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The experience of labor can evoke memories of early trauma. Learning to listen to survivors is a first step toward creating a safe environment. By Jennifer Burian
Experiences during the intrapartal care of a 17-year-old woman, whose
prenatal record contained an indication of a possible history of sexual
abuse, led to concern about the need to learn to assist survivors during
labor. Although some victims of sexual abuse do not have direct memories
of their experiences, all survivors have certain characteristics in common.
After securing a grant for further exploration of this issue, my co-investigator
and I documented the stories of seven survivors. Our goal was to pull together
common characteristics that would serve as a guide for sensitive care during
labor. While we cannot change what happened to these women, we can hear
their voices, learn from them, and change the way we respond to them in
Stephanie was the young woman whose experiences alerted me to the need for this project. During her labor, induced over a two-day period, her behavior reinforced my concern about an abusive history. Every aspect of her care had to be negotiated and then renegotiated. She could not tolerate being in bed strapped in the monitor belts and was hypervigilant, insisting that vaginal exams be done only when absolutely necessary and then with no more than one finger. The medical staff initially agreed to these requests and honored them. However, staff changed throughout the two days, and patience wore thin. Stephanie's requests were ignored, and she was treated as a hostile child. The most disturbing event occurred early in my shift on the second day. Exhausted from the forceful contractions, Stephanie was crying and asking for an epidural. I explained the need for a vaginal exam, to which she agreed, and I performed it. An attending physician, whom Stephanie had never met before, then entered the room. As Stephanie was still crying and asking for the epidural, he insisted that he needed to examine her, despite the fact that she and I both told him that I had just checked her. I explained to the physician how exams felt safest to Stephanie. He nodded, beginning with one finger, her hand guiding his. Suddenly, however, he grabbed her hand and completed the exam in a forceful manner. I rushed over, held Stephanie, and told her that she was safe and that this would not happen again, but I had lost her. She was sobbing. The bond I had worked so hard to establish had been destroyed.
There seemed to be a clear need to explore the reasons for Stephanie's reactions and alert medical personnel to appropriate responses in the future. A review of the literature indicates that as many as one third of women have been sexually abused, and many enter prenatal care or present in labor with no obvious indications of a troubled past (1-3). Among survivors, however, certain patterns do emerge. Some women have a history of panic attacks or suffer from phobias (1,4). Some engage in self-mutilation (5). Of patients with multiple personality disorder, 97 percent have histories of childhood abuse (6). Survivors may come from foster homes, have lived with stepfathers, and often have histories of running away from home (7). A 1981 study reported that 60 to 70 percent of prostitutes were sexually abused as children (8). Some survivors suffer from depression, manifested by flat affect, poor hygiene, and a lack of concern for their personal appearance (9). (For a guide to symptoms, see Recognizing Sexual Abuse Survivors in Labor.
Our project consisted of interviews with nine women, two health care
providers who worked with survivors, and seven abuse survivors, two of
whom were also health care providers. The seven survivors were either currently
in therapy or had been at some point since their abuse. Their educational
backgrounds ranged from high school to graduate school. Five of the women
were known personally to the investigators, and the others came forward
after learning about the project. Interviews, all private, took place in
locations where the women felt safe, including the investigators' offices
and homes. With the participants' permission, each session was tape-recorded.
It was explained that for this work, names would be deleted and pseudonyms
used. The participants included three members of one family, Martha, Helen,
and their mother Marie. The daughters were not married; both had been abused
by their father. Other participating survivors included Jean, a married
mother of two children; Anna, a single feminist college graduate with no
children; Leila, an obstetric nurse, married with three children, who worked
in a public health setting; and Liz, a maternal-child nurse with three
children. The health care professionals were Diane, a former obstetric
nurse who was working at an agency that assisted pregnant drug-addicted
women, and Moira, a Bradley-method childbirth educator. The two researchers
reviewed transcripts of the interviews in an attempt to identify consistent
themes. The strongest themes were those of disclosure and validation, avoidance
of health care, frequent somatic complaints, issues of control, and dissociation
during medical procedures. Only one respondent described triggered flashbacks,
which are noted frequently in the literature.
All but one of the survivors stated that they would not disclose their histories to health care providers. Telling such a profound secret requires a specific, trusting relationship, as described by Jean:
I would not want this part of my medical record. No. It would be terrible to me. I think people who've been abused really need to have control over who knows and what the circumstances are. It absolutely needs not to be just considered in my best interest to put that out there. Jean suggested that clinicians do not provide a safe climate for disclosure: There was somehow just no feeling, the opening, or the space there, that the sexual abuse was something I could talk about...If she [the RN] would have perhaps said...offered an opening, some little opening, like, "How is this on you? Sometimes this [childbirth] brings up a lot from people's past," or some little of awareness that it could be an issue, I think I would have right away given it...a teeny little opening would have taken it. But I never had the sense there was one. Anna described how she would like to be comforted. I would like to have someone put their arm around me, or something, and say, "I know this must be hard for you today to be here," or something about telling me that I have courage for coming in and having this exam, even. Liz described how she discloses her past now, after having concealed it during the births of her children. See, what you do is you start with a little bit of information, and then you see how the other person responds. If they're willing to listen and take the time, you know that right away in their response. And then, if you feel comfortable with how they respond to you, then you give them more information....I hid it from everyone. I was too ashamed and embarrassed. With the first [baby] and then the second one, I really needed to tell somebody, and when I needed to tell was after I delivered. And the nurses came in very infrequently. And if they would have come in more frequently, they would have seen me crying many times...and there were lots of times when the nurse would close my door at night, and I would just start crying.
Only one respondent said she would want her physician to know she was
a survivor, but, early in the interview, the same woman stated she would
only feel comfortable seeing a female sexual abuse survivor. "That's all.
That's the only way I would feel safe." Liz's comment was instructive:
"I really think it's so important to listen to what's not even being said."
Moira asks those who hire her as a birth attendant if they have a sexual
abuse history. She introduces that question with the following statement:
"Sometimes stuff surfaces during labor, and as a birth assistant, I might
see a panic or fear, or a labor that stalls...and if any of those things
would happen, I would be interested in looking for, emotionally, why they
were happening, and not to blame the woman...." This approach is precarious.
On the one hand, women with a history of abuse feel marked by disclosure
and avoid situations in which it may be forced upon them. On the other,
they seem desperate to share their stories, but cannot find a safe environment
in which to do so. They also have the need to be certain of the listener's
concern. Emotionally safe surroundings are a major issue for survivors.
Several of the women, survivors and health care providers, recommended
these opening remarks: "The birth of a baby can sometimes trigger other
memories in your life..." or "How has this pregnancy affected your physical
and emotional well-being?" Although the woman may respond with a neutral
answer, she may be aware that, should she want to talk, someone will listen.
(See Strategies for Sensitive Care for some general guidelines about establishing
a safe environment.)
Avoidance of Health Care
A common observation revealed during the interviews was how gynecological clinic visits resemble the original abuse. Lying on a table with one's legs in the stirrups, while a stranger places objects into the vagina, is often too much for a survivor to face. Delays are also intolerable, reminding the women of the waiting that was part of the abuse experience (9). The women do not feel safe and may be unable to make clinic appointments, or having made them, to keep them. Anna remarked, "I have to be half dead before I go...a yearly pelvic is about once every three to four years." Survivors report seeking alternative medical care through more holistic providers, such as midwives, nurse practitioners, acupuncturists, and chiropractors. The childbirth educator had a client who avoided a hospital birth altogether, stating that she could not "labor in a hospital with people standing over me, and with the risk that somebody is going to want to do something to me when I'm in a position where I can't explain why I'm uncomfortable." Pregnancy may be one of the first times a survivor forces herself to seek regular, consistent care. It is essential to understand that lying on the examination table or delivery bed while having contact with instruments may reflect the original abuse. Diane stated that for some survivors, "All it took was that first prenatal visit to trigger some of them ...If it did trigger a nightmare or a memory, they are not going to want to experience that again, and will not return." E. Sue Blume, a private therapist who works with incest survivors, suggests that health care providers be aware of the need to share information, power, and decision making during their interactions with survivors (1). She describes a partnership attitude that helps the survivor perceive that she does indeed own her body. Partnership is promoted by involving the woman every step of the way, with the realization that the assumptions of health care providers are sometimes at odds with a woman's true needs. Diane's views expanded on this idea:
Explaining to them, talking to them, asking them how they feel about
it...telling them we know it's uncomfortable, and do you have a problem
with it? And if so, how would you like us to work around that? What would
be most comfortable for you? How would you like this to happen? Would you
like only a woman to do this? Ask them, involve them in it. Nobody's ever
asked them before.
The interviews confirmed the frequent reporting of somatic problems noted in the literature. While survivors try to avoid the health care system, they may have to seek care. Common problems cited in the literature include migraines, neck pain, back pain, abdominal pain, continual vaginal infections, severe dysmenorrhea, and painful intercourse (9). Some women report gastrointestinal disorders or eating disorders. It has been established that patients with chronic pelvic pain, who have no obvious pathology, probably have a history of sexual abuse (10,11). Survivors react with disease at the sites of their abuse (1). Their bodies express what their voices cannot. Martha's experiences with pelvic pain support the need to explore this problem and treat women with sensitivity.
The doctor I have for gynecology, as I've told you, for awhile, didn't want to investigate the pain. She just thought having the birth control, it would be cured. And I was still having the pain and I was telling her about it; she didn't want to do anything....Immediately after I went out of that doctor's office, I cried. Because I knew there was something wrong and it's like, why can't somebody see that I'm in pain? ...hear my voice, hear me! Just don't say, "Oh, there's nothing wrong with you," and "It's all in your head," and everything else. What I feel in my body is because of my head, because of the abuse I've been going through.
Two of the respondents, who had been forced to have oral sex, suffer
from sporadic jaw, neck, and throat problems, symptoms also corroborated
in the literature. These women fear going to the dentist, gag easily, and
vomit spontaneously. Helen described her experiences: I was gaggy all the
time. I kept gagging. I gag easily. I can't stand to have anything put
in my mouth. I can't stand throat cultures or going to the dentist. I was
so scared of the gynecologist. I had eaten before I went, thinking I would
feel better if I didn't have an empty stomach. When she did the breast
examination, I threw up. I didn't think it was possible for me to do that,
and I was so ashamed. Fear of falling asleep, difficulty falling asleep,
nightmares, and early awakening are common, resulting in continual fatigue
for survivors. Most abuse for these women took place during the night.
As children, they would be awakened in their beds and did not find nighttime
to be a safe time.
Issues of Control
Sexual abuse is about control and power by a stronger person. In addition to the horror of the sexual trauma, victims of child abuse experience total loss of control, violation of trust, and the crossing of important boundaries (1). Survivors learn that to lose control is dangerous, both physically and emotionally, and structure their lives so that they regain feelings of strength. They do not consider compromise. Sexual abuse is about control and power by a stronger person.
The subject of control was the single most important issue revealed in the interviews. The interviews corroborated four ways in which survivors retain control, as indicated in the literature: through aggression, submission, ritual, and living in a state of crisis. Some survivors are bossy, aggressive, and behave in socially unacceptable ways, daring anyone to criticize them (2). Jean remembered one incident:
I tried to hang onto control up until the point where I was going in to the c-section thing, and then I gave up pretending to have control and that was fine. It felt awful, but it felt better than pretending. That was the point where I really started screaming. They wheeled me down the hall, screaming my head off.
Others adopt a passive demeanor, remaining soft-spoken or even nonverbal (2). They may have difficulty mobilizing support or recognizing and asking for what they need. Jean went on: I recognize that the strategy I'd opted for coping with the situation was the strategy I adopted for coping with when I was being abused. That the most pro-survival thing I would come up with was to cooperate. So I cooperated to the best of my goddamned ability.
Some survivors gain control by regulating every second and trying to
do the same with those around them. Routine is critical; these women must
keep to their agendas (2). The labor process, with its continually changing
tempo and timetable, can therefore be frustrating and frightening. Some
women present nurses with multipaged single-spaced birth plans containing
rules for the labor and delivery. These may be the first indication of
a possible history of abuse, and it is therefore important to avoid responding
defensively. Honoring the woman's needs will allow her ownership of her
labor, birth experience, and, above all, her body. Some women maintain
control of the situation by creating an atmosphere of chaos. This behavior
forces those around them to drop what they're doing to respond to the latest
The women repeatedly described dissociation as their primary coping response. This process -- feeling numb, not part of one's own body -- helped them to survive the sexual abuse, permitting them to avoid the full experience of physical and emotional pain (12). Dissociation as a coping response is carried forward to the present and used when emotional or physical pain begins to resemble the pain experienced during the abuse. Jean recalled feeling "like I was up in the ceiling watching everything at that point. But it was still better than pretending...." Leila stated:
You know, I never related birth as a really sexual type experience until that time [the third birth]. I could really take myself out of it before, with the first two, I could remove myself....I think the bottom half of my body was gone somewhere else...and the nurses were just, you know, "this woman is just marvelous! She doesn't feel pain...." You know, during labor and pushing, or anything, they [said], "You're such a good patient!"
As nurses, we cannot "just let them go." We can acknowledge the survivor's
pain and where she is, while helping her back and touching her gently,
to ground her in the present. Clear verbal directions, leading her to focus
on the room where she is and the purpose of the procedure, may also help
to guide her back (13). Moira recommends "getting them up and moving, because
when they're up and moving, they can respond to what their body is feeling."
Most important, survivors need repeated assurance that they are safe. The
issue of touching in the health care setting must be addressed. It is important
not to be put off if the woman pulls back slightly or recoils when touched.
Her experiences may be limited to feelings of sexual exploitation, being
out of control, and situations of terror. Repeated bouts of physical pain
and unwanted touch may have left her fearful, certain that the touch is
not for her benefit but for the benefit of the other (12). The health care
professionals who participated in the study addressed this issue: "Touch
is such an important piece for these women, because for the most part,
they've never been touched in a kind way" and "She gave the midwife some
pretty specific directions. She wanted no perineal massage, no perineal
support, and she didn't want anybody around her perineum when she was birthing
that baby." (14) is an important source for those working in obstetric/gynecological
settings. It describes the ritual of the vaginal examination and provides
specific suggestions. It is not written specifically for victims of abuse.)
A significant response reported in the literature is a flashback to
experiences of abuse, triggered, perhaps, by being touched on the sexual
organs or being in a particular position, or even by where the caregiver
is positioned (13). A smell, sound, sensation, or the personality of the
caregiver may trigger a frightening flashback. Only one respondent reported
having them. Reactions to flashbacks may consist of a sudden look of panic
across the face, rigidity, or a significant change in breathing (13). How
should a health care professional respond? It is important to let the woman
know that she is safe. Ask her to describe what she is feeling and what
would help her feel safe again. She may be unaware of what has happened
to her. Childbirth educator Penny Simkin recommends asking laboring women,
"Can you tell me what was going through your head during that contraction?"
The response may vary, from a visual picture, to a specific flashback,
to the inability or refusal to answer, which is often the most telling
answer of all. Simkin suggests reframing a violent image into a gentle
one. "It's feeling like a knife is scraping the inside of my vagina" can
be changed to the image of a smooth silver spoon, rounded and cool, and
these words can be repeated during the contractions (13). Also useful are
relaxation techniques to assist in controlling and breaking the anxiety
of the flashback. It is a privilege to care for women and their families.
We do it day in and day out, so many times over that it becomes second
nature. However, if a woman with a history of incest or sexual trauma comes
for prenatal care or to the labor room, she may manifest deeper needs than
are at first evident. On edge and hypervigilant, she is suspicious of our
intent, our knowledge, and what we might do to her. She'll test us repeatedly
to discern if we are that person with whom she can finally feel safe. Our
primary job is to help her lower the protective wall that she has built
over the years and connect on some level that will allow a small beginning
of trust. I am grateful to the women who shared their stories. They opened
the way to the development of some strategies for making childbirth a positive
event within the context of frightening histories.
RECOGNIZING SEXUAL ABUSE SURVIVORS IN LABOR
STRATEGIES FOR SENSITIVE CARE
Jennifer Burian, RN, BSN, is a labor and delivery nurse at Meriter Hospital, Madison, Wisconsin. The project described in this article was funded by the Perinatal Foundation, Wisconsin Association for Perinatal Care, Madison. The author gratefully acknowledges Sara Williams, RN, MSN, clinical nurse specialist at Meriter Hospital, who served as co-investigator on the project.
REFERENCES 1. Blume, E.S. Secret Survivors: Uncovering Incest and Its Aftereffects in Women. New York, Ballantine Books, 1989. 2. Morrison, J. A Safe Place: Beyond Sexual Abuse. Wheaton, IL, H. Shaw Publishers, 1990. 3. Leventhal, J.M. Have there been changes in the epidemiology of sexual abuse of children during the 20th century? Pediatrics 82:766-773, 1988. 4. Bass, E., and Davis, L. The Courage To Heal: A Guide for Women Survivors of Child Sexual Abuse. New York, Harper & Row, 1988. 5. Shapiro, S. Self-mutilation and self-blame in incest victims. Am.J.Psychother. 41:46-54, Jan. 1987 6. Putnam, F.W., and others. The clinical phenomenology of multiple personality disorder: review of 100 cases. J.Clin.Psychiatry 47:285-293, June 1986 7. Feldman, W., and others. Is childhood sexual abuse really increasing in prevalence? An analysis of the evidence. Pediatrics 88:29-33, July 1991. 8. Silbert, M.H. Sexual child abuse as an antecedent to prostitution. Child Abuse and Neglect 5:407-411, 1981. 9. Courtois, C.A. Healing the Incest Wound: Adult Survivors in Therapy. New York, W.W. Norton, 1988. 10. Hall, R.C., and others. Sexual abuse in patients with anorexia nervosa and bulimia. Psychosomatics 30:73-79, Winter 1989. 11. Rapkin, A.J., and others. History of physical and sexual abuse in women with chronic pelvic pain. Obstet.Gynecol. 76:92-96, July 1990. 12. Maltz, W., and Homan, B. Incest and Sexuality: A Guide to Understanding and Healing. Lexington, MA, Lexington Books, 1987. 13. Simkin, P. Sexual Abuse and How It Relates to Laboring Women. Taped lecture. Midwifery Today, P.O. Box 2672, Eugene, OR 97402. 14. Bergstrom, L. and others. You'll feel me touching you, sweetie: vaginal examinations during the second stage of labor. Birth19:10-18, Mar. 1992.
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