Monday, August 29, 2016

Retraumatization of Sexual Abuse Survivors

I invited Carol Meadows to write this post for me when she posted her opinion on one of our Birth Boot Camp Instructor Facebook groups regarding this subject. Let's start a discussion. The treatment of all pregnant and laboring women is important. Read on!

Pregnancy, labor, and delivery can be difficult and trying times for any pregnant individual. This time can have its ups and downs, it can be difficult to navigate. This is even more true for survivors of sexual violence and abuse. While maternity care, and the practices that it entails, are well intentioned, it can make this time in a survivor's life more difficult.

When Survivors Give Birth, written by Penny Simpkin and Phyllis Klaus, is required reading for Birth Boot Camp Instructors. Although I have been passionate about birth since 2009, preparing for my workshop in 2015 was the first time I had encountered this book. The book is written primarily for caregivers, doulas, childbirth educators etc., but mentions a few times that this book could be used as a reference for survivors as well.  For those who haven't read the book the three points below are important for the understanding of the rest of the blog post.

  • Survivors may have problems with things that are routine maternity care, that they might find it distressing and that these actions can bring back feelings related to their abuse. (Simpkin and Klaus, 31)
  • How an individual in labor is treated by those that love her, and the professionals present "can make the difference between confirmation of her self worth and retraumatization." (Simpkin and Klaus, 34)
  • Survivors may equate being abused with feelings of helplessness and loss of control, and therefore having control of a situation is a priority for many. (Simpkin and Klaus, 75)

Before I continue, I would like to say that I do not believe that When Survivors Give Birth is a bad book and should not be read. It absolutely needs to be read. Some people will really benefit from this book. There are birth workers who commit microaggressions towards survivors of sexual abuse every day, and they may not even be aware. A microaggression is an action that is directed at a minority, in this case survivors of sexual abuse, that is offensive in a subtle way, and is usually unintentional. When Survivors Give Birth has examples of that, which some birth workers need to be made aware of.

The problem with the book is it that it seems like many of the suggestions rely on the pregnant and laboring mother to disclose the fact that she has been sexually abused. I think this, in and of itself, is a problem. Is it fair to ask a person to tell strangers that they have been sexually abused?

Imagine yourself as a pregnant woman who has been abused. Imagine that you have thought long and hard about things that are routine maternity care. Because it is invasive and common, I am going to pick cervical checks. Many practitioners will do cervical checks routinely in the last weeks of pregnancy, and they are also done in labor to determine how dilated a woman is in labor. So here you are this pregnant woman you go in at 37-40 weeks and there is a sheet ready for you in the patient room. Your nurse tells you to remove everything off from the waist down for a cervical check to see how dilated you are. You have already decided to forgo cervical checks. This isn't a willy-nilly decision. This is a serious trigger. A trigger is something that reminds you of something from your past, in this case previous sexual abuse. It could be anything. It could be multiple things. It could be things you are not aware of.

Imagine you as a teenager were raped by your boyfriend. Someone you trusted, someone who you thought respected you. You are helpless and on your back, crying. You can fill in your own blanks of what happened. Imagine it is years later, that sometimes when you are intimate with your partner of 10 years that you are randomly triggered by the experience. Nothing out of the ordinary for you and your partner occurred. Suddenly you want to fight, you want to scream and lash out. You want to push your partner off you, run to the bathroom, bolt the door and cry. You are with a person you love, cherish, and have chosen to have a family with, and you are still triggered, taken back to an event that happened 15 years ago.

There is no way that you are comfortable with a stranger, even your care provider, reaching up inside you - not always very gently - as deep as they can go, feeling around for dilation and effacement, while you are on your back naked from the waist down, very exposed.

So, you keep your pants on. You have done your research, you know that your cervix is not a crystal ball. You know that how dilated you are today doesn't matter. It doesn't tell you when you are going to go into labor. So your doctor comes in, slightly surprised you still have your pants on. You tell them you have decided to forego cervical checks. Your provider tells you that is fine, but they will have to be done in the hospital. So you take a deep breath. You tell him or her nicely but firmly that you prefer not to have to cervical checks at all, during pregnancy and labor. You take a few more deep breaths. You open your mouth and very bravely tell them that you have been raped, and that the idea is abhorrent to you. You hope to make the doctor understand, even though it is hard to even talk about 15 years later, because every time you talk about it, you think about it. Even just mentioning it can take you back.

Why would we do that to a woman? Why should we have to? Why does a doctor need a reason to respect the wishes of their patient? Why should, as Simpkin and Klaus suggest, a survivor "be willing to remind the caregiver of her background of sexual abuse, and of what they previously discussed," assuming she could speak of the abuse at all? It is stated that "even within the context of short appointments and multiple caregivers, good communication is possible when both parties are willing to try." (Simpkin and Klaus, 150)

"Willing to try." Meaning, have a woman disclose over and over and over to each member of the practice that she is a survivor. What if it took that woman 8 years to tell her partner the details of that experience, because even just mentioning it was too much? Yet she should be expected to mention it to 3-6 individuals because they might be at the birth of her child? How is this fair to the survivor?

Another suggestion is that the survivor put the fact that she was abused in her birth plan so that she doesn't verbally have to tell the professionals involved in her care during labor and delivery. (Simpkin and Klaus, 151) On one hand this seems like a good idea. If her birth plan reads as demanding, the fact that she disclosed that she is a survivor would make the requests seem understandable. This might be more apparent in a survivor who feels the need to maintain control of a situation. Again though it begs the question of why does a survivor need to disclose this information to get compassionate care? You may be thinking that this is a worthy trade off, and for some survivors it might be.

However, what if the survivor lived in a small town? I had a baby when my youngest was in kindergarten. One of my attending nurses had a child in that same class. Of course HIPPA prevents the nurse from discussing it, but living in a small town you see people all the time. I would always see the senior nurse from my doctor’s office at the grocery store. That mom was at every class party. What if the survivor worked for the hospital? Should she have to disclose to her colleagues that she is a survivor? Again HIPPA would prevent them from talking about it, but put yourself in the survivor’s shoes. How would you feel if you felt like everyone knew something you didn't want them to know, but you disclosed the information so you could, hopefully, get compassionate care?

What if, despite telling people, it didn't matter? Put yourself back in the scenario in which the survivor was raped as a teenager. What if, after being so very brave, you were told that you would still need to have cervical checks. That you would need to have one at admission and then every hour or two to see how you were progressing in labor. You will have to be subjected to a triggering action multiple times during a time that is supposed to be joyful. The very thought of it makes you want to weep. It might not be cervical checks. The trigger might be having to be confined to the bed for electronic fetal monitoring. Your body tells you you need to be up and moving. The nurse comes in and admonishes you, telling you to lie down, that they can't get a good reading on the baby. You are fighting the contractions, you feel helpless, confined. It hurts to lay down during contractions. You are not allowed to listen to your body.

Why are we retraumatizing survivors? Why do we do it? Depending on the statistics, 1 out of every 5 or 1 out of every 6 women are victims of attempted rape or completed rape. That is a lot of women. As we have seen, in the case of being a survivor of sexual violence, labor and birth can become an obstacle for various reasons. I find it unacceptable that many of these women are further traumatized by their caregivers during their stay in L&D. It is enough of a systemic problem that there are birthing centers opening specifically for victims of sexual abuse. This whole blog post was inspired by this article. When I first read it my reaction was, "These need to be everywhere!" It was followed by, "Why do survivors need to go to a special clinic to get compassionate care? Maybe we need to fix how we treat pregnant and laboring mothers."

In 2011 Penny Simpkin wrote an article published on the blog Science and Sensibility. In it she talks about how childbirth can be traumatic for mothers and that it can lead to PTSD. Depending on the survey 18-33% of women report having traumatic birth experiences. Of the women surveyed, 3-9% of women developed PTSD after childbirth. An important note is made that the trauma may only be seen through the eyes of the individual giving birth.

What does PTSD after birth look like? "Key symptoms of PTSD include insomnia, irritability and angry outbursts, panic attacks, nightmares about the birth, a desire to avoid the baby or anything relating to the birth, feelings of detachment from loved ones, and a sense that some other disaster is imminent." How do you think that affects the postpartum period?

Imagine you are the survivor again. You just had an experience in which you were confined to a bed when you didn't wish to be. You were invaded over and over again by multiple doctors and nurses because you labored at the time of shift change. You had people in your room you had never previously met, never seen, and they didn't even introduce themselves. How do you feel about your birth? Do you feel like you were supported? Do you feel like your self worth was boosted or were you retraumatized?

We need to do better. We need to provide maternity care that doesn't retraumatize the survivor again and again and again. We need compassionate care for pregnant and laboring women, regardless of their circumstances, in which their autonomy is valued and respected. We should not require women to justify their choices.

Carol Meadows is a certified Birth Boot Camp Instructor. She lives on Colorado's beautiful front range, and teaches classes in the Colorado Springs/Pueblo area. Carol has been passionate about labor and birth since 2008, when she birthed her first daughter. Her knowledge and passion for birth has grown throughout the years. She penned this blog post as part of her ongoing effort to improve birth for everyone. She can be found at Meadow Mama Birth and on Facebook