Jewish Survivors of Sexual Violence and Pregnancy Issues

Jewish Survivors of Sexual Violence and Pregnancy Issues
(Incest, Childhood Sexual Abuse, Sexual Assault, Clergy Sexual Abuse, Professional Sexual Misconduct)

There are so many issues when it comes to incest, childhood sexual abuse, sexual assault, clergy sexual abuse and pregnancy, yet The Awareness Center is having a difficult time locating resources to address them. If you know of resources for Jewish survivors who were pregnant as a result of their abuse/assault, or if you have resources for survivors who were a product of abuse or assault, please forward it to The Awareness Center

We are also looking for information to help survivors of abuse deal with their own pregnancy if they find the process difficult.

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Statistics

• 62% of pregnant and parenting adolescents had experienced molestation, attempted rape, or rape prior to their first pregnancy.-- Boyer & Fine, 1993
• 74% of women who had intercourse before age 14 report a history of forced sexual intercourse.-- Alan Guttmacher Institute, 1994
• Between 11% and 20% of girls were pregnant as a direct result of rape.-- Boyer & Fine, 1993
• The adult pregnancy rate associated with rape is estimated to be 4.7%. This information, in conjunction with estimates based on the U.S. Census, suggest that there may be 32,101 annual rape-related pregnancies among American women over the age of 18.
• 1 - 5% women become pregnant as a result of a sexual assault. Melissa Holmes, 1996
• Over 32,000 pregnancies result from rape every year -- Melissa Holmes, 1996

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Disclaimer: Inclusion in this website does not constitute a recommendation or endorsement. Individuals must decide for themselves if the resources meet their own personal needs.

Table of Contents: 

Jewish Resources

1. Medical Professionals sensitive to issues related to sexual victimization
2. Articles
3. Abortion in Jewish Law - by Daniel Eisenberg, M.D.
4. Incest, Pregnancy, Abortion and Halacha (Jewish Law) - By Vicki Polin, MA, LCPC, Michael Salamon, Ph.D., FICPP, and Na'ama Yehuda, MSC, SLP, TSHH
5. Pregnancy From Rabbinical Sexual Misconduct - The Awareness Center is looking for information on this topic.
6. Resources for Survivors who got pregnant as a result of their abuse.
7. Resources for Survivors who had a child as a result of a sexual assault and are in child custody battles with their abusers.
8. Resources for Survivors who are a result of their mother being sexually abused or assaulted.
9. Information on Pregnancy and Survivors of Incest and Childhood Sexual Abuse

Secular Resources
Articles

1. Childhood Sexual Abuse as an HIV Risk Factor in Women - By Risa Denenberg, R.N., F.N.P., M.S.N.
2. Childhood Sexual Abuse and Its Effects On Childbirth - by Regine Spindler
3. Childhood Abuse & Household Dysfunction Associated With Higher Risk Of Unintended First Pregnancy - By Patricia M. Dietz, DrPH
4. Childhood Sexual Abuse and the Potential Impact on Maternity - By Andrya Prescott, Independent Midwife
5. Dear Abby: Pregnant 14-year-old covering for teacher at school
6. Genital Anatomy in Pregnant Adolescents: "Normal" Does Not Mean "Nothing
7. Happened" - By Kellogg ND, Menard SW, Santos A.
8. Link between rape and pregnancy - By BBC
9. Most Teens First Had Sex at Home - By Laura Meckler
10. Murder and Pregnancy - By April Greer. Evelyn Hernandez. Carol Stuart. Laci Peterson
11. Politics Of Rape And Contraception - CBS Evening News (Los Angeles)
12. Sexual Trajectories of Abused and Neglected Youths - By Brown J, Cohen P, Chen H, Smailes E, Johnson JG.
13. Sexual Trauma and Pregnancy: A Conceptual Framework - Carie S. Rodgers, Ph.D.; Ariel J. Lang, Ph.D.; Elizabeth W. Twamley, Ph.D.; Murray B. Stein, M.D.
14. Teenage pregnancy and associated risk behaviors among sexually abused adolescents - Saewyc EM, Magee LL, Pettingell SE
15. The interface between psychiatry and obstetrics: Comprehensive perinatal care - By Werner Tschan, MD
16. Verdict for Hospital That Failed to Report Child Abuse Is Upheld - By John Woods

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Medical Professionals sensitive to issues related to sexual victimization
 

New York

Leah Marinelli, RN, CNM, NP -  Home Birth With Love  (845) 641-5058, Suffern New York.

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Abortion in Jewish Law
by Daniel Eisenberg, M.D.
Aish HaTorah - Sunday, May 30, 2004

 The traditional Jewish view of abortion does not fit conveniently into any of the major "camps" in the current debate over abortion.

As abortion resurfaces as a political issue in the upcoming U.S. presidential election, it is worthwhile to investigate the Jewish approach to the issue. The traditional Jewish view of abortion does not fit conveniently into any of the major "camps" in the current American abortion debate. We neither ban abortion completely, nor do we allow indiscriminate abortion "on demand."

A woman may feel that until the fetus is born, it is a part of her body, and therefore she retains the right to abort an unwanted pregnancy. Does Judaism recognize a right to "choose" abortion? In what situations does Jewish law sanction abortion?

To gain a clear understanding of when abortion is permitted (or even required) and when it is forbidden requires an appreciation of certain nuances of halacha (Jewish law) which govern the status of the fetus.1

The easiest way to conceptualize a fetus in halacha is to imagine it as a full-fledged human being -- but not quite.2 In most circumstances, the fetus is treated like any other "person." Generally, one may not deliberately harm a fetus. But while it would seem obvious that Judaism holds accountable one who purposefully causes a woman to miscarry, sanctions are even placed upon one who strikes a pregnant woman causing an unintentional miscarriage.3 That is not to say that all rabbinical authorities consider abortion to be murder. The fact that the Torah requires a monetary payment for causing a miscarriage is interpreted by some Rabbis to indicate that abortion is not a capital crime4 and by others as merely indicating that one is not executed for performing an abortion, even though it is a type of murder.5 There is even disagreement regarding whether the prohibition of abortion is Biblical or Rabbinic. Nevertheless, it is universally agreed that the fetus will become a full-fledged human being and there must be a very compelling reason to allow for abortion.

As a general rule, abortion in Judaism is permitted only if there is a direct threat to the life of the mother by carrying the fetus to term or through the act of childbirth. In such a circumstance, the baby is considered tantamount to a rodef, a pursuer6 after the mother with the intent to kill her. Nevertheless, as explained in the Mishna,7 if it would be possible to save the mother by maiming the fetus, such as by amputating a limb, abortion would be forbidden. Despite the classification of the fetus as a pursuer, once the baby's head or most of its body has been delivered, the baby's life is considered equal to the mother's, and we may not choose one life over another, because it is considered as though they are both pursuing each other.

It is important to point out that the reason that the life of the fetus is subordinate to the mother is because the fetus is the cause of the mother's life-threatening condition, whether directly (e.g. due to toxemia, placenta previa, or breach position) or indirectly (e.g. exacerbation of underlying diabetes, kidney disease, or hypertension).8 A fetus may not be aborted to save the life of any other person whose life is not directly threatened by the fetus, such as use of fetal organs for transplant.

Judaism recognizes psychiatric as well as physical factors in evaluating the potential threat that the fetus poses to the mother. However, the danger posed by the fetus (whether physical or emotional) must be both probable and substantial to justify abortion.9 The degree of mental illness that must be present to justify termination of a pregnancy has been widely debated by rabbinic scholars,10 without a clear consensus of opinion regarding the exact criteria for permitting abortion in such instances.11 Nevertheless, all agree that were a pregnancy to causes a woman to become truly suicidal, there would be grounds for abortion.12 However, several modern rabbinical experts ruled that since pregnancy-induced and post-partum depressions are treatable, abortion is not warranted.13

As a rule, Jewish law does not assign relative values to different lives. Therefore, almost most major poskim (Rabbis qualified to decide matters of Jewish law) forbid abortion in cases of abnormalities or deformities found in a fetus. Rabbi Moshe Feinstein, one the greatest poskim of the past century, rules that even amniocentesis is forbidden if it is performed only to evaluate for birth defects for which the parents might request an abortion. Nevertheless, a test may be performed if a permitted action may result, such as performance of amniocentesis or drawing alpha-fetoprotein levels for improved peripartum or postpartum medical management.

While most poskim forbid abortion for "defective" fetuses, Rabbi Eliezar Yehuda Waldenberg is a notable exception. Rabbi Waldenberg allows first trimester abortion of a fetus that would be born with a deformity that would cause it to suffer, and termination of a fetus with a lethal fetal defect such as Tay Sachs up to the seventh month of gestation.14 The rabbinic experts also discuss the permissibility of abortion for mothers with German measles and babies with prenatal confirmed Down syndrome.

There is a difference of opinion regarding abortion for adultery or in other cases of impregnation from a relationship with someone Biblically forbidden. In cases of rape and incest, a key issue would be the emotional toll exacted from the mother in carrying the fetus to term. In cases of rape, Rabbi Shlomo Zalman Aurbach allows the woman to use methods which prevent pregnancy after intercourse.15 The same analysis used in other cases of emotional harm might be applied here. Cases of adultery interject additional considerations into the debate, with rulings ranging from prohibition to it being a mitzvah to abort.16

I have attempted to distill the essence of the traditional Jewish approach to abortion. Nevertheless, every woman's case is unique and special, and the parameters determining the permissibility of abortion within halacha are subtle and complex. It is crucial to remember that when faced with an actual patient, a competent halachic authority must be consulted in every case.

1. While there is debate among the Rabbis whether abortion is a Biblical or Rabbinical prohibition, all agree on the fundamental concept that fundamentally, abortion is only permitted to protect the life of the mother or in other extraordinary situations. Jewish law does not sanction abortion on demand without a pressing reason.
2. Igros Moshe, Choshen Mishpat II: 69B.
3. Shulchan Aruch, Choshen Mishpat, 423:1
4. Ashkenazi, Rabbi Yehuda, Be'er Hetiv, Choshen Mishpat 425:2
5. Igros Moshe, ibid
6. Maimonides, Mishneh Torah, Laws of Murder 1:9; Talmud Sanhedrin 72B
7. Oholos 7:6
8. See Steinberg, Dr. Abraham; Encyclopedia of Jewish Medical Ethics, "Abortion and Miscarriage," for an extensive discussion of the maternal indications for abortion.
9. Igros Moshe, ibid
10. See Encyclopedia of Jewish Medical Ethics. P. 10, for references.
11. See Spero, Moshe, Judaism and Psychology, pp. 168-180.
12. Zilberstein, Rabbi Yitzchak, Emek Halacha, Assia, Vol. 1, 1986, pp. 205-209.
13. Rabbi Shlomo Zalman Aurbach and Rabbi Yehoshua Neuwirth cited in English Nishmat Avraham, Choshen Mishpat, 425:11, p. 288.
14. Tzitz Eliezer, Volume 13:102.
15. Rabbi Shlomo Zalman Aurbach and Rabbi Yehoshua Neuwirth cited in English Nishmat Avraham, Choshen Mishpat, 425:23, p. 294.
16. See excellent chapter in English Nishmat Avraham, Choshen Mishpat, 425 by Dr. Abraham Abraham, particularly p. 293.

Author Biography:

Dr. Daniel Eisenberg is with the Department of Radiology at the Albert Einstein Medical Center in Philadelphia, PA and an Assistant Professor of Diagnostic Imaging at Thomas Jefferson University School of Medicine. He has taught a weekly Jewish medical ethics class for the past 10 years. He moderates the monthly Jewish medical ethics study group at Albert Einstein Medical Center and lectures internationally on topics in Jewish medical ethics.
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Secular Articles

Childhood Sexual Abuse as an HIV Risk Factor in Women

Treatment Issues, Vol 11, No 7/8; July/August 1997

Risa Denenberg, R.N., F.N.P., M.S.N.

In doing HIV/AIDS work, it is critical to operate with the awareness that a large proportion of adolescents and adults were sexually abused as children and that abuse has had a profound and devastating effect on their consequent psychosocial development. Childhood sexual abuse has been strongly associated with numerous disturbing behavioral and psychological outcomes in adolescent and adult women. Among them are further domestic violence, adolescent pregnancy, child abuse, drug and alcohol abuse, bulimia, sexually transmitted infections, depression, prostitution, self-mutilation, running away from home and dropping out of school (Rosenfeld, 1993; Boyer, 1992). The emotional trauma of childhood sexual abuse is compounded by the fact that the perpetrator of the violence is usually a close, male family member. In most cases, sexual abuse occurs in a family atmosphere of silence, secrecy, protection of the perpetrator and disbelief or blaming of the child victim.

The link between child sexual abuse and risk for HIV infection has been proposed by several authors (Caseese, 1993; Paone, 1993; Rosenfeld, 1993; Zierler, 1991), and recent research strongly confirms that association. Large, prospective, multisite studies of cohorts of women with and at high behavioral risk for HIV have uncovered striking data by conducting structured interviews with participants. Of 771 women enrolled in HIV Epidemiology Research Study (HERS) sites in Baltimore, Detroit, and the Bronx, 43% had been sexually abused as children and 45% had been sexually abused as adults (Vlahov, 1996). In this cohort, 28.3% of the women reported having witnessed a murder.

In the Women's Interagency HIV Study (WIHS), data from 1560 women enrolled in New York City, Chicago, Washington, DC, and Los Angeles revealed that 40% reported a history of childhood sexual abuse (Cook, 1997) For these women, a history of sexual abuse, physical abuse or domestic abuse was highly correlated with engaging in risk behavior for HIV. In particular, childhood sexual abuse was significantly associated with: use of IV drugs; exchange of sex for drugs, money or shelter; higher number of sexual partners; and having had a sexual relationship with a person at high risk for HIV. Additionally, childhood sexual abuse was significantly related to adult domestic violence as well as adult sexual abuse.

HIV and Increased Domestic Violence

A review of the first 138 deaths at Chicago's Cook County Hospital program for HIV-positive women and children provided further evidence of the extent to which HIV and violence are interrelated. The review discovered that only 80% of the deaths were due to AIDS. Substance abuse, cardiac disease and other chronic illnesses accounted for most of the remaining 20%. Significantly, 3% of the deaths in this group were due to domestic homicide (Cohen, 1996). Childhood sexual abuse may be emerging as a primary risk factor for HIV infection, but violence is a major risk factor for mortality in HIV-positive women.

For HIV-positive women, there is increased risk of domestic violence related to HIV status. The decision to test for HIV, disclosure of HIV status to family and partner, partner notification and mandatory newborn HIV screening (as in New York State) are all situations that may increase the risk for violence. There is evidence that women have been beaten, abandoned, shot, and even murdered by domestic partners after revealing their HIV-positive status (North, 1993; Lester, 1995). It has been shown that when physical abuse has occurred in the past, it is even more likely to occur during a pregnancy (Amaro, 1990). Thus, HIV testing during pregnancy, and newborn screening for HIV may set women up for further violence.

Abuse Survivors and Their Care Providers

Childhood sexual abuse may also set the stage for unsatisfactory relationships with health care providers. In general, clinicians fail to screen for a history of childhood sexual abuse or current risk for domestic abuse. Symptoms of domestic abuse may be easily misread. Often an abused woman will miss appointments and be considered noncompliant. Or she may report injuries, falls, forgetfulness and clumsiness. Women who have histories of childhood sexual abuse often have numerous physical complaints, including: digestive upsets, headaches, joint and muscle pains and chest pains (AMA, 1992). When clinicians are unable to find underlying medical causes for these symptoms, they become frustrated and often label the patient a "malingerer."

Sexual trauma can also result in post-traumatic stress syndrome with symptoms such as anxiety, phobias, hypervigilence and isolation. Common coping behaviors in sexual abuse survivors are denial, dissociation and repetition compulsion (Caseese, 1993). Denial and repetition compulsion (repeating behaviors that lead to trauma) are major mechanisms operating when engaging in risk behaviors, or staying in an abusive situation. Dissociation (pushing painful experiences and emotions out of conscious recognition) often occurs when survivors are asked about the trauma. They may respond blankly or without any emotional affect. Care providers often interpret dissociative reactions as the patient being "not too bright," "spaced out" or "on drugs."

The available data on the incidence of sexual trauma and domestic abuse in the U.S. is staggering. It is estimated that more than 30% of all females and nearly 15% of all males in the U.S. have been victims of childhood sexual abuse. Seventy-five percent of sex workers (female and male) have experienced sexual abuse. One in four women have been raped, and one in five women have experienced domestic abuse. During pregnancy, it is estimated that one in six women is sexually or physically assaulted by her partner.

Investigation and data regarding the prevalence, consequences and relationship to risk for HIV of the sexual abuse of boys are nearly absent in the literature. There are currently no clinical recommendations regarding incorporating what is known about childhood sexual trauma into HIV prevention efforts or into principles for forming therapeutic alliances with HIV-positive clients who are trauma survivors.

In most cases in which a history of trauma is uncovered, the individual should be referred to a competent therapist, with the message that recovery, healing and relief of symptoms is possible. A woman who is currently in an abusive situation needs a counselor who is trained in crisis intervention and domestic abuse. In addition, the following guidelines may be useful in approaching and working with individuals with a history of sexual or other trauma (adapted from Denenberg, 1993):

Provide assurance that any abuse that has occurred was not the survivor's fault.

Validate the experience of sexual abuse ("I believe you") and reassure the survivor that she is not alone ("This has happened to others").

Offer the survivor support and the ability to be in control of her body during any medical examinations, especially during genital exams, rectal exams and other invasive procedures.

Assess if the survivor is in a safe living situation at the present time.

Assess if there are any children living with the survivor who are currently at risk for sexual abuse.

Incorporate knowledge of the survivor's history into current and future interactions, including any teaching about risk reduction.

Make appropriate referrals for counseling, crisis intervention, safe housing and other services.

References

1. American Medical Association (1992), Diagnostic and Treatment Guidelines on Domestic Violence. Chicago, IL.
2. Amaro H et al. American Journal of Public Health. May 1990; 80(5):575-79.
3. Boyer D & Fine D. Family Planning Perspectives. January 1992; 24(1):4-11.
4. Caseese J. SIECUS Report. 1993; 22(4):1-7.
5. Cohen M et al. Women and HIV Infection Conference. February 22-24, 1995; abstract TC2-118.
6. Cook JA. National Conference on Women and HIV. May 1997; abstract 122.4.
7. Denenberg R. Gynecological Care Manual for HIV-Positive Women. EMIS 1993.
8. Lester P et al. Journal of AIDS and Human Retrovirology. November 1995; 10(3):341-9.
9. Morrill A. National Conference on Women and HIV. May 1997; abstract 122.2.
10. North RL & Rothenberg KH. The New England Journal of Medicine. October 1993; 329(16):1194-6.
11. Paone D & Chavkin W. SIECUS Report. 1991; 21.
12. Rosenfeld S & Lewis D. AIDS & Public Policy Journal. 1993; 8(4):108-13.
13. Vlahov D et al. XI International Conference on AIDS. 1996; abstract Tu.D.135.
14. Zierler S. American Journal of Public Health. May 1991; 81(5):572-5.

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Childhood Sexual Abuse and Its Effects On Childbirth

by Regine Spindler

INTRODUCTION

At the dawn of a new millennium, many caregivers are asking themselves and the healthcare system, why a high technological environment, surrounding such a natural event like childbirth, is not preventing a rising rate of cesarean sections, contrary to certain other European countries such as Holland, where homebirths are the rule and where the rate of cesarean sections is one of the lowest in the world. However, a certain number of medical interventions in childbirth are due to anatomical abnormalities or emergencies .

The caregiver should be aware that these abnormalities are rare. But this is not the topic of this study , and I will concentrate on childhood sexual abuse, which can be the cause of labor dystocia and its symptoms, such as failure to progress (FTP). I will also focus on the consequences of childhood sexual abuse on pregnancy, and on the relation with the caregiver.

In this paper, I used testimonies of sexual abuse survivors obtained on a support group maintained on Internet and researches having being completed already on the subject.

I will first try to define sexual abuse, its components, its background, and the signs and symptoms that a caregiver should recognize.

I will then proceed in quoting several excerpts of the testimonies I have obtained and will analyse their content to outline what happens to those survivors during pregnancy and childbirth.

In the next section, I will describe some symptoms which should help the caregiver in forecasting what could be expected from a survivor, and will suggest approaches to facilitate the relation between the caregiver and the survivor during pregnancy and childbirth, as well as describing other proposals of prevention and healing .

Even though this paper is primarily designated to be read by Gyn Doctors, Midwives, Doulas, and Childbirth Educators of my area (Catkill NY), I hope that facilities such as the family planning, rape crisis centers etc., will understand the necessity of reading this study, in order to start detecting the problem even before the onset of pregnancy, if possible, and start the healing process way before the survivor comes to the healthcare provider for the birth.

WHAT IS SEXUAL ABUSE?

Definition: In the USA, childhood sexual abuse is defined as having any kind of imposed sexual activity under the age of 18 years old. It is usually performed on a child, male or female, by an older person, male or female, having some power or authority on the child. It can happen in any family, regardless of its social-economical background. A member of the family or a neighbor can perform the abuse. It can be a rape, caresses, exhibitionism, sex talk etc. (Simkin, 1994).

Several researches show that 1 woman in 3 is a survivor of childhood sexual abuse, but it is very difficult to make a correct estimate, due to the fact that many women suffer from amnesia until they are much older, or they feel too traumatized to admit what happened. (Holtz, 1994).

Signs and symptoms: Some survivors can demonstrate behavioral symptoms such as: poor grooming, addictions of any kind, eating disorders, teen pregnancies, (Holtz, 1994; Frye, 1998) Psychosomatic symptoms such as pelvic pains, headaches, G I track disturbances are common. Women can experience over exaggerated gag reflexes, neck pains and endless nausea. Survivors who have not recovered any memory from the past abuse, usually experience at least some of these symptoms.

SEXUAL ABUSE AND CHILDBIRTH

Analysis of testimonies

One of the very first thing that I could gather after reading those "confessions", was a general fear of losing control, expressed by all these women during their pregnancy and childbirth. It is not surprising, during an or several continuous episodes of abuse, the individual have no control whatsoever on what is happening to them, many of them being sometimes under physical threats such as weapons.

"The labor was progressing so fast that I felt out of control and scared, and my baby hurt a lot.... My body began pushing. The pain became so intense that I found myself retreating out of my body.... My mind was full of images of the rape I endured when I was 2 years old, when my mother's older relative tore me open from the top of my clitoris down to my urethra." (Rose, 1992)

"I hated pushing and that was a big let down, since I had hoped that it would be easier than the dilating stage. I have a hard time coping with anything that my body does that I cannot control, like pushing out a baby, vomiting, menstruating etc." (E-mail).

"The less I am `messed up with' during childbirth, the better I do. Any time the control is taken out of my hands and put in to the hand of a medical professional, it brings back the terror and the powerlessness of the abuse all over again." (E-mail)

On the other hand, some women let others take control over them: "I managed to enter in an emotionally abusive relationship with doctor who attended the birth. I found that one physician who did home births, and went with him regardless of the fact he made me feel 3 inches tall every time I saw him." (E mail)

They also feel that there is no place safe, so they slip away somewhere else. "In fact, I felt as if I were viewing the whole scene from outside my body, up near the ceiling and to my left, about 10 feet away from where I lay. (Rose, 1992). "But when the contractions came I lost it and just pushed and screamed that it hurt, I cried for my mommy.... I just went someplace else, someplace safe in my mind. I know it sound strange but I just could not handle it, and I was so tired of being touched. " (E mail).

Being touched or examined by the caregiver can trigger traumatic flashbacks and therefore putting an obstacle in a healthy relationship between the mother and caregiver. "And I had talked about not even getting checked during labor before." (E-mail). "Hospitals only mean pain, humiliation, and illness to me." (E-mail). "If I could not endure this vaginal exam on my first prenatal visit, how was I ever going to birth a baby? But I did not trust my body, would not, could not let myself push without her permission {the Midwife}" (E-mail).

Not feeling safe, mistrusting oneself and the caregiver seem to be a constant element, and is demonstrated by refusing exams and especially vaginal exams. Dissociation and flashbacks are also very frequent and play a determinant influence not only in the relation with the caregiver but during the labor itself.

Understanding and recognizing the symptoms

Pregnant women do often reenact unconsciously the abuse or the rape during prenatal exams and birth. They feel, as seen in the precedent section, totally under the control (imaginary or not) of the caregiver and can react to careless interviews, or exams, during their pregnancy and birth. Triggered memories can surge in forms of flashbacks, difficult to handle during labor (Kitzinger, 1992). Women need to feel safe and not disturbed for a good and efficient labor. Mammals are always looking for a retired and dark place in order to give birth. If they feel threatened the survival reflex predominates, and labor stops or is slowed down due to the influx of catecholamines insuring the fight or flight response (Odent, 1999). This is also true for women and this is one of the reasons, in my opinion, why so many survivors experience labor dysfunction, especially in first stage (Tallman & Herring, 1998).

List of symptoms (Simkin in Frye, 1998)

Psycho-social problems - Mistrust towards the caregiver, Bonding failure, Post Traumatic Stress Disorder, Eating disorders, Obesity, Desire to change one's name, Failure to remove one's clothes when appropriate, nervousness about being watched.

• Mental problems - Fear of pain, Phobias of needles, pelvic exams or other invasive procedures. Dreams and nightmares, Dissociation disorders, Anger issues, Rigid control of though process, Poor self image, Blocking all early childhood memories,
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• Physical problems - Infertility, Migraines, severe PMS, Swallowing and gagging sensitivity.
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• Sexual problems - Sexual addiction, Inability to achieve orgasm, Prostitution (most have been abused), pregnant teens (66% remember abuse)
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• Problems during pregnancy, childbirth and postpartum - Fear of being "ripped apart" during birth, Inability to breastfeed or having difficulties, Hyperemesis gravidarum, threatened premature labor, May hold the labor at a certain point to protect genitals area or the baby, Fear of losing control.
• 
  
• The author advises to avoid generalizations and being conscious of the fact that not every woman displaying several of those symptoms may have been abused.

WHAT CAN THE CAREGIVER DO?

Labor dysfunction will most frequently occur during the first stage, whether the abuse episode has been shared or not with the caregiver (Tallman & Hering, 1998), and is due to unconscious maneuvers from the woman in childbirth, who cannot control the pain anymore, as well as feelings of fear and the stress triggered by the fight for survival.

Establishing a basic bond between the caregiver and the patient during early pregnancy

Since one of the symptoms described previously is a basic mistrust in caregivers, it becomes obvious that step #1 is establishing a minimum level of trust with the client. It will enable the caregiver to recognize further down the road, possible problems and establish tentative of solutions. It is however challenging since symptoms of abuse may not be obvious at first sight.

Anne Frye suggests that disclosure of abuse is possible if the client is aware and remembers the episode(s). Questions such as: "Did you experience sexual abuse in your life", is a direct and healthy way to start the issue. Some women will be comfortable enough to admit it if this is the case. However, some others do not because they cannot admit it due to feelings of guilt even if they remember, and some do not remember the events at all.

This is where the caregiver skills are challenged not only to recognize symptoms, but also to establish a relation where the client will feel safe. It is important to recognize them early in pregnancy, in order to allow sufficient time for the caregiver to assess data and organize a plan of care according to the highest possibilities of the client. (Fusco, 1998)

The room environment where both parties meet is essential : decoration, furniture, examination tables, clothes worn by the care giver etc...Permission should be asked before entering the client's personal and intimate space and explanations should be given during pelvic exams, along with a constant preoccupation of letting the client know that it could be stopped at any time and resumed when the client feels safe enough (Holtz, 1994).

This is also the time where one will recognize non-verbal clues, such as rigidity of the body, grimacing or inappropriate behavior such as laughing or withdrawal.

Flashbacks can be experienced during exams and interviews and it is important to validate them whether the patient is verbalizing them or not (Frye, 1998).

Jennifer Burian (1995), labor nurse advises:

1. "Consider what your response would be if a woman disclosed a history of sexual abuse to you.
2. Provide an emotionally and physically safe environment for survivors.
3. Establish an atmosphere of openness and unhurried listening.
4. Be aware of your language. False intimacy in a soothing voice may trigger memories of perpetrator's demeanor during the original abuse.
5. Be aware of the discomfort of body exposure
6. Remember that a vaginal exam can feel like a repeat of the abuse. Let the woman choose the timing and talk through it, stopping if she appears at all physically and emotionally unable to continue.
7. Assure her that she is safe, and affirm her strength through labor and birth.
8. Above all honor the emotions that she is feeling."

During labor

It is crucially important that during the first stage of labor, continuity should be given to what may have been started during pregnancy, by the caregiver, the childbirth educator, and the doula. Ideally, the three parties should have remained in constant communication and interaction during the client pregnancy. Survivors in childbirth do need a maximum of compassion and understanding in order to allow themselves to express what they would feel during this time. The doula is essential to bring the extra support and care that will make the difference in the labor. She can advocate, interpret, and be the interface between the laboring woman and the nurses if they are not aware of the situation. We know that most of the caregivers do not stay during the whole duration of labor, which can be sometimes very long. The doula will be soothing, reinsuring, listening to the survivor as much as needed.

It is essential to remember that past the first stage, and when women get into transition, flash backs or dissociation are frequent, women may slip somewhere else refuse to push or dilate. They may even go back to an early stage of dilatation. The doula and the caregiver will have to continue to reinsure and keep eyes contact with the survivor to get the maximum of her strength and energy (Courtois & Courtois Riley, 1992). Its is also the moment to validate her feelings and emotions as well as her possible physical manifestations, screaming, closing her legs, refusing to be touched, etc. (Simkin, 1992).

Post Partum

Even though all of the above may have been provided, several problems may arise after the birth of the baby. Depression, difficulty in bonding with baby, problems in breastfeeding such as milk retention or repulsion to have the baby suck at the breast (Grant, 1992).

Seeking a solution

I borrowed the title of this section from an article from Nora Tallman and Cammie Hering, a midwife and a counselor, in which they explain that even after having done everything described above, they were still noting that survivors were having more medical interventions during childbirth than the regular patient. They concluded that it was already too late for the survivor at childbirth and that despite of all the measures they had taken, survivors were still experimenting labor dysfunction as early as the first stage, mostly FTP (failure to progress).

They are suggesting setting up a special prenatal preparation, with a support group: "We designed a prenatal support group to help SOCAs (survivor of child abuse) heal their wounded sense of self. Its purpose is to develop psychological and emotional tolls for coping with the challenges of pregnancy, labor, and parenting. Although we do discuss past traumas, the group is primarily focused on the practical aspects of their upcoming birth experience and the challenges of parenting. Topics include dissociation and flashbacks, dealing with pain and fear, control, communication, and relationship issues. By limiting the group to SOCAs, a midwife and a counselor, participants feel safe to discuss painful subjects and to experience both giving and receiving support with others who have experienced similar traumas. Above all, we hope these women experience their empowerment and self-respect."

Sheila Kitzinger (Midwife archives, 1990) encourages the educators counselors midwives to create a birth crisis network where women as women, "could support each other, question obstetrics policies and practices, and get involved in the politics of birth."

Jan Stanton, director of Heart to Heart, headquartered in Chicago, is especially concerned with the rate of teen moms having been raped prior to their pregnancy and the average age of their first sexual abuse (9.7 – 12 years old), and the fact that 50% of these abuses were committed by family members. She also states that violence and weapons were involved in 75% of these cases.

She believes in teen parental education prevention in the form of workshops, such as knowing how to protect themselves and their children from sexual abuse, with an extensive support and information from community network (Sue LaLeike, midwife archives).

CONCLUSION AND DISCUSSION

Why concluding on such a note, after describing extensively what could have been done between the survivor and the caregiver? Many researches have been done already, and many things have been tried, therefore there must be something good in them, despite statistics showing bigger figures in labor dysfunction .

So should we solely turn and focus on prevention and forget the role of the caregiver in the story? It seems obvious, that as presented earlier in a previous section, prevention plus an extremely tight connection between all the parties involved, seems crucial in order to offer the survivor, the highest chances for empowerment, healing, and feelings of success and self realization during their birth, post-partum period, and parenting

I would like to mention that this paper will be offered to the Family Planning, the Reach Center, Columbia Memorial Hospital (Hudson NY), Domestic Violence Program, as well as to the local Midwives Gyn Doctors, in Columbia and Greene County NY and to any childbirth educator and doula interested in it.

Finally, I would like to address my very warm thanks to the survivors who were willing to share with me their stories, through the internet support group, and to Marsha Fusco who, very trustfully, offered her own paper on the subject.

REFERENCES

1. Burian J. (1995). Helping survivors of sexual abuse through labor. The American Journal of Maternal Child Nursing 20 (5): 252-256
2. Courtois C. & Courtois Riley C. (1992). Pregnancy and childbirth as triggers for abuse memories: Implications for Care Birth 19 (4): 22-223,
3. Frye A. (1998). Holistic Midwifery. Portland: Labrys press
4. Fusco M. (1998). The long term health effects of childhood sexual abuse, Issues and interventions. New York (SUNY Empire State College)
5. Grant L. (1992). Effects of childhood sexual abuse: Issues for obstetric caregivers.
6. Birth 19(4): 220-221
7. Holtz K. (1994). A practical approach to clients who are survivors of childhood sexual abuse. Journal of Nurse-Midwifery 39 (1): 13-18
8. Kitzinger J. (1992). Counteracting, not reenacting, the violation of women's bodies: The challenge for perinatal caregivers. Birth 19(4): 219-221
9. Notes from Sheila Kitzinger Talk.1990). Crisis in the perinatal period. Midwife archives.
10. Laleike S. Many teen pregnancies caused by rape. Midwife Archives Http://www.gentlebirth.org/archives/index.html
11. Odent M. (1999). Birth and sexuality. NY Open Center, The art of birthing, audio tape
12. Rose A. (1992). Effects of childhood sexual abuse on childbirth: one woman's story. Birth 19(4): 214-218
13. Simkin P. (1992). Overcoming the legacy of sexual abuse: The role of caregivers and childbirth educators. Birth 19(4): 224-225
14. Simkin P. (1994). Memories that really matters. Childbirth Instructor Magazine. Winter: 20-24
15. Tallman N. & Hering C. (1998). Child abuse and its effects on birth. Midwifery Today.45: 19-21.

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Childhood Abuse & Household Dysfunction Associated With Higher Risk Of Unintended First PregnancyBy Patricia M. Dietz, DrPH

The Journal of the American Medical Association (JAMA) - October 19, 1999

Patricia M. Dietz, DrPH, from the Centers for Disease Control & Prevention in Atlanta, Ga, & colleagues analyzed the results from surveys of adult women to assess whether unintended pregnancies are associated with exposure during childhood to psychological abuse, physical abuse, sexual abuse or household dysfunction. To determine exposure to household dysfunction, the participants were questioned about physical abuse of the mother by her partner, substance abuse by a household member & mental illness of a household member. The researchers found that 45.4% of 1193 women surveyed reported that their first pregnancy was unintended & 65.8% of the women reported exposure to at least 2 types of abuse or household dysfunction. Psychological & physical abuse were the most common types of childhood abuse reported by the respondents.

After adjusting for marital status & age at the time of first pregnancy, the researchers found the following associations between unintended pregnancies & different types of abuse:

Respondents who reported frequent physical abuse were 1.5 times more likely than women who did not report experiencing abuse during childhood to have an unintended first pregnancy

Respondents who reported frequent psychological abuse were 1.4 times more likely than women who did not report experiencing abuse during childhood to have an unintended first pregnancy

Respondents who reported frequent physical abuse of the mother by her partner were 1.4 times more likely than women who did not report physical abuse of the mother by her partner to have an unintended first pregnancy

The authors also found that women who reported experiencing 4 or more types of abuse during their childhood were 1.5 times more likely to have an unintended first pregnancy than women who did not report experiencing abuse during childhood & that 1 in 5 unintended first pregnancies was associated with reported exposure to childhood abuse.

The authors believe additional research is needed to determine the cause of the association between childhood abuse & unintended pregnancy. The authors write: "Abuse or household dysfunction may influence a woman's feelings of control or power in sexual relationships & may lead to difficulty in negotiating contraceptive use with a partner."

The study reports the results of a survey of adult women enrolled in the Kaiser Permanente Medical Care Program who had received a standardized medical examination between August & November 1995 or January & March 1996. The questionnaire included questions about childhood psychological abuse, childhood physical abuse, childhood sexual abuse & childhood exposure to household dysfunction. Childhood was defined as the first 18 years of life.

The women included in the study were 20- to 50-year-olds who had had their first pregnancy at or after the age of 20 years old; most were white (61.0%), had some college education or had graduated from college (80.6%) & were married at the time of their first pregnancy (72.8%).

Citing other studies, the authors write: In 1994, 49% of US pregnancies were unintended (ie, unwanted or occurring before the woman had intended to become pregnant). Approximately half of all unintended pregnancies result in abortion & those that result in live births are associated with more maternal complications & poorer infant outcomes than intended pregnancies. Several studies have identified exposure to sexual or physical abuse during childhood as a risk factor for teenage pregnancies, most of which are unintended. Adolescents who have been sexually abused are more likely to have a greater number of sexual partners & not to use contraception, behaviors that increase their risk of unintended pregnancy.

"The pathways though which childhood abuse & household dysfunction affect sexual behavior in adulthood are complex & not fully understood," according to the authors. "Nonetheless, our findings suggest that medical providers need to be aware that a history of abuse or household dysfunction is common among adult women & may be affecting their patients' ability or motivation to prevent an unintended first pregnancy."

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Childhood Sexual Abuse and the Potential Impact on Maternity
By Andrya Prescott, Independent Midwife
MIDWIFERY MATTERS, Issue No.92, Spring 2002 - Association of Radical Midwives


At the ARM meeting in Chichester I offered to run a workshop on how sexual abuse in childhood can impact on the experience of becoming a mother. I wanted to provide an insight into why acknowledging childhood sexual abuse is important to midwifery. I focused on ways of broaching the subject with women and offering empathetic and appropriate care. I believe that it is important that midwives should be able to identify good attitudes and behaviours in themselves as well as recognising where there is need for improvement.

Ideally midwives should be able to find ways of bringing the issue into the open, allowing women to discuss their experience if they choose. Midwives can thus empower women and minimise the potentially negative impact of previous abuse on childbearing and parenting. Definitions of abuse can range from, "any unwanted touching" (Finney, 1992) to considering the experience itself and not by physical acts alone (Bass and Davies 1988). Often the literature distinguishes between a victim - a person who is still in abusive relationship, and a survivor - a person who has physically survived and is no longer in the relationship.

I would like to add that some people find that they are not ready to be called a survivor even though they are out of the original abusive relationship. Classification belongs to the woman! Child abuse is divided into many different boxes - ritualistic, emotional, physical, sexual and so on, but women may not feel they fit into any category.

Different effects are experienced by different women, some may find it very emotionally traumatic, some may be in denial, where one woman tells everyone and anyone who will listen, another will cope by not talking about it. There are no hard and fast rules, many extremes are prevalent, exceptionally loud women or exceptionally meek, quiet women may be survivors. Women can be at radically different stages of the healing process if indeed they have found that pathway at all. Why ask?

Why should we ask women if they have experienced abuse? The fact that anything between one in ten and four in ten women have been abused is compelling enough for me. Parratt (1994) found that 65-70% of women who had been abused were "permanently damaged". All midwives will encounter abused women. By asking we can affirm that it is not OK to have been abused, the pain and anguish often caused by abuse is then validated. In the early days of awareness of abuse, people need to hear over and over again from many sources that abuse is not something they deserved or asked for. It is the manipulation by adults who were responsible for their actions. Not asking reinforces society´s attitude that abuse is not to be discussed and is not or should not be of any consequence. If an affirmative answer is given then the midwife can offer appropriate help or referral.

Even when women do not talk about abuse, or where they may not be aware of it, it is not uncommon for women to have memories triggered by the changes that occur to their body, certainly as they start to consider the birth or even during the birth itself. If they have been asked about abuse in some way then they have the opportunity to talk at any time. It implies a supportive and safe atmosphere.

Midwives should be aware that the pregnancy itself may be as a result of the abuse, in which case the woman may need support from the social services and, if she is young, then the help of the child protection service as well as emotional and psychological support from appropriate people.

I have listed some of the issues that arise during pregnancy and into motherhood and it is self-evident that we should ask in a sensitive and caring way. Not asking does not mean the issue will not arise.


Factors to consider:
Control Control is essential. Abused women have learnt that losing control is dangerous physically and emotionally and they may structure their life to feel strong. Such a woman may be unable to risk anything that compromises her perception of control; she may need help to find a chink in her defences and take down the wall, must be sure of yourself and what you can offer, honesty is essential.

A woman's perception of control is often maintained by extremes – aggression – submission – ritual – living in state of crisis.

Confidentiality. If a woman discloses a history of abuse, document it only with her consent.

Midwifery care. The woman's body has been violated once already; she may experience midwifery care as further violation. Ask for consent for your actions! Remember your language, words like "relax" and "sweetie" may have been used before in very different circumstances.

Body image Body memories can emerge as a woman's body changes in pregnancy. Moreover, as the pregnancy becomes visible, taboos on body boundaries are lifted. The woman's belly appears to become part of the public arena.

Screening and blood tests Many women who have been abused have an overwhelming terror of needles. They need to know how appropriate blood screening is for them and must be able to make a truly informed choice. The midwife must be very sensitive in the way she takes any blood.

Routine examination is routine only to maternity professionals! Palpation, especially of baby's head, may be extremely uncomfortable. The need for extreme sensitivity in speculum examination or vaginal examination goes without saying.

Flashbacks Vivid memories of abuse may be triggered by any aspect of treatment. An abused woman may experience an extremely vivid memory of something that has happened to her in the past, or she may panic while being totally unaware that her present experience mirrors the past in some way. Help her to feel safe – she may not know what happened. Flashbacks can be triggered by touch, language, and the position of woman or caregiver. Her reaction may be to go rigid, to tell you, or her breathing or facial expression may change, she may show signs of absolute panic. She may speak to someone who isn't physically in the room with you or may appear suddenly terrified.

You may be able to help her by asking, "Can you tell me what was going through your mind during the last contraction?" You could also try asking her to reframe the current experience, differentiating it from her previous experience; if she says felt sharp like a knife, suggest smooth like a spoon.

Dissociation Many survivors cope with the after effects of abuse by `dissociation', a way of distancing themselves from their body and or mind, a numbness. A midwife may be impressed with how a woman is coping with the pain, by not feeling anything, but the woman may need to be helped back into the present. The midwife can use clear verbal directions to achieve this, asking the woman to focus herself into the room, to focus on the birth here and now. It may help to get her up and moving, reassuring her that this is safe environment, helping her to trust her body.

Physical sensations During the birth other specific factors come into play. The pelvic area being stretched can simulate feelings of abuse – the midwife should help her to empower and reclaim her body. Talk her through the pain speak of the stretching as a 'coming out' not a 'going in'.

Procedures Monitors and straps and VEs may be reminders of past abuse. Informed choice and honest discussion must play a large part in considering how appropriate each procedure is for an individual woman.

Positions Lying on a bed really may not be OK for a woman who was abused every night when she tried to go to sleep!

Slow progress It is often the unconscious mind that stalls labour. Fear of becoming a mother releases adrenalin thereby stopping progress. The midwife should work towards creating a feeling of safety using the power of imagery and visualisation and by her actions. Laughter is a great help in dissipating fear if you can find some humour.

Hands off the perineum Practise helping women to birth their babies by themselves with no meddling. Consider the impact of an episiotomy, tearing and suturing. A woman may have scarring from the abuse so antenatal advice about caring for the skin using Vitamin E oil and or perineal massage might be appropriate.

Lithotomy Does any woman like this position? If it becomes a necessity then try to work out what she needs to stay in control and in the present – if that is what she needs!

A general anaesthetic may provoke fear that a woman is totally out of control; other women may need a general anaesthetic in order to cope.

Elective caesarean There is no guaranteed safe path to travel through childbirth. It takes a lot of courage to face natural childbirth in our society, particularly for abused women, but the rewards are great. For some women, however, an elective caesarean is the only means of retaining control over the birthing process.

Postnatal care In the postnatal period many issues surrounding parenthood may arise. Constructive help from specialist groups could be appropriate to the needs of a woman who has been abused.

Overprotecting or underprotecting her children may be an issue that develops long after the midwife has discharged her.

Breastfeeding carries much emotional baggage for many women in our society which overemphasises the sexual appeal of the breasts at the expense of their physiological function. Midwives must be sensitive and aware that although, physically, a woman is likely to be able to breastfeed, emotionally it may not benefit her or her baby. The laudable desire to achieve 100% breastfeeding rates must not blind us to any emotional contra-indications. While I would be the first to advocate supporting all women as positively as possible about the benefits of breastfeeding, physically and emotionally this aspect must be considered.

Fear of their child being abused and the fear of abusing their own child is commonly something women will have come up for them. It would be sensible to encourage women to seek support if they feel that they may lose control and endanger their baby. Women can also be encouraged to develop openess with their children as they grow so the children will feel able to talk about anything uncomfortable happening to them.

Signs of abuse Many articles about childhood sexual abuse contain lists of characteristics and ways of spotting women who have experienced abuse. These can be very useful if used appropriately. However, they should not be taken as positively indicative of past abuse. You may recognise some of these signs in yourself while knowing that they are not the result of trauma in your childhood! Use the list to aid your intuition.

1. Anxiety
2. Highly stressed
3. May appear over anxious or stroppy
4. Inappropriate response
5. Hostility
6. Depression
7. Psychiatric illness
8. Post Traumatic Stress Disorder
9. Avoided antenatal care
10. Multiple unplanned pregnancies
11. Addictions
12. Multiple sexual diseases
13. Self destructive/ mutilation
14. Phobias especially of needles or body fluids
15. Gag reflex
16. Refuses interventions e.g. catheter
17. Recoils when touched
18. Insists on women caregivers (consider culture also)
19. Obsessive cleanliness
20. Sexual dysfunction
21. Low self esteem
22. Nakedness is an issue
23. Not wanting to lie on the bed
24. Somatic discomfort – abdominal pain – vaginal infections – painful intercourse – gastrointestinal disorders - eating disorders – insomnia, fear of sleep / dreams – migraines – neck pain – back pain

Helping women who may have been abused

Language. Think about the language you use: spoken, body and especially written. Are you using shallow phrases? Are you showing her the respect she deserves? When discussing procedures available to her be aware of her response to different words – 'relax' is a favourite for causing tension before an internal examination!

Reclaiming one's body. Encouraging perineal massage can help a woman to reclaim that part of herself as well as all the physical benefits.

Informed consent. We should be asking all women for informed consent and we should respect their decisions. When a woman consents to any intervention it may be helpful to explain what you are doing as you do it. Ask what she is comfortable with.

Education. An abused woman may welcome information on what behaviour most people would consider normal and what behaviour is not generally acceptable within a relationship.

Listening and focusing. Some women will present you with an impossibly long list of problems and concerns; encourage them to take control and select the most important things to deal with.

Flashbacks. When a woman is experiencing a flashback – remind her that this is a memory not the abuse. Stay close to her, don't let her go away without support.

Reassurance. Reinforce the fact that the woman is not to blame, it is not her fault; incest is not an act of love, it is never OK. Physical arousal during abuse does not constitute consent, it is merely a reflex bodily response to stimulation and does not imply emotional acceptance of the abuse. Children need love and affection not abuse and sex. Emphasise the fact that she is allowed to say no if she needs to - it is her body.

Avoid internal examinations. Minimise or avoid internal examinations altogether – use other ways to assess progress, for example watch out for the red line, use your excellent observational skills.

Minimising harm. If a VE is necessary, consider asking the woman to take up a position which she finds less threatening and is likely to trigger fewer memories.

Informed choice.

Epidural anaesthesia may make women feel invaded or it may remove them from pain.

Breastfeeding support should be hands off.

Avoid further abuse. Don't do anything you would find personally abusive.

Disclosure. Consider what your response would be if a woman disclosed abuse to you?

Provide a safe environment.

Listen to women in an unhurried environment.

Assure a woman that she is safe and affirm her strength.

Honour the emotion women are feeling.

Get some support for yourself. Ask your Supervisor or an ARM member.

Refer on. If you feel unable to help her directly then find an appropriate midwife, recommend counselling, homeopathy or therapy.

Provide a resource list of helpful books and organisations.

Conclusion
We are not always going to know which women have been abused. So how do we care for them? Why do we treat women who have been abused especially differently from women who have not? Don't all women deserve to be treated and cared for with respect, kindness, and tolerance? Don't all women need to be well informed and have autonomy and control of their bodies and babies? We do not always get the feedback; however, when you have helped to break the cycle of abuse for a woman, you may well have planted the seed for her to start her recovery and gain control over her body and life. Don't underestimate yourself or your actions. Next time you go to do something as a part of your routine consider how relevant it is and of what benefit it will be for the woman you are with.


REFERENCES AND FURTHER READING

1. Ainscough and Toon (1993). Breaking Free, Sheldon Press, London.
2. Bass and Davies (1988). The Courage to Heal, Cedar Press, London.
3. Burian J (1995). 'Helping survivors of sexual abuse through labor', American Journal of Maternal and Child Nursing, 20, 5, 252-256.
4. Coutois C and Courtois Riley C (1992). 'Pregnancy and childbirth as triggers for abuse memories: Implications for care', Birth,19, 4, 222-223.
5. Davies L (1991). Allies in Healing. A Support Book for Partners,Harper Row, USA.
6. Holz (1994). 'A practical approach to clients who are survivors of childhood sexual abuse', Journal of Nurse Midwifery, 39, 1, 13-18.
7. Parrat (1994). 'The experience of childbirth for survivors of incest', Midwifery, 10,1, 26-39.
8. Smith M (1998). 'Childbirth in women with a history of sexual abuse (1)', The Practising Midwife, 1, 5, 20-11 – Parts 2 and 3 follow in consecutive months.
9. Tilley J (2000). 'Sexual assault and flashbacks on the labour ward', The Practising Midwife, 3,4, 18-20.

Andrya Prescott may be contacted at: andrya@independentmidwife.com

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Dear Abby
Pregnant 14-year-old covering for teacher at school
Universal Press Syndicate - Dec. 17, 2003

DEAR Abby: I am 14 and pregnant. My baby's father is a 35-year-old teacher at my school. He doesn't know I'm pregnant, and I'm afraid if I tell him, he'll be mad.

My parents know I'm pregnant, and they are devastated. But they do not know who the father is.

I am having trouble sleeping, and I'm sick most mornings. What should I do? Please help. 

–– Pregnant in Milwaukee


Dear Pregnant: You MUST tell your parents who the father is. You need their emotional support, and I'm sure you'll receive it once they understand what has happened. You should not have to tell this teacher about your pregnancy alone. Your parents, the principal and the local police should do it with you. If he does get mad, it should be at himself for betraying his trusted role as an educator and committing statutory rape. Please do not be afraid to speak up, and don't blame yourself. What your teacher did is criminal.
 
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Genital Anatomy in Pregnant Adolescents: "Normal" Does Not Mean "Nothing Happened"
Kellogg ND, Menard SW, Santos A.
Pediatrics 2004 Jan; 113(1):E67-E69.


Many clinicians expect that a history of penile-vaginal penetration will be associated with examination findings of penetrating trauma. A retrospective case review of 36 pregnant adolescent girls who presented for sexual abuse evaluations was performed to determine the presence or absence of genital findings that indicate penetrating trauma. Historical information and photograph

documentation were reviewed. Only 2 of the 36 subjects had definitive findings of penetration. This study may be helpful in assisting clinicians and juries to understand that vaginal penetration generally does not result in observable evidence of healed injury to perihymenal tissues.

Departments of Pediatrics. Family Nursing Care, University of Texas Health Science Center, San Antonio, Texas. Alamo Children's Advocacy Center, San Antonio, Texas.


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Link between rape and pregnancy
BBC - June 20, 2001

It may be that ovulating women attract unwelcome attention

Scientists have made a disturbing finding about rape which they believe may explain why the crime has been so common throughout history.

They have found that a single act of rape may be more than twice as likely to make a woman pregnant than a single act of consensual sex.

This suggests, they say, that in a strictly biological sense, rape is a successful way for a man to spread his genes.

In our experience rape is used in domestic violence to exert power and control, and not necessarily to spread one's genes

But such a theory fails to take account of either the emotional trauma that rape causes, or the fact that for rape to be a successful evolutionary strategy the benefits of the crime have to outweigh the potential costs for the rapist if he is caught.

Psychologists have also warned that it may be misinterpreted by those seeking to justify the unjustifiable.


Violence study
New Scientist magazine reports that researchers Jon and Tiffany Gottschall, from St Lawrence University in Canton, New York, looked at data from a major study of violence against women.

They found that, of 405 women who had been raped between the ages of 12 and 45, some 6.4% became pregnant.

When women who had been using some form of contraception were removed from the calculation, the figure jumped to nearly 8%.

They compared this finding with a separate study which found the proportion of women in a similar age group who got pregnant from a one-night stand or other one-off act of consensual sex was just 3.1% despite the fact the women were not taking precautions.

The Gottschalls believe one possible explanation is that women feel more attractive and sexy when ovulating and unconsciously give off signals that rapists might pick up.

Another possible explanation is that rapists target attractive and healthy-looking women.


Difficult conclusions

Rape is complex behaviour which is often associated with power, control and sadism

Ged Bailes, head of forensic clinical psychology at the Norvic Clinic in Norwich, told BBC News Online, it was very difficult to draw any firm conclusions from a one-off study.

He said: "Rape is complex behaviour which is often associated with power, control and sadism.

"How do things like that fit into an evolutionary theory? And if this was the case why would some rapists want to kill their victim?

"We have to be very careful about making inferences of this type because there is a danger that they will reinforce some people's views about the myths surrounding rape."

Myra Johnson, communications manager for the Women's Aid Federation, a charity which helps women who have been the victims of domestic violence, warned against drawing the wrong conclusions from the report.

She said it was vital that any notion of a possible evolutionary basis for rape should not detract from the personal responsibility that a rapist had for the devastating impact of his actions.

She also told BBC News Online: "In our experience rape is used in domestic violence to exert power and control, and not necessarily to spread one's genes."
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Most Teens First Had Sex at Home
By LAURA MECKLER
The Associated Press - September 26, 2002


WASHINGTON (AP) - Parents wondering if their teenagers are having sex might look upstairs or down the hall. New research finds most sexually active teens first had sex in their parents' homes, typically late at night.

The findings, being released Thursday, should dispel myths that teens are most often having sex after school, when parents are still at work, researchers said. The message for parents, experts say, is nothing new: Be aware of what your kids are up to.

``Kids no longer need to drive to lookout point to have sex,'' said Sarah Brown, director of the National Campaign to Prevent Teen Pregnancy. ``The data suggest the adults may be in the house.''

By the time students are in the ninth grade, 34 percent have had sexual intercourse. That rises to 60 percent by 12th grade.

The report, by researchers at Child Trends, is based on a national teen survey that has been tracking about 8,000 teens since 1997. The ages of the teens ranged from 12-16 when the survey began, and researchers have interviewed the same group every year since then. This report looks specifically at the 664 teens who reported having sex for the first time between 1999 and 2000.

Of those surveyed in 2000, 56 percent said they first had sex at their family's home or at the home of their partner's family.

Another 12 percent had their first sex at a friend's house; 9 percent at a teen's own home; 4 percent in a truck or car; 3 percent at a park or other outdoor place and 3 percent at a hotel or motel. Ten percent said someplace else.

The findings reinforce earlier research that parents can have a significant impact on their children's decisions about sex, Brown said.

``This notion that it's impossible to supervise kids is ludicrous if a lot of them are having sex in the rec room,'' she said.

Earlier this month, researchers reported that teen girls who are close to their moms are more likely to stay virgins. That report, by researchers at the University of Minnesota, also found that half of mothers of sexually active teens didn't realize their children were having sex. Further, while the vast majority of mothers strongly disapprove of their teenager's having sex, large numbers of teens don't realize how their moms feel.

``Parents need to know where their children are and what they're doing,'' Brown said. ``This is not a new idea.''

As for timing, Thursday's report found 42 percent of teens said their first sexual encounter was at night, between 10 p.m. and 7 a.m. Another 28 percent said it was in the evening, between 6-10 p.m.

Just 15 percent said it was in the late afternoon, between 3-6 p.m.

That cuts against the conventional wisdom among parents and policy makers alike that teens are more ``at risk'' of sex after school, said Jennifer Manlove, a researcher at Child Trends.

Research has shown that teens are more likely to commit crime during the after-school hours, Brown said. But people have wrongly assumed that the same goes for sex, she said.

The National Longitudinal Survey of Youth did not look at whether teens were having sex on weeknights or weekends. And it did not ask if parents were home at the time. Although the survey has been interviewing teens since 1997, this was the first year the questions about where and when teens first had sex were asked.

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What Do These Women Have in Common?
Murder and Pregnancy
By April Greer. Evelyn Hernandez. Carol Stuart. Laci Peterson.


What do all of these women have in common?

They were all pregnant when they were murdered.

A 2001 study by the Journal of the American Medical Association showed that homicide was the most common cause of death among pregnant women in Maryland. This study is easily extrapolated to the rest of the United States, and this number is probably higher in reality because only 17 states and New York City list on death certificates whether or not a woman was pregnant at the time of death. This study was undertaken to categorize the major health risks associated with pregnancy. The results were a surprise to researchers.

But not to women's advocates.

And who are these killers? Foreign terrorists? Domestic terrorists? Mad slashers from teenage horror movies? A stranger hiding in the bushes?

No.

The killers are most often fathers of the child; the boyfriend or husband of the victim; the guy next door. Women's advocates know that the main reason men abuse women is control. And in pregnancy, many men feel that they have totally lost control over the body of their wives or girlfriends and lost control over the course of their own lives. Sadly, in many of these cases the families of the murdered women didn't even know there was a problem in the marriage, because of the shame that abused women feel. Domestic abuse remains a big secret because of this shame, and all too often situations escalate until murder occurs.

Most women stay with their batterers because they hope things will improve. Unfortunately, the situation almost always gets worse. The violence becomes more frequent, and the level of force increases over time. The only way to break the cycle of violence is to get away.

In Why Do Women Return? I highlighted the obstacles that battered women face when they try to escape before they are killed. In this article, I'll give you ideas on how to overcome those obstacles.

The majority of reasons that battered women return to their batteres are due to basic economic necessities:

• A place to live
• Food
• Medical care
• Child care

Until society helps meet these needs, battered women will find it very difficult to escape their abusers.

If you need to escape an abusive situation, your best resource is your local Women's Shelter. That name and phone number will be listed in the front of your local phone book, or you can find it at the link just mentioned. You can also call Information or the police to find a shelter or crisis center in your area.

Each state has different resources and different laws, so talking to an expert at the shelter or crisis center is the best way to find help available in your area. These resources are there to help you, so don't hesitate to ask for help.

Ask if there are women's shelters in your area, or if transitional housing is available. Even if you don't intend to leave when you talk to these experts, just learn about the help available to you and come up with a plan for the future.

Ask the advocates about the shelters. Are they nearby? Are they full? If you have a teenage son, are there provisions to help him too? Talk over the details of your situation and explore your options. If your medical insurance is in your batterer's name, what are the alternatives in your state? Are there educational grants for battered women? What about internship or jobs programs? Are there government child care centers or job training programs?


Murder and Pregnancy
If the shelters are full or there aren't any available, think about alternatives. You will need a safe place to stay so you can get back on your feet. The length of stay will depend on your emotional and financial needs. If your parents or a sibling would welcome you into their home, in many ways that is better than a shelter. You will be back among people who love you; you will be back in a ready-made support system. But remember that you will probably still need the services of the crisis center for support groups, help with court systems and restraining orders, and other forms of emotional and physical healing.

Often, the batterer has worked very hard to isolate his victim. He has insulted her friends, driven off her family, and made life unpleasant for anyone who can give her support. If you are in that type of situation, don't despair. It may feel like you have no friends, but that is not the case. The friends and family members he has driven off still love you. Even if you defended him or told them to mind their own business, they know this situation is his fault. They still think about you. They wish there was something they could do. If you called them, they would be relieved and delighted to help you. It's difficult to reach out for help. The shame you may feel can be overwhelming. But your friends and family would much rather have you safe and alive.

It's very difficult to leave an abuser. But there are people and organizations out there that can help you. Start with a phone call to a hotline. Talk about your options. Your call can be totally anonymous. Learn about the powerful friends you have in law enforcement, the courts, the medical system. Like any tool, you have to know what the system can do for you. Discuss your situation with an expert at a crisis center. They will be happy to work with you to develop a safety plan.

And if you are a friend or family member of a woman whose husband has tried to isolate her, take the first step yourself and call her. Ask if she is safe. Remind her that you care about her and only want the best for her. This simple action may save a life.
____________________________________________________________________________________

Politics Of Rape And Contraception
CBS Evening News - LOS ANGELES, June 9, 2005

Lori Robinson is a survivor.

"When I got to my front doorstep I saw the barrel of a gun pointing at my head," she says. "I was rushed up to my apartment, blindfolded and gagged with duct-tape and tied down on my bed, and I was raped by two strangers."

She feared disease, emotional collapse but not pregnancy, because the hospital in Washington D.C. offered her emergency contraception.

Being told about the emergency contraception, she says, "in that time of total devastation, it was a relief."

But, as CBS News Correspondent Bill Whitaker reports, it wasn't a right, because these days emergency contraception is embroiled in the bitter politics of abortion.

Now, there's some confusion over just what emergency contraception is. It is not RU-486 - the pill which can cause an abortion early in a pregnancy. Emergency contraception is also known as the morning-after pill. Taken soon after a rape, it can actually prevent a pregnancy.

In Colorado, a measure that would have required hospitals to offer emergency contraception to rape victims was vetoed by the governor.

He was strongly supported by the Catholic Church, which calls it tantamount to abortion.

"If ovulation has occurred, there's a potential for new life in that woman, so then the church's responsibility is to protect both the woman and the new baby," says Alia Keys, coordinator of the Office of Marriage and Family for the Archdiocese of Denver.

The federal government is siding squarely with religious conservatives. Dr. Michael Weaver helped draft national guidelines for rape victims, which strongly recommended offering the morning-after pill.

But when the Justice Department released the final version, all mention of emergency contraception had been removed.

"If indeed this prevents an unwanted pregnancy then that subsequently prevents abortions down the line," says Weaver of St. Luke's Hospital in Kansas City.

Some 25,000 women become pregnant from rape each year. To this rape survivor, there is no debate.

"How dare someone tell me what's best," says Robinson.

But for many hospitals and physicians it's a moral issue.

"I think that it's not their decision to make," says Robinson.

Right now, that depends where a rape occurs.
____________________________________________________________________________________   
Sexual Trajectories of Abused and Neglected Youths
Brown J, Cohen P, Chen H, Smailes E, Johnson JG.
J Dev Behav Pediatr 2004 Apr; 25(2):77-82.


ABSTRACT.: The study objective was to examine whether childhood abuse or neglect is associated with the age of onset of puberty and sexual and romantic behavior. A cohort of children (the Children in the Community study) was randomly selected and studied prospectively from childhood to adulthood. A sample of 816 youths were interviewed in their homes at a mean age of 14, 16, and 22 years in 1983, from 1985 to 1986, and from 1991 to 1994. The outcome measures included age of menarche, signs of male puberty, first being in love, dating, sexual intercourse, and pregnancy reported by youths. Child abuse and neglect were measured by official records and youth reports. A history of two or more incidents of sexual abuse was significantly associated with early puberty and early pregnancy after gender, class, race, paternal absence, and mother's age at the birth of the study child were controlled statistically. Public education regarding risk for premature sexual behavior among youths who have experienced sexual abuse is warranted. Efforts to prevent teenage pregnancy should include monitoring and educating sexually abused children as they enter puberty.

From: Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York; Columbia University School of Medicine, New York State Psychiatric Institute, New York.

____________________________________________________________________________________



Sexual Trauma and Pregnancy: A Conceptual Framework
Carie S. Rodgers, Ph.D.; Ariel J. Lang, Ph.D.; Elizabeth W. Twamley, Ph.D.; Murray B. Stein, M.D.
J Womens Health 12(10):961-970, 2003.


Abstract and Introduction

Abstract
In this paper, we propose that a history of sexual traumatization is associated with pregnancy complications and poor pregnancy-related outcomes. We further hypothesize that this relationship is mediated by the sequelae of trauma (psychopathology, health problems, and increased negative health behaviors). We review the literature linking sexual trauma with psychopathology, health, and health behavior and then outline the impact of these variables on pregnancy. Based on this review, we draw conclusions about the potential impact of sexual trauma on pregnancy outcomes. We suggest future directions for this area of research and discuss the clinical implications of this association, including the development of prenatal intervention and prevention programs.Introduction

Although estimates of sexual trauma vary considerably, epidemiological evidence suggests that it is a major societal problem. Lifetime estimates in women range from 7% to 17% for sexual assault, 3%-15% for rape,[1] and as high as 30%-50% for sexual harassment.[2] A history of sexual trauma (including sexual molestation, sexual assault or rape in either childhood or adulthood, and sexual harassment) is associated with (1) increased rates of psychopathology, (2) more frequent health problems, and (3) negative health behavior (i.e., behavior with a known negative impact on health outcomes).

Given the high prevalence of sexual trauma, it is likely that a substantial proportion of pregnant women have been victims of sexual trauma at some point in their lives. Further, sexual traumatization is associated with a number of behaviors that are known to negatively affect maternal health and the health of the fetus. In spite of this, very little research has examined the impact of psychiatric and physical health consequences of sexual trauma on pregnancy. Therefore, it is important to examine the nature of the relationship between exposure to sexual trauma and pregnancy outcomes. Our primary purpose in this paper is to generate hypotheses about the association between maternal history of sexual trauma and pregnancy outcome.

We first present literature linking sexual trauma to psychopathology, health problems, and negative health behaviors. It is our intent to provide an overview of these topics and present a few specific examples of the literature on these topics. We chose to include only quantitative studies in this paper, and studies that employed case studies or very few participants were excluded. Most of the studies cited were published after 1995, and all were indexed either in PsycInfo or MEDLINE databases. Many authors have examined these issues more completely than we do here, and the reader is referred to comprehensive reviews of these topics where appropriate.

Next, we outline the impact of psychopathology, health problems, and negative health behaviors on pregnancy and thereby hypothesize about the associations of maternal sexual trauma experience with pregnancy outcomes. We present a conceptual framework relating sexual trauma and pregnancy outcome mediated by increased psychopathology, poor health behaviors, and health problems. Finally, we discuss the implications of the proposed framework for prenatal care and pregnancy outcomes.


Sexual Trauma and Psychopathology
Female sexual trauma survivors are at high risk for multiple psychological problems. Many thorough review papers have been published in the last decade examining both the short-term and long-term psychiatric sequelae of sexual trauma.[3-5] It is our intent to highlight some of the more prevalent disorders that follow sexual trauma.

Posttraumatic stress disorder (PTSD) frequently is associated with exposure to sexual trauma. Norris[6] found that sexual assault was associated with a higher rate of current PTSD than other types of criminal victimization, natural or man-made disasters, or accidents. In our own work using a self-report measure of PTSD-related symptoms, we found that 47% of female military veterans with adult sexual assault or rape histories scored in the range associated with diagnosable PTSD, compared with 16% of the women without such a history.[7] In a nationally representative sample of the United States, Molnar et al.[8] reported that women who reported childhood sexual abuse were eight times more likely to be diagnosed with PTSD than women with no history of childhood sexual abuse. Not only are PTSD symptoms distressing and impairing, but also they increase the risk of additional psychopathology.[9-12]

Other anxiety symptoms appear to be prevalent in sexually traumatized women as well.[13,14] Falsetti and Resnick[11] found that 69% of participants seeking treatment for sexual trauma-related symptoms reported having panic attacks. Interestingly, Leskin and Sheikh[15] found higher rates of both adult and childhood sexual assault in a community sample of panic disorder patients without comorbid PTSD than in a community sample of PTSD patients. Stein et al.[16] compared a clinical sample of women with anxiety disorders (panic disorder, social phobia, and obsessive-compulsive disorder) with an age-matched and gender-matched community sample and found that women with anxiety disorders were significantly more likely to report childhood sexual abuse histories. Similarly, patients seeking psychiatric care who meet criteria for multiple anxiety disorders have increased rates of childhood abuse over patients with only one anxiety disorder.[17]

Depression frequently occurs soon after exposure to a traumatic event and is often present for months after the event.[18] Hankin et al.[19] found that outpatient female military veterans who reported being sexually assaulted as adults were three times more likely to screen positive for depression than were those who did not report such a history. Similarly, in a nationally representative sample of the United States, Molnar et al.[8] found that women who reported childhood sexual abuse but reported no other lifetime traumas were 3.8 times more likely to meet criteria for a major depressive disorder (MDD). Sexual abuse during childhood has been linked to chronic or recurrent episodes of major depression in both community and clinical samples,[20, 21] and suicide attempts in depressed adults.[22] In a systematic review of the literature on childhood sexual abuse and adult depression, Weiss et al.[23] found that women who were sexually abused in childhood were more likely to develop depression in adulthood. This pattern was consistent across studies and appears to be stronger for women than for men.

Sexual trauma also appears to be associated with personality disorder and dissociative symptoms. In studies of inpatients, Zanarini et al.[24] found sexual trauma to be a risk factor for dissociation. In addition, women with a diagnosis of borderline personality disorder were more likely to have experienced rape in adulthood than were axis II controls.[25] Yen et al.[26] examined the prevalence rates of sexual trauma in a community sample of participants diagnosed with personality disorders or MDD. They report a stronger correlation between the diagnosis of borderline personality disorder and physically forced/unwanted sexual contact, rape, and witnessing sexual abuse in either childhood or adulthood than in participants with other disorders.

Although research investigating sexual trauma and psychopathology consistently points to a relationship between these variables, many of the studies in this area are limited by confounders that are difficult to control for outside of randomized experimental designs. Most of this literature relies on retrospective self-report rather than more objective measures of both trauma and psychopathology (i.e., police reports, diagnoses based on structured clinical interviews), leaving unexamined the possibility of either overreporting or underreporting of variables. In addition, variables such as socioeconomic status, race, and other forms of trauma are difficult to control for but likely overlap significantly with sexual trauma.

Two recent studies have addressed some of these confounding variables in the relationship between childhood sexual abuse and psychopathology by examining samples of twins. Dinwiddie et al.[14] and Kendler et al.[27] examined the prevalence of psychiatric disorders among community samples of twins who were discordant for childhood sexual abuse, thus controlling for possible confound such as family environment or genetic vulnerability. Kendler et al.[27] found that women with childhood sexual abuse are at greater risk for developing psychopathology later in life and that this pattern was stable in comparing an exposed twin in a twin pair discordant for childhood sexual abuse with a nonexposed sibling. Similarly, Dinwiddie et al.[14] found nonsignificant trends for increased rates of psychopathology in abused twins when compared with nonabused co-twins.


Sexual Trauma and Health
Sexual trauma can have a direct impact on a woman's health. During a traumatic event, a woman may be injured or exposed to a sexually transmitted disease (STD). Both childhood sexual abuse and forced rape have been associated with reported STD-related symptoms and diagnosis as well as more episodes of different STDs.[28-30] Sexual trauma may also indirectly increase the likelihood of injury. For example, past work has shown that a sexual trauma history is associated with injury as a result of involvement in abusive relationships. In one study, college students who had been raped were more likely to have been in a physical fight with a boyfriend or spouse than women who had not been raped.[31] Cohen et al.[32] found that childhood sexual abuse was strongly associated with later domestic violence. When compared with women who have not been sexually abused, women with a history of sexual abuse report that their intimate relationships involve more incidents of severe forms of violence, such as hitting, kicking, and beating.[33] This increased severity of intimate partner abuse has the potential to lead to more serious injury (during pregnancy and at other times).

In community samples as well as samples of medical patients, female victims of rape or sexual assault in adulthood perceive their physical health as poorer and report more somatic symptoms and pain than do nontraumatized women.[34-36] In addition, women who report histories of either adult or childhood sexual assault/molestation or rape report higher rates of chronic illnesses, most commonly gastrointestinal and gynecological, but also including respiratory disorders (e.g., asthma, emphysema, and bronchitis), peptic ulcer disease, heart problems, hypertension, arthritis, and diabetes.[34,36-38] Gynecological complaints associated with sexual trauma include dysmenorrhea, excessive menstrual bleeding, sexual dysfunction,[39] abnormal Pap smears, pain in the lower abdomen other than during menstruation,[7] burning sensation in sexual organs, and pain during intercourse.[37] Golding et al.[40] interviewed women seeking treatment for severe premenstrual syndrome (PMS) and found that at least one attempted or completed sexual abuse event was reported by 95% of the sample and that 81% of these women reported being raped.

Given their higher rates of reported symptoms and illness, it is not surprising that traumatized women show higher rates of physical disability[37] and increased use of medical facilities.[41,42] Although the reasons for the association between sexual trauma and health problems are not well understood, differences in current symptomatology do not appear to be attributable to higher rates of past illness or family history of illness among traumatized women.[34]


Sexual Trauma and Negative Health Behaviors
There is growing evidence that female victims of sexual assault engage in more negative health behaviors than women without sexual trauma histories. One such type of behavior is substance use. Several studies have shown that traumatized women are more likely to smoke, begin smoking earlier, and smoke more heavily than nontraumatized women.[7,31,35,43,44] Increased risk of alcohol use disorders among traumatized women also has been demonstrated.[10,45] Traumatized women have been shown to drink more heavily than women without a trauma history,[31,35] are more likely to screen positive on an alcohol abuse/dependence measure,[7] more frequently engage in risky behaviors in conjunction with drinking, such as driving,[31] and report feeling the need to decrease alcohol use.[43] Traumatization also has been associated with problematic illicit drug use.[43] These studies included clinical as well as community samples and included women with histories of sexual assault and rape during childhood or adulthood or both.

Another negative health behavior that has been associated with trauma is failure to maintain healthy body weight. A number of studies have shown greater rates of obesity in traumatized women.[36,43,46] In one study, criminally victimized women were more likely than women without such history to report overeating.[35] In epidemiological and medical clinic samples, traumatization has been associated with eating disorder symptoms, as well as disturbances in eating patterns and body image.[47,48] Little research to date, however, has examined possible determinants of these outcomes, such as poor diet and lack of regular exercise.

Sexual trauma also appears to be associated with risky sexual behaviors. Victims of childhood sexual abuse report earlier initiation of voluntary sexual intercourse, more total partners, and more pregnancies before age 18 than nonabused women.[7,43] They are more likely to have multiple sexual partners and to have sex without knowing a partner's sexual history.[7] Women who have histories of sexual assault in either childhood or adulthood are more likely than nontraumatized women to use alcohol or drugs in conjunction with sex,[31] engage in prostitution, have sex without contraception, and have sexual intercourse with partners at risk for HIV.[49,50] These behaviors put them at risk for both retraumatization and contraction of STDs.[29,51]

Similar to the literature examining the association between sexual trauma and pathology, this area of study suffers from confounding variables that are difficult to control. The studies reviewed here all assess sexual trauma history using retrospective self-report, and confounders, such as family environment and socioeconomic status, have not been controlled. Thus, it is important to stress that assumptions about causality cannot be made based on the current state of the literature in this area.


Trauma-Related Problems and Pregnancy
As we have established, sexual trauma is associated with numerous negative health-related outcomes. There is good reason to believe that trauma-related symptoms and behaviors put traumatized women at risk for poorer pregnancy outcomes as well.Psychopathology

Untreated psychiatric complications during pregnancy put both women and their children at higher risk for many negative outcomes. Maternal anxiety disorders have been linked with low birth weight and irritable neonatal behaviors as well as a doubled risk of hyperactivity in 4-year-old males.[52] Seng et al.[53] found that women with PTSD during pregnancy were at higher risk for ectopic pregnancy, spontaneous abortion, and hyperemesis than were those who did not have PTSD.

Depression during the prenatal and postnatal periods is of concern as well. Prenatal depression puts women at risk for lack of prenatal care, poor nutritional intake, and nicotine and other substance use.[54] In addition, infants of mothers who were depressed during pregnancy show changes in neurobehavioral functioning and are more withdrawn, irritable, and inconsolable than infants of asymptomatic women.[54] Postpartum depression appears to have detrimental consequences for the offspring, such as dysregulation in infant behavior, physiology, and biochemistry.[55] Prenatal and postpartum depression in women also has been associated with temperament difficulties in toddlers[56] and poor adjustment in 41/2-year-old children.[57]

Kelly et al.[58] examined the prenatal care received by all women giving birth in California in 1994 and 1995. They found that women who had been given a psychiatric or substance use diagnosis had more than three times the risk of inadequate initiation and use of prenatal care services. Women who do not receive prenatal care or who receive poor prenatal care (few visits or late term care) are at high risk for poor pregnancy outcomes, including low birth weight and fetal deaths.[59]Health

Sexual trauma has been associated with increased rates of a number of health problems. Many of these trauma-related health problems have implications for pregnancy. Pregnancy may alter preexisting medical conditions, and health problems may affect the pregnancy. For example, women with arthritis had offspring who were significantly lower in birth weight than those of women without arthritis.[60] Asthmatic women are at risk for idiopathic preterm labor, preeclampsia, hypertension, chorioamnionitis, and cesarean delivery, and their infants are at risk for preterm birth and low birth weight.[61] Women with heart disease are at risk for cardiac events during pregnancy as well as delivering premature and low birth weight babies.[62] Diabetes, too, puts women and their offspring at risk for poor pregnancy outcomes. Compared with those with gestational diabetes, women with pregestational diabetes were at greater risk for cesarean delivery and gestational hypertension or toxemia, and their offspring were at increased risk for preterm birth and need for neonatal intensive care.[63]

Involvement in a violent relationship during pregnancy places both the mother and offspring at high risk for poor outcomes. Women in abusive relationships are more likely to deliver by cesarean section and to be hospitalized before pregnancy for such complications as kidney infection, premature labor, and trauma due to blows to the abdomen.[64] The delivery of low birth weight infants[65] and infants who require neonatal intensive care[66] also is more common in women who have been subjected to partner violence during pregnancy.

STDs have been linked to adverse pregnancy outcomes, including ectopic pregnancy, premature rupture of membranes, preterm birth, and puerperal sepsis.[67] In addition, children born to women with STDs are at higher risk of having abnormalities of the major organ systems, and some STDs can be transmitted to the offspring.[67]Negative Health Behaviors

Many of the negative health behaviors associated with sexual trauma can have serious detrimental effects during pregnancy. Substance use often has far-reaching consequences on pregnant women and their offspring. The effects of nicotine, alcohol, and illicit drug use during pregnancy have been well documented. Smoking puts mothers at risk for having spontaneous abortions and puts infants at considerable risk for thyroid enlargement,[68] low birth weight, and deformities.[69] There is also evidence that maternal prenatal cigarette use predicts lower mental scores on the Bayley Scales of Infant Development (BSID) for infants up to 19 months of age.[70]

Poor outcomes are also related to alcohol use during pregnancy. Research points to an association between chronic maternal alcohol use and serious morphological and developmental abnormalities in the fetus.[71] Although not all alcohol-exposed children suffer from such severe conditions, other adverse neurocognitive outcomes, such as lower reaction times and reduced attention spans, have been linked to intrauterine alcohol exposure.[72]

Use of illicit drugs is problematic during pregnancy. For example, third-trimester marijuana use has been linked to decreased scores on the BSID.[70] Marijuana use during pregnancy has been linked to hyperactivity, impulsivity, inattention, delinquency, and externalizing problems in children as old as 10 years of age.[73] Prenatal cocaine exposure is associated with impaired auditory information processing,[74] increased risk of spontaneous abortion, premature labor, stillbirth, and microcephaly.[75] Use of heroin or other narcotics can cause preterm birth, fetal death, addiction in the fetus, low birth weight, and cognitive and behavioral problems in the offspring. In addition to a multitude of problems for the mother, PCP use can lead to low birth weight and poor motor control in the baby. Finally, use of LSD and inhalants has been associated with birth defects.[76]

Unhealthy eating is another negative health behavior associated with poor pregnancy outcomes. Lower birth weight and length have been linked to maternal disturbances in eating behavior.[77, 78]

Prepregnancy obesity has been associated with increased risk for gestational diabetes, preeclampsia, eclampsia, cesarean delivery, delivery of a macrosomic infant,[79] anencephaly, spina bifida,[80] and antepartum death.[81] Baeten et al.[79] found a significant increase in the risk of infant death in the first year after birth for offspring of obese women.

Women with eating disorder symptoms during pregnancy are at higher risk for cesarean section and have more difficulty maintaining breast-feeding than women without eating disorder symptoms.[78, 82] They also frequently continue to show eating disorder psychopathology after delivery and are at high risk for postpartum depression.[78, 82]

Good nutritional intake and appropriate levels of regular exercise are important to healthy fetal development. For example, folic acid intake has been linked with neural tube closure,[83] and low gestational weight gain appears to be associated with higher risk of neural tube deficits.[84] Excessive gestational weight gain, on the other hand, puts women at risk for hypertension.[85] Regular exercise (three to four times per week) appears to be important for fetal development. Clapp et al.[86] found that the offspring of women who engage in this type of exercise behavior are neurodevelopmentally more advanced than the offspring of nonexercisers. However, both excessive exercise (>/=5 times per week) and low levels of exercise (</=2 times per week) are associated with low birth weights in infants.[87]

Based on the information presented, we have developed a conceptual framework relating sexual trauma and pregnancy outcome. We believe that sexual trauma negatively affects pregnancy outcomes and that this relationship is mediated by psychopathology, health, and health behaviors (Fig. 1). Specifically, we hypothesize that women who have been victims of sexual trauma have higher levels of depression and anxiety disorders, including PTSD. They also report more somatic symptoms, pain, and chronic illnesses and are at high risk for obesity, tobacco, alcohol, and illicit drug use, and risky sexual behaviors. We hypothesize that they have poorer nutritional intake and more disordered eating behaviors and engage in significantly less exercise than women who have not been sexually traumatized. Most importantly, we believe that these problems will be present during pregnancy, thus increasing the risk of poor pregnancy outcomes (e.g., pregnancy complications, pain and complications during delivery, and premature births) and negative effects on offspring.


Figure 1. A conceptual framework relating sexual trauma and pregnancy outcome.

There is a clear need for more work in this area. First, the relationship between sexual trauma and poor pregnancy outcomes should be examined, controlling for potential confound (e.g., low socioeconomic status and ethnicity). Further, if the hypothesized association between sexual trauma and poor pregnancy outcomes is established, the determinants of this relationship (i.e., mediating variables) should be investigated. We recognize that there are probably relationships among the mediational variables that should be examined. For example, we speculate that poor health leads to increased psychopathology and that psychopathology and poor health (alone or in combination) increase negative health behaviors. In addition, although this paper focuses on sexual trauma, the conceptual model we propose may be relevant to other forms of trauma and violence as well, such as physical abuse, emotional abuse, and other forms of domestic violence.

Establishing such a conceptual model is important because it provides a theoretical framework on which to design effective interventions that target pregnancy outcomes. Women with a trauma history may respond better to prenatal care programs that not only address basic health issues during pregnancy but also target sequelae of sexual trauma, including trauma-related psychopathology, health problems, and negative health behaviors. For example, it may be important to directly address PTSD or depression in a prenatal intervention for sexual trauma victims. An improvement in mental health may indirectly improve physical health and decrease negative health behaviors, eventually resulting in better pregnancy outcomes.

We also believe that women with a history of sexual trauma may be at higher risk for developing problems related to the stress of pregnancy. If this hypothesis is supported, the model we propose may inform the development of preventive services for pregnant women. For example, re-lapse rates for substance use may increase, and traumatized women may be at higher risk for developing depression during pregnancy. Education about these risks and other impacts of trauma-related symptoms on pregnancy health and outcomes is an essential component of such a program. In addition, increased physician monitoring may significantly reduce pregnancy complications and poor pregnancy outcomes in these patients.

In order to provide optimal care to these patients, identification of women with a history of sexual trauma is important early in pregnancy. We suggest asking routine screening questions as part of a comprehensive medical interview during the first prenatal obstetrics visit. Read et al.[48] piloted such a screening at a veterans' women's health clinic and found that 32% of their sample reported some history of sexual trauma. They reported that this type of screening was both viable and useful and that women were more likely to report a sexual trauma background if asked when they were seeking gender-specific services. The screening questions did not interfere with patient medical care, and many patients reported that they had never been asked about their sexual trauma history and were appreciative that their experiences were being addressed.

A history of sexual trauma could be construed as another factor associated with an at-risk pregnancy. Such women could then be handled accordingly, with more careful monitoring by their healthcare team, specifically for mental health symptoms, exacerbations of physical health problems, and negative health behaviors. Referrals to mental health providers should be offered if follow-up care for mental health issues becomes necessary or appears to underly physical health problems. Empirically validated interventions designed specifically to address sexual trauma may be appropriate to address symptoms in this population.[88] The conceptual framework presented in this paper indicates that special attention to physical and psychological symptoms in victims of sexual trauma may help prevent poor pregnancy outcomes in this at-risk group.

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Teenage pregnancy and associated risk behaviors among sexually abused adolescents
By Saewyc EM, Magee LL, Pettingell SE.
Perspect Sex Reprod Health. 2004 May-Jun; 36(3):98-105.


CONTEXT: Previous research suggests a link between adolescent pregnancy and sexual abuse history, but most studies have used clinical samples of females only and single measures of abuse.

METHODS: Associations between pregnancy involvement, risk behaviors and sexual abuse were examined in sexually experienced teenagers from the Minnesota Student Surveys of 1992 (N=29,187) and 1998 (N=25,002). Chi-square tests assessed differences in pregnancy involvement and related risk behaviors among four groups of adolescents, categorized by type of abuse experienced: none, incest only, nonfamilial only or both. Odds ratios for pregnancy involvement and risk behaviors, adjusted for grade level and race, were calculated for each gender by using logistic regression analysis.

RESULTS: Sexual abuse was reported by 6% of males and 27% of females in 1992, and by 9% and 22% in 1998. Reports of pregnancy involvement were significantly more common among abused adolescents (13-26% of females and 22-61% of males, depending on type of abuse) than among nonabused adolescents (8-10%). Abused adolescents were more likely than others to report risk behaviors, and teenagers reporting both abuse types had the highest odds of pregnancy involvement and risk behaviors. The differential in the odds of pregnancy involvement and most behaviors was larger between nonabused and abused males than between nonabused and abused females.

CONCLUSIONS: Teenage pregnancy risk is strongly linked to sexual abuse, especially for males and those who have experienced both incest and nonfamilial abuse. To further reduce the U.S. teenage pregnancy rate, the pregnancy prevention needs of these groups must be adequately addressed.

Author contact: Center for Adolescent Nursing, University of Minnesota School of Nursing, Minneapolis

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The interface between psychiatry and obstetrics: Comprehensive perinatal care
By Werner Tschan, MD, Psychiatrist in Private Practice - Email: tschankast@bluewin.ch
Presented at: 157th American Psychiatric Association Annual Meeting at New York, NY
Thursday May 04, 2004 : 11:00am-12:30 pm - Lyceum Room, Fifth Floor, Marriott Marquis


Abstract
Mental health issues in pregnancy and postpartum are often neglected by obstetricians just as the puerperal period is foreign to psychiatrists. This places women at risk for undiagnosed mental disorder. At Basel University we established a comprehensive care program with close cooperation between obstetricians and psychiatrists.

Johannes Bitzer: The role of the obstetrician in detecting mental disorders in pregnant women. The focus will be on instruments for obstetricians to detect mental disorders. Examples will be discussed: posttraumatic stress disorder (PTSD), affective disorders, personality disorders, wishes for primary caesarian section, etc.

Maria Hofecker: The role of the psychiatrist in early perinatal care. The focus will be on psychiatric treatment, crisis intervention, parenting assessment, and rehabilitation.

Werner Tschan: Psychiatric follow-up care of the patient, the new-born and the partner. The focus will be on outpatient care in the community, treatment of psychiatric disorder, networking, systemic-oriented care involving the family, experiences, and techniques in medium and long-term care.


Psychiatry and birth
Although psychiatrists are involved in almost all parts of the life-circle, their experience and knowledge has been widely neglected by obstetricians. Until the mid 1990s only little research has examined the impact of traumatic events on pregnancy and post-partum outcomes. The traditional risk assessment is based on "hard facts", such as laboratory and ultrasonic findings. The emotional reality is in most cases not included into the risk assessment. In accordance with other authors (Rodgers et al. 2003) we propose that a history of sexual traumatization and emotional neglect is associated with pregnancy and post-partum complications. According to results from the affective neuroscience we have clear evidence that traditional western dualistic metaphysics with the distinction between mental and physical illness is a misleading conception (Panksepp 1998). Often mental illnesses are in general less accepted and often regarded as somehow not quiet real, with an implication of weakness, fault, or loss of reasonable thinking in patients who have those (Sharpe et al. 2001). There is considerable evidence, however, how CSA (child sexual abuse) and neglect affects self-esteem (Fonagy et al. 2002), personal development, and both neuroendocrine and neuroanatomic reactions (Heim et al. 2001, Meany et al. 2003). Attachment Theory provides us with a framework for how the effects of disturbed relationships in case of child abuse and neglect are related to further developments. Finally, the revolutionary new diagnostic approach provided by PTSD and DID (Dissociative Identity Disorder), which was integrated 1980 into the DSM III and later revised in DSM IV (1994), helps to better understand the mediation role of psychological trauma on the individual's development.

Today, the psychological approach to somatic problems uses more of a psychophysiological concept to explain personal imbalances and diseases. The research focuses on characteristic physiological reactions (stimulus-response specifity), and whether different individuals react in characteristic ways to stimuli (individual-response specifity). The influence of the traditional approach of psychosomatic medicine has now decreased. However, it is important to note that much of the early work on somatic disorders was based on patients who were seen after several previous medical referrals, ineffective attempts at treatment, and a variety of potentially conflicting explanations of the problem (Salkovskis 1989). It often leads to a well known outcome: the patient is told after many months or even years of medical investigation that there is no further medical treatment and that the only avenue for further help is through the acceptance of psychological help (Salkovskis). Therefore, patients perceive themselves as having a psychiatric problem arising out of their chronic somatic condition, and also become distressed with the failure of medical treatment. Psychiatric treatment then becomes a "last resort", which is definitely not an ideal precondition for a successful outcome.

Psychiatrists are involved in child and adolescent treatment, as well as in adult treatment of both male and female patients. Furthermore they are involved in the treatment of martial and family problems, in difficulties of sexual life, in aging and in death. The knowledge we gain from both women and men regarding birth problems enables psychiatry to provide a conceptual framework for obstetricians who want to improve their risk assessment by including emotional aspects. We will focus in our presentation on the impact of psychological trauma (e.g. sexual abuse and emotional neglect) on pregnancy and post-partum outcomes. We will discuss the implications on prenatal care, the risk assessment and the post-natal outcomes including the long term care for both the newborn and the parents.

The identification of women suffering from sexual abuse and emotional neglect is important early in pregnancy. Establishing a risk assessment leads to an increased monitoring of these women, that may help to significantly reduce pregnancy complication, to identify risk factors, and can also help increase pregnancy outcomes. Without a conceptual framework of both prevalence and implications of CSA and other forms of devastating experiences, the clinical is not able to perform this risk assessment. We also have to consider that some women are sexually abused by professionals while searching help and support. The devastating experiences of PSM (Professional Sexual Misconduct) can lead to phobic reactions towards professionals, and undermines trust in the health care system. In self-reporting questioners 3-4% of gynecologists disclosed a sexual relationship with current or former patients (Wilbers et al. 1992).


Somatic versus mental problems
The are four main avenues which lead to psychological problems related to attachment experiences: (1) sexual violence (2) physical violence (3) emotional violence, and (4) abuse and neglect. The detection of traumatic events in patient histories is in most cases difficult for a variety of reasons. The majority of patients usually do not consider a link between their actual symptoms and the past traumatic experiences, which often happened years, if not decades, ago. Furthermore, feelings of shame, loyalty, and guilt often undermine the ability to openly disclose what had happened to women, further increased by the fear of not being believed or being blamed. The diagnostic procedure always rests with the clinician, therefore, the creation of a trustworthy doctor-patient relationship is the main precondition for disclosing these experiences. The duty to build up and maintain a "secure base" is one the physicians first tasks. The PTSD concept can serve as a comprehensive model, how psychiatrists come to their diagnoses: is there a relation between the current symptoms and past traumatic and threatening experiences, which leads to a functional impairment? This approach is illustrated by the following figure:


Traumatic symptoms:

• event ( reexperiencing(flashbacks, nightmares)
• avoidance (phobic avoidance of own memory)
• hyperarousal (hypervigilance, irritability)
• emotional numbing

Aside from the exposure to one or more traumatic events, the diagnosis requires a characteristic response, such as intense fear, helplessness, or horror, and the symptoms must lead to a significant distress or functional impairment. There was reluctance among health professionals to acknowledge that PTSD can also occur following childbirth, and women have not been offered appropriate treatment (Lyons 1998). Kitzinger (1992, quoted in Lyons) proposed that there are similarities between traumatic obstetric experiences and the experience of sexual assault. In childbirth, as in rape, a woman may be stripped, forcibly exposed, her legs splayed and tethered, and her sexual organs put on display to all comers. The woman is no longer of control of her own body and of her intimacy. This may trigger horrifying past experiences such as sexual abuse histories.

However, in most cases of severe and repeated trauma during childhood, the psychological response is different from this simplified pathogenic model as suggested by the PTSD-concept. When complex traumatic experiences such as chronic sexual child abuse (by own father or less common by own mother) occur, the outcome is more characterized by DID, personality disorder, depression, psychosis, substance abuse, and somatic problems such as eating disorder, chronic pain disorder, fibromyalgia, chronic urogential problems, etc. The link to severe trauma in all these diagnostic entities is based on rather new results - mainly stimulated by research following the implementation of PTSD and DID since 1980. The vast majority of these studies were published after 1995.

How common traumatic experiences such as sexual abuse are, is a matter of how the sexual abuse is defined. If someone uses a narrowly defined approach or includes non-contact experiences such as exhibitionistic behavior, leads to a great variation of research findings (see next paragraph). The recently published World Report on Violence and Health by the WHO (2002) estimates that about 20% of all women worldwide, and up to 10% of all men, suffer sexual violence as children or adolescents. Russel (1983, 1986) reported in a study that 38% women in the sample had suffered sexual abuse involving physical contact, whereas the figure was 54% when experiences involving non-contact were included. Therefore we agree with Rodgers et al. (2003): "Given the high prevalence of sexual trauma, it is likely that a substantial proportion of pregnant women have been victims of sexual trauma at some point in their lives."

Detrimental past experiences can lead to avoiding pregnancy or to fear of childbirth. Several authors showed that there are women who need to deliver by caesarean section because of their previous negative experiences of childbirth (Ryding 1993). Current research suggests that it is not possible to determine whether a traumatic event or experience will trigger a post-traumatic response for a given individual (Lyons 1998). Flashbacks may be triggered by pain, touch, not being in control, lack of privacy, and/or unprofessional behavior. According to Foy (1992) PTSD following childbirth can be caused by:

• women's personality
• social support
• socio-economic group
• antenatal preparation
• subsequent expectations
• difficult pregnancy
• obstetric interventions
• worse experience of childbirth than expected
• memories of previous childbirth traumas
• miscarriage
• death of a child
• memories of sexual abuse or assault may be triggered by childbirth
• The fear of losing a baby seems to be the most powerful trigger for PTSD symptoms after pregnancy and childbirth.
• The bodily experience of birth can be a trigger for abuse memory

There is an ongoing discussion whether repressed memories really do exist or not. From a practitioner's perspective there is overwhelming evidence that these phenomena are based on real experiences. This view has become the basis of today's DID conception (Sinason 2002). A widely cited study on this question is that by Briere and Conte (1993), who found among 450 adults with sexual abuse histories, that 59% had lost their memories for the abuse over a certain amount of time. The authors concluded that amnesia for abuse was a common phenomenon. Other studies showed lower incidences of repressed memories (see e.g. in Loftus et al. 1994). As part of a larger project on the association between reports of traumatic life events and clinical diagnoses, Loftus et al. investigated 105 women (in out-patient treatment for substance abuse) about memories of childhood sexual abuse (n=57/105, 54% reported sexual abuse) and 19% of the women claimed that they had repressed memories. The authors of the study published some interesting facts:

• Frequency of types of childhood sexual abuse (Loftus et al. 1994) (n=105)
• At least one item 57 54%
• Did anyone show you their private parts? 41 39%
• Did anyone masturbate in front of you? 19 18%
• Did anyone ever touch your body in a sexual way? 41 39%
• Did anyone try to have you touch in a sexual way? 31 30%
• Did anyone rub their private parts against your body? 37 35%
• Did anyone attempt to have sex with you? 44 42%
• Did anyone have intercourse with you? 32 31%
• Did anyone ever put their penis in your mouth? 12 11%
• Did anyone ever put their penis in your butt? 5 5%
• Did anyone ever take pictures of you? 9 9%
• Did you have any other sexual contact? 8 8%
• Frequency of abuse (n=55)
• once 19 35%
• several times 27 49%
• many times 9 16%
• relationship of abuser to victim (n=55)
• parent 5 9%
• stepparent 8 15%
• sibling 5 9%
• other relative 21 38%
• friend of the family 27 49%
• any family member 30 55%
• stranger 21 38%

Keeping in mind the epidemiological findings it is not surprisingly therefore, that in some cases the experience of birth can be the first trigger in the adult life of the experience of penetration as a child and the associated pain. A prepartal assessing of these women will reveal no information about a specific psychosomatic risk for birth. The same difficulties arise when you claim to detect substance abuse, which is often a co-morbid phenomenon in patients with sexual abuse histories. For a variety of reasons many victims of child sexual abuse will not disclose what had happened to them - this may explain the underestimation of the problem of sexual violence as a risk factor for birth complications.

Accordingly with Lyons (1998), great caution should be exercised in the prompting of disclosure of sexual abuse during pregnancy. Reasons for this caution include:

Most women are emotionally vulnerable during pregnancy. Their reactions to disclosing sexual abuse histories may be intensified. The mother-child relationship can be negatively affected.

Women with sexual abuse histories have higher rates of depression, self-harm and suicidal attempts.

If a woman discloses memories of abuse to professionals, it is possible that the mother will associate the memory of the disclosure with that particular professional. If the same person, especially a midwife, should then assist at the woman's delivery, her presence may actually increase the chance of experiencing flashbacks.

If a pregnant woman refuses to talk about her devastating experiences, professionals should accept this, unless the woman clearly indicates, that she needs help related to this issue. The more the affected woman feels under control, the better the results. Referring her to a psychiatrist against her free consent will lead to detrimental experiences in most cases.

Several authors have studied the impact of domestic and sexual violence during pregnancy itself. According to epidemiological findings, pregnancy is a high-risk period during which violence may begin or escalate. Rates up to 20% of all pregnant women experiencing violent acts have been reported (Cokkinides et al. 1999, Hedin et al. 2000, McFarlane et al. 1996). Violence during pregnancy is associated with adverse maternal conditions, which may also have a direct or indirect influence on the fetus. An influence is documented with:

• self induced or attempted abortions
• spontaneous miscarriages
• divorce and separation during pregnancy
• secondary psychological problems like alcohol and drug abuse
• maternal antenatal hospitalization
• labor and delivery complications
• higher rates of cesarean delivery
• preterm birth
• low birth weight
• postnatal complications

In the aftermath of pregancy and birth, some other problems arise. Holding the newborn baby in her arms, a woman with a history of sexual abuse can suddenly gain a shocking awareness of her own vulnerability, when she was sexually abused as a child, either by a male or a female Even more hidden and disturbing are sexual abuses by females (Hislop 2001). It is estimated, that in about 20% of all sexual abuse cases the perpetrator is female. Lamott and Pfaefflin have reported about the characteristics of 37 women who killed their own children. All of them had suffered from severe trauma in their own childhood (sexual abuse 33%, death of a parent or another important person 62%). Using the AAI (Adult Attachment Interview) they showed in 31% a secure attachment pattern, and in 69% an unsecure attachment (dismissing 31%, enmashed-preoccupied 38%). Recent data suggest that the effects of severe trauma on neural network provide a common diathesis for PTSD and psychotic disorders (Seedat et al. 2003). Again, there is no research available about a possible link between sexual abuse and postpartum complications such as postpartum depression and psychosis. We suggest further research about the association between sexual trauma and pregnancy and postpartum outcomes.

A German research group has recently published their data from a prospective study investigating the association between traumatic experiences and premenstrual dysphoric disorder (PMDD). In contrast to some previous clinical studies among sexually abused women, the now available data suggest a causal effect of traumatic events on PMDD (Wittchen et al. 2003). At the moment, the implications of this data on risk assessment of birth problems are unclear, but they will certainly stimulate more research about the specific effects for PMDD as well as for pregnancy outcomes.


Preparing for parenthood
The number of men present during their partner's labor has increased to nearly 100% today. Decades ago, the medical professionals rejected fathers' presence for a variety of reasons. What has become evident in the meantime is that women who have their partners present while attending birth will suffer less pain, will need less medication, and have shorter labors (Niven 1985). Fathers attending the birth of their baby feel confirmed as fathers, and often reported that their presence in the labor facilitated a close relationship with the child, and that their involvement in the day-to-day care of their baby was easier to perform (Palkovitz 1987). To be involved in the birth attendance and antenatal care often gives fathers the feeling of being the parent and not just the provider, which helps reinforcing both the role of fathers and male role-taking. Finally, fathers must realize that they are involved in the pregnancy not only for the benefit of their partner and the baby, but also for themselves.

The birth of a baby is just the beginning of major change in the life of its parents. There is no question that the mother is the one most profoundly affected. We fully agree with Ball (1995), when he states: "as childbirth is such a common experience, it is perhaps easy to overlook the tremendous and unique changes which it brings." Contrary to the general joy and delight related to the offspring, the process of pregnancy and parenthood leads to a serious of losses: loss of control over one's physical state, loss of control over lifestyle and the loss of sleep which caring for a small baby brings (Ball 1995). The tremendous changes require a period of adjustment and adaptation. The birth of a baby is not only the beginning of the infant's life, but it is also a major life-change for the entire family and the wider society. In most cultures the birth is marked by a variety of rituals and rites of passage.

Postnatal care and outcome studies usually focuse on the mother and her baby. When the father is considered, in most cases it is as the absent father. The number of single-parent families or functional single parent-parent families (due to the absence of one parent, in most cases the father) has increased over the years and is estimated to touch the 50% rate soon. Fathers-to-be, especially first-time-fathers, are often suffering from couvades (??) syndrome. The prevalence varies from 10% to over 60% (Khanobdee et al. 1993). Men suffer from postnatal depression up to 9% (Ballard et al. 1994). Several risk factors identified for women as increasing the likelihood of postnatal depression, are directly related to their partners' mental health, e.g. poor martial relationship and lack of social support. Again, there is an abundance of literature examining postnatal depression in women, but not in their male partners. Studies suggest that non-depressed partners may buffer the effects of infants having depressed mothers (Hossain et al. 1994). The quality of the relationship is an important source for the woman's well-being, and caregivers should therefore encourage both parents to discuss any difficulties they may be having in the transition of parenthood.

Although positive aspects will counterbalance the stress provoked by any major life-change, some fail in the transition process. The satisfaction of personal needs produces a state of emotional security which can be described as an internal feeling-state of confidence and emotional well-being. When the normal mechanisms for dealing with changes are not effective, some degree of stress will be experienced. Postnatal depression (onset within one year after childbirth) is the most common mental health problem after childbearing, affecting approximately 10-15% of all women. The baby blues has a considerable impact both on the newborn (Grace et al. 2003), as on the mother and the family. Young infants are highly sensitive to the quality of care they receive, and the child's brain development depends directly on the interaction with the mother (Glaser 2000). Data on psychosocial interventions clearly indicate that prevention of postnatal depression by offering intervention courses such as "preparing for parenthood" is effective (Wheatley et al. 2003).

• individual internal needs (desire for approval and achievement)
• coping process
• external demands and expectations of behavior (peer values, culture, society)

The coping process as described by Lazarus (1969). The coping process illustrates how a person responds to change or stress. Lazarus places great emphasis on the need to understand the coping process in the context of the individual's environment and the socio-cultural support someone receives.

To remain realistic, it is important to consider data from young urban adolescent girls, which often suffer from a compounded community trauma, and a high proportion among them become teenage mothers. In interviewing these young mothers Horowitz et al. (1995) reported that: "only in their relationship with their young baby they are able to experience a zone of safety, connectedness, and trust otherwise missing in their lives." Just referring them to a psychiatrist does not work. ".. the high rate of avoidance symptoms noted in these adolescent girls is one indicator of the unlikelihood that they would seek or accept standard psychiatric treatment ..." (Horowitz et al. 1995).

Sex offenses are generally thought of as being committed by men. There is increasing knowledge about female sexual offenders (Cavanagh Johnson 1989). At the same time, in her article Cavanagh Johnson noted that 100% of the examined females who molested children had been previously sexually abused, and 85% of them by family members. Despite the fact that articles from 50 years ago had already pointed out that incest is far more prevalent in our society that one would estimate (Raphling et al. 1967), the vast majority of professionals tend to ignore the disturbing facts. To simply expect that women will disclose things such as maternal-neonatal incest is unrealistic (Chasnoff et al. 1986). However, such things do happen, as unbelievable as it may sound.

As professionals involved in child birth and neonatal care, our understanding should be based on scientific results rather than on general assumptions. We should take note of these facts, which help us to enlarge our understanding of certain problems. Most of the knowledge about the associations of sexual trauma and the impact on personal development has been gained through therapeutically working with both victims and offenders. The professional community should take note of these findings, because there is increasing evidence that a history of sexual abuse constitutes a major risk factor for the development of severe mental problems (Heim et al. 2001, 2002). Whether these experiences constitute a major risk factor for pregnancy difficulties, birth complications, and postpartum maternal imbalances, including family disturbances, should be carefully examined.

As a mother once told me during a treatment session: "The abuser of my son not only abused my loved one, but he also abused the whole family." Sexual abuse always has an impact on associated victims as well. Partners of victims of sexual abuse need help and support, often to a greater extent than the effort for the direct victim. The lack of general awareness of their situation and the help offered to these associated victims is often minimal.


Medium and long term care
Experiences of sexual trauma and emotional neglect can have a direct impact both on women's health as well as an indirect impact on their infants and their partners. There is an increased risk for suicidal and even homocidal behavior, and for negative health behaviors such as failure to maintain healthy body weight (Springs et al. 1992, Felitti 1991). Substance abuse and excessive smoking among traumatized women has been demonstrated by various studies (references see Rodgers et al. 2003). In a paper presented by Legl to the 7th Conference of IATSO Vienna 2002, he reported that among the patients admitted to the substance abuse treatment unit, about 80% of all women and about 60% of all men reported histories of sexual abuse. Traumatized women also smoke more heavily than non-traumatized women (Anda et al. 2002). Smoking puts mothers at an increased risk for having spontaneous abortions. Offspring of smoking women are at a considerable risk for thyroid enlargement (Chanonie et al. 1991), low birth weight and deformities (Haustein 1999).

The experience of sexual trauma is also associated with risky sexual behavior (Springs et al. 1992). Some of them engage in promiscuous and abusive relationships, where they are re-traumatized. They have sex without contraception, have multiple sexual partners, often without knowing their partner's sexual history, all of which puts these women at a greater risk of acquiring STDs (sexually transmitted disease) such as HIV. The consequences of adult sexual traumatization and domestic violence are greater in persons suffering from CSA due to the re-traumatization. STDs are clearly linked to a variety of adverse pregnancy outcomes, including ectopic pregnancy, preterm birth, puerperal sepsis, and abnormalities of the major organ systems (Moodley et al. 2000).

With the focus on attachment interventions, psychiatry provides a trans-generational understanding of adverse personal experiences on human interactions and development (Levy et al. 1998). The inner working model of relationships and related social expectations are based on the basic experiences provided by attachment figures such as parents. Other data on relational aspects are gained from an area which seems to be far away from the subject we are dealing with, which is the individual's vulnerability to combat stress. A regression analysis indicated that the father's negative parenting behaviors were more predictive of PTSD symptoms severity and at relatively lower levels of combat exposure in Vietnam veterans (McCranie et al. 1992), than the direct combat influence itself. It is therefore not surprising that in a study published by Cohen et al. (2000), they found that childhood sexual abuse was strongly associated with later domestic violence.

According to Monk (2001), maternal anxiety disorders are associated with low birth weight and irritable neonatal behaviors. Other researches, such as Seng et al. (2001), have reported that women diagnosed with PTSD were at higher risk for ectopic pregnancy, spontaneous abortion, and hyperemesis, than those without this diagnosis. Currently, there is no literature available that shows whether psychiatric treatment will have an effect on pregnancy outcomes in affected women. Hypothetically we can assume that analogous to the influence on stress related symptoms, psychotherapeutic interventions will have an effect on these women (Heim et al. 2002). There is a clear need for further research in this area. We can assume that untreated psychiatric conditions put both women and their offspring at higher risk for many negative outcomes during pregnancy and in the postpartum time.

Psycho-educative interventions about personal risk factors associated with earlier life experiences and their relations to current symptoms as well as their relation to birth and postnatal problems are an essential part of every therapeutic strategy. Many patients reported that they have never been asked about their trauma history, especially never about devastating experiences with other professionals. According to our experience, affected women appreciate it very much when these issues are being addressed. The general belief shared by many professionals is that asking about bad experiences will always lead to detrimental effects. However, this is a misconception and probably has more to do with a negative attitude towards the reality these women suffer from. It is disturbing to hear these stories without knowing what to do professionally, so there is a clear need to integrate this topic in medical formation and training.


The interface between psychiatry and obstetrics: Comprehensive perinatal care

Emotional and psychosocial aspects are often considered as mere addenda in traditional medical formation. The subject of sexual violence - which highly influences women and children's personal development - is often neglected by academic teachers (WHO 2002) Even professionals working in the area of CSA treatment did not receive systematic training on the topics of sexual violence (Campbell et al. 1995). Decision makers tend to consider sexual violence more as a problem of the criminal justice system then that of health care. Without question, the participation in specific training programs improves professionals' knowledge about sexual abuse issues (Hazzard et al. 1986, Hibbard et al. 1987).

There is an urgent need, from both economic and developmental consequences, to integrate this topic into medical school curricula. Switzerland, as many other countries, failed to do this in its most recent update of learning objectives for medical training (Buergi et al. 2002). We see a considerable bias among academic teachers related to the issue of sexual violence. This bias is even greater when related to PSM. Consequently health care professional have no awareness of the magnitude of the problem, and due to this lack in psychopathological knowledge are often unable to diagnose sexual and domestic violence in their patients. The recent discussion about patients' safety has clearly shown that the health care system needs fundamental changes (see report: To err is human, 2001).

Establishing a comprehensive care program with close cooperation between obstetricians and psychiatrists helps the physicians gain awareness of the underlying psychological problems. The cooperation also helps to overcome the "single-disciplinary ghetto effect", a traditional formation we still have today. By establishing an interdisciplinary approach, both psychiatry and obstetricians can share their experiences and create a framework for how to approach the issue scientifically. The program provides an in-depth awareness for participants, which enables them to establish an effective prenatal risk assessment and to identify those women who are in need of supportive psychiatric treatment. This paradigm shift is in concordance with the most recent medical guidelines (Charter 2002), which stipulates under professional responsibilities a commitment to professional competence: ÆPhysicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. More broadly, the profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanism are available for physicians to accomplish this goal."

The charter also stipulates an integration of practical knowledge of those working in the field: "Physicians must be dedicated to continuous improvement in the quality of health care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, increase patients' safety, minimise overuse of health-care resources, and optimise the outcomes of care. Physicians must actively participate in the development of better measures of quality of care and the application of quality measures to assess routinely the performance of all individuals, institutions, and systems responsible for health-care delivery. Physicians, both individually and through their professional association, must take responsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care."

Emphasis should also be given to the fact that working with patients who has personal traumas can be very demanding and therefore, caregivers, too, need to be supported. We should not forget that the impact of working with the problem of sexual abuse can be seen as paralleling the impact of sexual abuse itself. Denial, secrecy, rationalization, avoidance, disbelief and victim-blaming are all the factors influencing professionals (Erooga 1994). The impact of sexual violence remains highly controversial, leading to ambivalent attitudes and many tensions within the professional community. There is lack of consensus, which for sure does not help victims to overcome their devastating experiences.


Conclusions
To provide optimal care, identification of psychological risk factors is important early in pregnancy.

A comprehensive risk assessment is based on both emotional and somatic problems.

The high prevalence of sexual abuse makes it likely that a substantial proportion of pregnant women have been victims of sexual trauma at some point in their lives.

PSM (Professional Sexual Misconduct) does not just happen elsewhere, it also takes place within gynecologists, midwifes, as well as nursing and other hospital staff.

The identification of histories of sexual abuse and emotional neglect is only possible if professionals know what and how they have to address these issues.

Increased physician monitoring of those patients suffering from devastating life experiences may significantly reduce pregnancy complications and poor pregnancy outcomes.

The subject of sexual violence and its impact remains highly controversial, therefore lack of consensus in the professional community, which impedes helping victims overcome their devastating experiences.

Referring patients with histories of sexual abuse and emotional neglect as early as possible to psychotherapeutic treatment is essential.

There is clear need to a curricular integration of sexual and domestic violence into medical formation and training.

Women and their partner also need education about risk factors and their impact on personal developments and outcomes.

Cooperation between psychiatry and obstetricians helps overcome the single disciplinary ghetto effect, and also helps with better identifying possible risk factors in pregnancy.


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Acknowledgement

The presenter is indepted to Melanie Kast, Vicki Polin, Karyn Walsh and Na'ama Yehuda for their comments on the handout.

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Verdict for Hospital That Failed to Report Child Abuse Is Upheld
By John Woods
New York Law Journal - October 10, 2002, Thursday
Vol. 228; Pg. p. 1, col. 3


THE APPELLATE Division, Fourth Department, has upheld a Niagara Supreme Court jury verdict in favor of a hospital that did not report alleged child abuse, even though the jury found the hospital negligent in a previous verdict it was instructed to reconsider because of an error in the apportionment of liability.

Also, in a case involving Massachusetts plaintiffs suing New York drug companies over in utero exposure to diethylstilbestrol (DES), the Fourth Department dismissed plaintiffs' claims because Massachusetts law, which was applicable in the case, does not allow for the market share liability the plaintiffs were seeking.

In Bowes v. Noone, 914 CA 01-00700, plaintiff Vicki Bowes sued the Inter-Community Memorial Hospital in Newfane, N.Y., for failing to report to the statewide child abuse register evidence that her daughter Chelsea was abused, allegedly by her father.

Last year, a Niagara jury returned an initial verdict finding that the resident on duty, Dr. Thomas Noone, had reasonable cause to suspect abuse, but his failure to report it was not actionable because it was not willful. The jury found the hospital was negligent in not properly educating Dr. Noone on how to recognize child abuse, but that lack of instruction was not a proximate cause of Chelsea's subsequent injuries related to continued abuse. The jury did find, however, that the hospital's failure to provide Chelsea's pediatrician with emergency room records was a proximate cause. In apportioning liability, the jury apportioned 25 percent to Dr. Noone and 75 percent to the hospital. Because that was inconsistent with its verdict regarding Dr. Noone, the jury was instructed to reconsider its verdict with respect to apportionment.

The trial court denied the plaintiff's request to have the jury instructed that it had the ability to reconsider any question on the verdict sheet during its second deliberation. But upon the jury's request, the court allowed the jurors to reconsider any question that affected apportionment. The jury found none of the defendants liable.

Following a failed motion to set aside the verdict, the plaintiff appealed claiming the trial court should have entered the "non- inconsistent" portions of the verdict before the jury reconsidered it, and that the jury's finding that Dr. Noone had reasonable cause to suspect abuse was inconsistent with its finding that he had not deviated from accepted medical standards.

On reconsideration, the jury was free to alter its original statement to conform to its real intention, and was not bound by its original verdict, stated the memorandum and order issued by Justices Samuel Green, Donald J. Wisner, Henry Scudder, Christopher J. Burns and Jerome C. Gorski.

"Although Dr. Noone and the nurses ... admitted that they knowingly did not report child abuse to the central register after Chelsea was examined at the hospital on January 6, 1990, they also testified that they did not believe on that date that child abuse had occurred. Thus, a jury could rationally find that Dr. Noone and the nurses did not willfully fail to comply with their statutory duty to report suspected child abuse."

In Armata v. The Abbott Laboratories, 912 CA 02-00648, three Massachusetts women and one Connecticut woman sued several drug companies that manufactured the pregnancy drug DES, which was allegedly taken by their mothers and has the potential to cause birth defects.

Last year, the drug companies moved to dismiss the claims of the Massachusetts women because they sought a market share liability apportionment of the damages, something not allowed under Massachusetts law, which the parties agreed was controlling. The motion was denied by Erie Supreme Court Justice John F. O'Donnell.

The Fourth Department panel, also consisting of Justices Green, Wisner, Scudder, Burns and Gorski, reversed.

"[I]n a prior appeal, the parties have conceded that Massachusetts substantive law is applicable to the claims of the Massachusetts plaintiffs," Justice Burns wrote for the court. "The law in Massachusetts remains unsettled on the issue of whether its courts recognize non-identification theories of liability, including the market share theory of liability. We conclude that, without a clear indication from its appellate courts whether such theories of liability are recognized, we should not expand the law therein to allow the Massachusetts plaintiffs to allege such theories."

In other decisions, the Fourth Department:

• Vacated a permanent injunction issued by Monroe Supreme Court Justice Eugene Bergin preventing a drainage pipe on a car dealership's property from spewing water to an adjacent lot. The court ruled that Justice Bergin abused his discretion with the injunction, and that water would have flowed onto the adjacent lot regardless of whether a drainage pipe existed or not.
• Reinstated a complaint against Xerox Corporation that was summarily dismissed by Monroe Supreme Court Justice Harold Galloway. The Fourth Department concluded that the plaintiff raised triable issues of fact that his termination by the company was discriminatory based on age.
• Reversed the criminal possession of a controlled substance conviction of a man whose person was searched after police found drug paraphernalia during a warranted search of his apartment. The alleged paraphernalia, plastic baggies found in a closed kitchen drawer, did not raise sufficient probable cause for the search of his person and should have been suppressed by Monroe County Court Judge Joan S. Kohout, who denied a suppression motion, the court ruled.
• Reversed the decision of Erie Supreme Court Justice Robert E. Whelan allowing plaintiffs injured when their automobile hit a pothole in Buffalo to file late notices of claim and an amended summons and complaint against the Buffalo Sewer Authority. The panel found no valid reason to authorize the late service.
• Affirmed the decision of Oneida Supreme Court Justice John G. Ringrose, who declined to set aside a $117,333 jury verdict for a plaintiff whose learning disabled son was at times confined in a small room by the Rome City School District.

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