbors and clergy are sexually abusing our children.  Scary movies are about running from the boogeyman. What happens if the boogeyman lives in your house and comes to your room every night? What if he is your father, brother, uncle or babysitter?

Our daughters and sons who survive sexual abuse grow up broken and scarred.  Trust has been stolen and shame is internalized.  Children grow into adults and many adults become parents. How do we help our mothers who come to us for guidance and support as they navigate through the sacred experience of birth?

Penny Simkin writes:

“One in four, one in three, or one in five? Who knows the actual frequency of childhood sexual abuse in our society? All we really know is that it is shockingly common, meaning that many women in midwifery or obstetric practice or in a childbirth education class are burdened with the psychosocial after effects of victimization”.

“Surprisingly, with all the sexual connotations of pregnancy, birth, and breastfeeding, virtually nothing is published in the social science or medical literature on the possible effects of childhood sexual abuse on later childrearing. Even mental health publications have failed to address this grave issue. Eating disorders, chronic pelvic pain, severe premenstrual syndrome, sexual dysfunction, various phobias and other psychosomatic disorders are known to be associated with childhood sexual abuse, but what about disorders in childrearing?” 

(Simkin, 1992, 2006)

Asking a woman directly regarding being a sexual abuse survivor is not the best approach. We must be sensitive to her desire to keep that part of her life hidden; or in some cases, a woman may not even have conscious memory of abuse (Simkin, 1992, 2006). According to Simkin and Klaus, (2004), a few symptoms that are common to survivors (but not necessarily to all) are:

  • Fears of male caregivers (or in some cases female)
  • Vaginal exams as instruments of rape
  • Nakedness or modesty issues
  • Excessive pain and tension
  • Passivity, submission, or the “easy, good patient”
  • Lack of cooperation with staff, pushing positions
  • Dependency on partner, doula, caregiver
  • Fears, repugnance of blood, secretions
  • Fear of the unknown
  • Dissociation

In a childbirth education class, we may notice the woman who is, perhaps, very uncomfortable with lying on a mat on the floor in front of strangers, or having her support person touch her in front of others. When we introduce ourselves at the beginning of class, we should also include that all of the activities are optional and no one should feel obligated to do them if not comfortable.  Comfort techniques can be practiced at home. We should also remind our participants that we are available to discuss things privately if they so choose. We can also provide a box in the front of the room for participants to write down their questions. This can be a wonderful, non-threatening anonymous way for women to share their concerns.  If appropriate, those questions can be brought to the class for further discussion.

We should familiarize ourselves with local resources, which would include support groups, mental health professionals and women’s shelters. We can keep a resource list on a table in the front of class which can include additional resources such as where to purchase baby slings, nursing bras etc… as to not single out the issue of abuse. We may have women in our classes who are not only survivors of childhood sexual abuse but who are currently in an abusive relationship. It is within the scope of the childbirth educator or doula to connect her with community resources.

In our classes, we can find creative ways to address our understanding of this issue by weaving it into our curriculum when we discuss different comfort techniques. We can be careful to use language that is more inclusive and sensitive such as “partner” or “support person” not “coach”.  Phrases such as “listen to your body” or “surrender to your body” can be triggering (Simkin, 1992, 2006).  It is understandable that pain in labor can cause feelings of being out of control or evoke feelings that something is wrong.  Maintaining control and feeling safe are important to all mothers in labor, but especially for the survivor. As Doulas, when we help a mother write her birth plan or birth wishes, we should be mindful of those words or procedures that may involve surrendering control to others. We can help a woman regain some of the sense of control by encouraging her to express her needs in language that feels safe to her.

As I prepare to teach at my local hospital this spring, I have consulted my thesaurus to find different ways to say common words. For example, one survivor shared her discomfort with the word “contraction”. It reminded her of the physical sexual abuse pain she suffered. Often following an assault, she was plagued by a “knot” in her stomach and a strong presence of nausea. Sometimes she would even vomit.  As a result, she had grown up with a “nervous stomach” and suffered abdominal pain for many years. As her Doula, she preferred I use words such as “intensity”, “strength” and “rushes” to describe the feeling of the contraction.

As educators, we should familiarize ourselves with respected books and articles on the subject of abuse. Our mothers are looking to us for guidance and support. We may be the only person in the room who understands her needs.  April is National Sexual Violence Awareness Month. Let’s do our part by becoming advocates for children, mothers and families.

Sources:

  • Simkin, P. (1992, 2006) Birth 19(4). Excerpts adapted from When Survivors Give Birth Workshop February 2012.

Some valuable books on the subject:

  • Simkin, P., Klaus, P. (2004). When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women. Seattle: Classic Day Publishing.
  • Sperlich, M., Seng, J. (2008). Surivior Moms: Women’s Stories of Birthing, Mothering and Healing after Sexual Abuse  Eugene: OR.  Motherbaby Press.

National  Resources:

 Ngozi is a Doula, LCCE, and Lactation Consultant in Pennsylvania.

Childbirth Education, Do No Harm, Guest Posts, informed Consent , , , , ,

  1. avatar
    Tresa
    February 27th, 2012 at 15:55 | #1

    I have found that many nurses blow this subject off and continue to try to force their beliefs onto their patients. One subject that I find very difficult for me is breastfeeding and the sexual abuse pt. I believe that many sexual abuse pts are not comfortable with breastfeeding but the policies of the hospital are to be “baby friendly” and try to convince pts that they need to breastfeed. One hospital that I worked for went as far as locking up the formula and throwing away the pasifire’s. What resources do you have or can suggest in the appropriate way to deal with breastfeeding and the sexual abuse pt? I know that I was forced to attempt to breastfeed after I delivered my baby and it was a horrific experiance for me…..I DO NOT want to do that to my patients. Please Help

  2. February 28th, 2012 at 15:11 | #2

    I’m sorry your own experience learning to breastfeed was “horrific”. Learning to breastfeed is a challenge for many women.

    The WHO’s Baby Friendly Hospital initiative is intended to encourage breastfeeding, not to be stifling or restrictive. The formula is locked away, and treated the same way medications are treated in the hospital – to keep an accurate count of how much formula is being used, and to whom it has been given. This is in accordance with step 6 of the 10 steps to being Baby Friendly “6 – Give newborn infants no food or drink other than breastmilk, unless medically indicated.”

    It is the same with pacifiers: “9 – Give no pacifiers or artificial nipples to breastfeeding infants.

    More about Baby Friendly here: http://www.babyfriendlyusa.org/

    I agree, breastfeeding can be a trigger for sexually abused women. This needs to be respected by both the childbirth educator, prenatally, and the hospital staff, postpartum. As such, we should work to minimize additional traumatization to the mother. No one can, or should be forced to breastfeed. However, all women need to have a basic education about the health benefits of breastfeeding to both her infant and to herself, so that she may make an informed choice whether or not to breastfeed.

    Some resources: Breastfeeding and the Sexual Abuse Survivor
    http://www.domesticviolenceservices.com/breastfeeding-abusesurvivor.html

  3. avatar
    Ngozi
    February 28th, 2012 at 22:36 | #3

    Great points both of you. I too understand that breastfeeding can be challenging for some survivors. Dr. Kathleen Kendall-Tacket wrote a very informative article on the subject in the Journal of Human Lactation Vol. 14 in 1998. In this article she discusses how nighttime feedings may be difficult for a survivor if her abuse occured at night. For others, nursing in bed could be triggering. For some, when the babies become toddlers and play at the breast memories can be triggered. Each nurse, Childbirth Educator, Birth Doula, Lactation Consultant and Postpartum Doula should first practice the art of listening when serving mothers. Listen for language that could indicate the need for extra special care and sensitivity in regards to breastfeeding. a mother should never feel as though she is being talked into breastfeeding or “pushed” into it. Yes, we know that breastfeeding is the healthiest way to feed our babies. At the same time, we must recognize that our role is to listen, inform and support. For some survivors, breastfeeding is painful emotionally and causes great distress for the mother. Exclusive pumping and/or formula feeding may be best in that situation. Our role is not to be so pro breastfeeding that we miss a mother’s true needs to heal and feed her baby in the manner that feels best for her.

  4. avatar
    Ngozi
    February 28th, 2012 at 22:39 | #4

    @Tresa
    Tresa, let me also add that I am sorry you had that negative experience breastfeeding.

  5. March 1st, 2012 at 08:46 | #5

    Hi – I want to start out saying that I think this is a great topic to raise awareness about the needs of sexually abused women and birthing. I provide specialized classes for persons needing special attention in pregnancy & birth, such as those persons with traumatic histories or chronic pain.
    But, I am a bit confused by the comments chosen for inclusion in this article. I first want to say that I love Ms. Simkin and last went to one of her workshops at PSI’s annual conference last September. She is wonderful.
    Perhaps the quote is taken out of context?

    In mental health literature, it is well-known and well-researched that any personal trauma, including sexual, physical & substance abuse trauma is subject to intergenerational transmission. There are numerous books on this topic and upmtten research articles on the transmission of abuse from generation to generation. In the field of mental health, in such areas (to name only a few)as clinical practice, object relations theory and practical parenting classes, it is well known and clearly addressed that a person’s unhealed childhood wounds influence their childrearing/parenting practices. So, I am not sure where the lack of research is here.
    Thanks for the article!

  6. avatar
    Ngozi
    March 3rd, 2012 at 13:34 | #6

    @Kathy Morelli, LPC (@KathyAMorelli)
    Hi Kathy, the quote from Penny was an older one from many years ago but was included in the booklet for When Survivors Give Birth Workshop. I still believe there are few resources available for childbearing women who are survivors. Yes, there is more written about the subject but not as much as should be written regarding this special time in a woman’s life.

  1. March 7th, 2012 at 21:14 | #1
  2. September 16th, 2013 at 18:02 | #2