Keywords

1 Introduction

Sexual abuse can affect various areas of a person’s life. One area is motherhood, with related factors like the decision to have a child, getting pregnant, pregnancy experience, delivery, and the postpartum period. In this chapter, we want to present how these areas may be related to the plight of women who have experienced the trauma of sexual abuse. Many aspects of this trauma are comparable to physical and emotional abuse. First, we theoretically explain how memories can affect the present, and then, based on clinical experience with sexually abused clients, we highlight the importance of the facts that should be known to anyone who encounters survivors in their work. Finally, we will add for health care professionals (HCPs) statements of women who shared what would be the most soothing to hear, with examples of specific sentences for HCPs to help promote emotional security and positive experiences.

2 Before Pregnancy: Pondering Motherhood and Making the Decision to Have a Child

A decision to have a child is undoubtedly one that calls for the highest degree of responsibility, as when one becomes a parent, one remains a father or mother for the rest of one’s life.

Even without a traumatic past, the decision to have a child can awaken various feelings, from excitement, joy, anticipation, and longing to all sorts of fears, doubts, insecurities, and anxieties. These emotional oscillations and adversities can be even more pronounced in women who have experienced sexual abuse. Eventually, they can even lead to re-traumatisation, should memories of sexual abuse be awakened. It is important to emphasise that sexual abuse includes not only sexual violence but also acts that do not involve physical violence and can accompany touching and caressing. The consequences can be similar for sexual abuse that occurs without touch, such as showing pornography, nudity, and masturbation. The main purpose of the perpetrator is sexual arousal, but most of the time, the primary motivation for abuse and sexual gratification is a feeling of dominance, power, control, or even revenge. The victim feels humiliated, ashamed, and guilty because their most intimate boundaries have been violated [1]. Clinical experience shows that victims of physical or psychological violence can experience similar feelings, but in sexual abuse, there tends to be even more disgust and shame. Although the perpetrators are more often men, women are not excluded. When the sexual abuser is a woman, the abuse is often more hidden under the guise of caring for and nurturing the child, and it can leave even deeper wounds.

For the sexually abused woman, even the thoughts about having a child, conceiving, or already being pregnant are often full of distress and questions about whether she will be a good mother or able to protect the child from abuse in a life that is full of suffering, whether she will be able to take care of, play with, emotionally feel, and comfort the child. Sexual activity can also be a problem in the sense that she does not want it, rejects it, and feels repulsion at the very thought of natural conception, so some women opt for alternative forms of fertilisation that do not involve sexual intercourse or even for adoption (Simkin and Klaus, 2004). In clinical practice, abused women often express fears about the child’s gender. Some are afraid of having a female child because they project their childhood feelings of helplessness and being abused on their potential daughter [2]. Others fear that a boy growing in their body will awaken memories of the perpetrator, who was also male and that they might not be able to love the boy-child enough [3]. The fear of conceiving and having a child is even worse if the woman has previously experienced one or more abortions or has not been able to conceive, which can raise the worry of being infertile.

On the other hand, many sexually abused women consciously choose rather never to become a mother than expose the child to such a horrible childhood as they have had and are unwilling to take risks. Some even go so far as to consider sterilisation [2].

Important Notes

Never judge. Do not try to convince the woman that, in your opinion, her thoughts or actions are wrong. Let her express her concerns, feelings, and fears and show compassion.

3 Pregnancy in a Woman with a History of Sexual Abuse

Pregnancy can be a trigger that may make a woman aware of her experience of sexual abuse for the first time [4]. Even if she does not remember it, her body has memorised this experience and can, during pregnancy, start ‘talking’ very loudly about that experience. Research shows that, after sexual abuse, pregnant women are more likely to report depression and PTSD symptoms, think more about suicide, have more health problems (high blood pressure, vomiting, pelvic pain, bleeding), and are more likely to be hospitalised [3].

On the other hand, some pregnant women with childhood abuse history can almost wholly disconnect from their bodies, especially from the waist down, to the point that they do not feel the child’s movements. That is a defensive dissociation or physical numbness that once served to protect her from the horrors and pains of sexual abuse.

Severe distress can also be caused by the changes in her pregnant body (with the growing belly, and enlarged breasts). Many women feel as if something is wrong, feeling dirty or hurt inside. With unstoppable bodily changes, they often experience a loss of control over what is happening to their body [3].

All of a sudden, the woman’s body is more noticeable. As a child, she had to hide every physical sign so that no one would notice that she had been abused. Now, her body has become part of the ‘public arena.’ People feel they are allowed to comment on it or even touch it [5]. which can activate the memory of sexual abuse. The same goes for more frequent vaginal examinations and procedures that interfere with intimacy because her body is being touched. For instance, the position on the gynaecologist’s chair can strongly resemble a sexual abuse situation, with legs apart and the HCP penetrating her vagina with fingers or a clinical instrument. The body has unconsciously memorised the abuse, with sensations that intrusively activate the memory of the trauma, sometimes so disturbing that the woman cannot separate the present from the past. According to clinical practice, the two most common types of responses of women to vaginal examinations are: numbness and freezing because they experience horror and fear and wait for the examination to be over as soon as possible; or they experience ambivalence during these interventions: with on the one hand arousal, and, on the other hand, aversion, disgust, and shame at their bodily responses. Such arousal can be a mixture of physical arousal and explicit sexual arousal. Many women try to avoid vaginal examination because of these problematic effects or visit the gynaecologist or midwife only late in pregnancy.

The HCP must be professional and sensitive, as the woman is even more susceptible to any touch and procedure related to her femininity and her body [6].

If the woman smokes and consumes alcohol or other drugs that she discontinues during pregnancy because she wants to take care of herself and the baby, this can trigger unpredictable stress. These activities often protect her from painful feelings related to sexual abuse and serve to release internal tension. With the loss of these defence mechanisms, repressed memories and emotions can surface, leading to severe anxiety [3].

Clinical experience shows that distress and anxiety are even more intense when an unplanned pregnancy occurs due to unprotected sex or rape. In the case of the former, the woman can experience pregnancy as another abuse or punishment imposed on her by the child’s father, society, or God. Thus, they re-experience the feelings of being a victim, helpless, and unable to control their own destiny [3].

As a result, some women choose to terminate the pregnancy, which often brings forth feelings of guilt, either immediately or later, even after several years. In most cases, the man is exempt from decision-making, and she is the only one to choose what to do.

If pregnancy results from rape, it is extra difficult to decide whether or not to keep the child or give up the child for adoption immediately after the birth. In this case, in addition to the trauma of rape, the woman is struggling with an accidental pregnancy, and she questions herself about what to do.

She can quickly see herself as a criminal if she does not accept the child. However, if she accepts the child (due to the pressure of those around her or religious beliefs), the child will remind her all her life of the rape. And she will find it difficult to accept the child or develop a negative attitude towards the child because the progenitor was sexually violent. It was by no means her fault that this had happened to her.

Important Notes

  • In the case of rape or otherwise unplanned and unintended pregnancy, it is imperative that regardless of the decision whether to keep the child or not, you do not blame the abused woman; allow her to say what she feels, what makes her calmer and gives her a sense of security. Avoid WHY-questions, as they always bring about even more guilt than the traumatised person already bears. Many decisions would undoubtedly change if, in such crises, a woman had at least one compassionate, supportive relationship in her life.

  • Even if you do not understand the triggers that arouse the memories of abuse, take all her feelings seriously, stay calm, and tell the pregnant woman that she is safe now, that the abuse is just waking up and not happening anymore, and give her the opportunity and a safe space to tell whatever worries and bothers her. The fact that she will be able to speak out loud and be heard when expressing her needs will be reassuring.

  • Always ask permission before a vaginal examination.

  • Suppose a pregnant woman confides in you her experience of sexual abuse. In that case, it makes sense to refer her to therapy with a sexual abuse specialist before giving birth and work with her and her partner to make a ‘safe plan’ to ensure that she is as relaxed as possible and that she masters various techniques helpful in childbirth (visualisation, breathing techniques, autogenic training, etc.).

4 Labour

A sense of security is a crucial protective factor that contributes to the course of childbirth. If a woman feels safe and can trust, she will find it much easier to cope with the instructions of the HCPs and with what her body tells her. Abused women have learned that losing control means physical and emotional danger, so they feel stronger and safer if they have a structure - if they know what will happen during childbirth, how it approximately will develop, what is normal and what to expect.

This information will help the woman take a break from constant worrying, monitoring, and waiting for what will follow. Those worrying feelings are very much related to abuse, where a person learns that she is ‘safer’ if she is constantly alert. On the other hand, a sense of being threatened can lead to extreme behaviour—aggression, subordination, rituals, constant crises, etc. Certainly, childbirth is related to a relatively high degree of unpredictability, where the woman faces the uncertainty about when labour will begin, how long it will last, how much it will hurt, how well she will tolerate the pain, how her body will react, if she will suffer injury, or if complications with the child will occur [3].

Since sexual abuse is always also an abuse of power and trust, sexually abused women are very susceptible to this dynamic. That is why she may experience fear of the medical staff because they represent authority, power, and control, reminding her of the people who abused her. As a result, she often doesn’t dare to share her worries, discomforts, or disagreements, resulting in feeling insignificant and unseen, precisely what she experienced at the abuse. During vaginal exams, she may thus become completely submissive (or aggressive) due to feelings of threat and fear, but when the situation is over and she feels safe again, anger and sadness may arise [5]. In a good relationship, her partner can offer the best support. But the midwife and the doula (if present) play an additional essential role in the feeling of security, as they accompany the woman for the longest time.

That is why the midwife must know how to create a safe atmosphere while carefully monitoring the woman’s reactions. The midwife should be open to a conversation to make the expectant mother feel that abuse is not happening now and that she is safe. More sense of security can be given by the partner or somebody else who knows the fears and feelings of the woman and how to calm her down (since during the abuse, she was alone and nobody protected her and calmed her down). This dual awareness and the ability to distinguish past and present is essential for the expectant mother [7].

Certain body positions, such as lying in bed, can present a problem. Abused women can also be sensitive to words uttered by the staff, as well as painful and escalating contractions, nausea, vomiting, bloody discharge, instinctive responses such as moaning, shaking, grunting, screaming, pelvic dilation, and feeling the baby inside the vagina as they all can awaken the body’s memory of sexual abuse. The woman can be upset due to the changes of staff (unpredictability, lost sense of security) and a darkened room (reminiscent of the room that was dark when the perpetrator came to abuse her). She can react in different ways: with excessive fear and panic or by freezing, becoming rigid and numb. The latter—dissociation—enabled her to endure sexual abuse and distance herself from her body and mind.

This reaction (called freezing) often happens to those victims who experienced severe pain during the abuse. Therefore, it is very likely that these women will experience dissociation even during childbirth, float away without feeling physical pain (because they will freeze, the same as during trauma) and thus unconsciously fight the psychological distress, which can significantly prolong and hinder the course of childbirth. In such moments, it is crucial that the woman stays as much as possible ‘present’ during labour and that the midwife or partner, if he is by her side, ‘calls’ her back with her name and calming words, reassuring her that she is safe and that she can trust that everything will be fine with her body [7].

Fear of a caesarean section (with general anaesthesia) can also cause fear in a woman, particularly the feeling of losing control over her body. However, general anaesthesia makes it for some women easier to cope with childbirth.

Clinical experience shows that fear can also increase due to the thought of possible injuries (perineum, vagina) and the fact that the child will get dirty because they will come out through the part of her body defiled by the penetration of the perpetrator; the woman can experience immense disgust about her genitals. On the other hand, some women report that childbirth was a positive experience, and they experienced a kind of cleansing—as if the fact that they were able to give birth and that the child came out through the same body part where the abuse ‘came in’ the childbirth healed this part of the body’s memory.

On the outside, the reactions described above may seem exaggerated or inappropriate. Although the cause lies in the past, the reactions are triggered in the present. So, emotions and sensations associated with the abuse that flare up when she is supposed to prepare for the child’s arrival can be very stressful. How her partner and the HCPs approach her significantly impacts whether she will feel worthy or re-traumatised.

Important Notes

  • For the care of the mother and child, the woman with a history of sexual abuse will be most helped by the presence of the same staff (as few shifts as possible) who provide emotional security. If they know the possible triggers of sexual abuse, they will recognise the woman’s reactions when her trauma flares up and, therefore, blocks her, increasing stress and panic.

  • If a woman feels it appropriate, she can confide in her experience of sexual abuse. In this case, the staff’s response is essential because it can relax the atmosphere or, conversely, cause dissociation. Stress, anxiety, and fear cause the secretion of epinephrine, norepinephrine, and cortisol, hormones that slow down childbirth. Thus, unconscious mechanisms and fears can prevent the progression of the delivery and lead to otherwise preventable surgeries, causing further potential emotional and physical trauma.

  • Persons present at birth should listen and take into account the potential needs and wishes of the mother, which may be trivial when observed from the outside, but are very important to her. Allow her to express her worst fears and biggest hopes about childbirth (e.g. absence of students at the delivery, no unnecessary vaginal examinations, only as much nudity as is necessary, and the unacceptability of specific touches and positions, even if they are well-intentioned).

  • The key to a sense of security is also that the woman is familiar with the normal course of childbirth, procedures, and interventions and that she has the opportunity to participate in decision-making. She must be assured that her decisions will be respected and taken into account (with the health of the mother and child always coming first). It is wise to talk about all this already during pregnancy.

5 After Childbirth: The Beginning of Motherhood

In therapy, it often turns out that things that may seem most self-evident and natural (such as caring for a child, breastfeeding, washing the baby, putting the baby to sleep, soothing the crying baby) can be powerful triggers for an abused woman, additionally increasing tension and anxiety. A child’s crying can greatly increase a mother’s distress, helplessness, and anxiety because she can be unconsciously reminded of herself crying out loud when a child or calling out in silent cries, begging her closest people to protect her from abuse. On the other hand, embracing and caressing her newborn can be reassuring, as the young mother feels able to soothe her child with her presence, voice, and gazing in the child’s eyes and gains hope that she can succeed in giving her love and being a good mother.

For instance, breastfeeding can trigger a memory of abuse in the maternity hospital soon after birth. Breastfeeding is related not only to the mother’s body but also very strongly to emotions and experiences. If a sexually abused young mother has an aversion [8] to breastfeeding because it may arouse feelings of abuse and remind her body that someone was disrespectful to it, she should be supported as much as possible and not forced to breastfeed at all costs. Even if her body is fully prepared for breastfeeding, her psyche is not necessarily so, and that is why emotional contraindications should also be considered [6]. Clinical experience shows that this happens more often to women whose breasts have been touched by the perpetrator during abuse, perhaps even commented. As a result, she can feel that her milk is ‘dirty’ and therefore unconsciously experience a psychological blockage because she doesn’t want the child to drink from her ‘dirty’ breasts in order ‘not to ‘get the baby dirty’. Sometimes the infant’s gender is also related to the feelings accompanying breastfeeding. When the perpetrator was a male, abused mothers tend to be more relaxed with a daughter than with a son. Then a son can cause associations with breastfeeding a male).

The timeslot for breastfeeding can also be an influencing factor. Breastfeeding can be more peaceful during the day than lying in bed at night. A darkened room can create unpleasant associations with the abuse when going to bed as a child. Then, one should look for a more suitable time, place, and conditions without distress.

Nudity alone, remembering nudity, exposure, and insecurity during abuse, may be too much. In many situations in the maternity hospital, the body is exposed in front of others. That occurs in contact with HCPs during medical check-ups, and especially in case of failure to establish proper breastfeeding. Such failure may be enough to awaken the woman’s shame, especially if milk production doesn’t start properly, which can occur due to all the earlier mentioned distress factors [8].

Motor/vestibular memory of what happened to her breasts during the abuse can awaken. For instance, by being touched by the infant, by herself, and perhaps by a midwife or nurse who wants to help the young mother not yet used to the proper grip. But also by strong, painful sensations in the initial phases of breastfeeding, and she does not know yet whether these are normal. The baby’s constant demands and the noticeable pleasure during sucking can cause some mothers to decide not to continue breastfeeding [3].

Clinical experience shows that in extreme cases, some sexually abused women decide, already before childbirth, to bottle-feed their baby because they want to avoid additional stress.

On the other hand, the hardships associated with breastfeeding can be the reason for dissociation as a defence mechanism—so the woman does not feel her body and breasts as if they do not exist. In this way, she avoids all feelings and sensations while feeding the baby. For some women, this is the only way to breastfeed at all [8].

Another common challenge can be caring for and bathing the child. The necessary washing of the baby’s genitals can awaken the fear that she may somehow violate boundaries. That clearly shows how the mother’s abuse is awakening because the perpetrator has violated her boundaries. If the woman is aware of her sexual abuse, then the fear of her abusing the child is a kind of ‘protection’ that, in most cases, prevents her as a mother from sexually abusing the child. In therapy, some women say that there may be situations where they change, bathe, or breastfeed the baby and feel aroused. Her body tells her that something is happening that is not natural. That can especially happen if she has been sexually abused at the changing table or while bathing and may not even have images in her explicit memory so that she could recall the abuse itself. It is enough that the body remembers the abuse stored in the woman’s organic, implicit memory. So if there is arousal or disgust, it is important that the mother learns to control herself, take her time, and evaluate these feelings. In other words, she must set boundaries for herself, know that her abuse is awakening and that her child deserves pure love. If necessary, she also knows how to withdraw, maybe turn to her partner and talk to him about these feelings if she is not yet able to process them independently [9]. But when that does not work, the mother must seek professional help to process these feelings of abuse (disgust, shame).

Important Notes

  • HCPs should encourage breastfeeding but never force it or even condemn and blame a woman if she cannot overcome her psychological blockages. The baby is better fed with a bottle and without anxiety than breastfed, absorbing the mother’s anxiety with her milk.

  • In case the midwife (or lactation consultant) helps the woman or wants to show her how to facilitate breastfeeding with a certain position or grip, she should ask what the woman prefers: to only verbally tell her what to do (i.e. use the hands-off technique) or also use her hands on the mother’s breast to show her.

  • If the mother’s body responds with arousal, disgust, and fear when changing and caring for the baby, this is usually a sign of an unprocessed experience of sexual abuse. Helping her seek professional help is the right thing to do. Otherwise, the fear and guilt can be severe enough for the mother to start avoiding her baby and consequently feeling that she is a bad mother.

6 Statements of Abused Women

What They Would Like to Tell the HCP to Get the Most Helpful Responses

  1. 1.

    “Don’t judge me, don’t force me verbally if I freeze, start crying, react in a way showing my sadness, shame, and helplessness. Your compassion, calmness, and respect help me feel secure and make it easier to feel that everything will be fine.”

  2. 2.

    “Don’t ask me WHY I’m doing or not doing something because it will only make me feel even more guilty, and it will worsen. Tell me that you are backing me, that I am not alone, that I am ‘here and now’ and that this is only awakening of some feelings that belong to the past.”

  3. 3.

    “If I have a sense of control, if I know what’s going on or what’s going to happen, it’s a lot easier for me, so please explain to me earlier what you’re going to do. It will be very reassuring to hear that everything happening is normal in certain circumstances.”

In moments of distress when memories of abuse are stirred, some of these sentences are most helpful when uttered by the HCP.

Very important: These words must be spoken slowly and calmly! Before you start talking, say the person’s name because it helps disconnect the flow of dissociation, which took her into the past, and recall her back to the present.

  • Ad.1: “_____ (woman’s name), everything is fine… Just look around you and see where you are… You are safe now… Just some past memories have awakened, and your body has reacted. You can cry if it helps you or get angry… Just breathe calmly, deeply, and slowly to get those feelings out of your body. There is nothing wrong with you….

  • Ad.2: “_____ (woman’s name), You are not alone. These feelings that have flooded your body have awakened and are a thing of the past. It’s just the aftershock: the quake is over. Today you are safe, and you can say anything you feel, set a boundary, and have control. I understand. And I feel that it is not easy for you. I’m here with you.”

  • Ad.3: “_____ (woman’s name), you are safe. We will explain everything to you as we go, and your responses are perfectly normal, given the circumstances and what you have experienced. Your body is just responding to a traumatic memory of where you couldn’t have any control. But here, today, you are in control, and you are not alone. We will do everything in our power to make it easier for you, just tell us; and if something bothers you, you can always set a boundary…”.

7 Conclusion

A decision to have a child, pregnancy, give birth, and accept motherhood can be a major challenge for a woman who has experienced sexual abuse. These challenges can awaken painful, repressed memories of trauma and leave a woman with a bitter aftertaste, a sense of guilt, incompetence, pain, and betrayal by her own body. Even though she may consciously not remember the abuse, her body remembered it. No matter what comes to the surface, we should never blame a woman for what happened to her. Despite the many triggers that bring new hardships, it is important to point out that, for some abused women, this period can be one of the most positive experiences in their lives, even a ‘healing’ experience if their partner is understanding and if they are surrounded by professional medical staff who are open to compassion and understanding of their plight. In such safe circumstances, the woman will be able to hear that everything is fine with her, that she is ‘normal’, that her body is doing something right and can carry a new life, give birth, breastfeed, hug, nurture, and raise her child with love. As a result, she will feel stronger and experience more confidence in her body, her growing child, and her ability to mother.