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Giving Birth with Rape in One’s Past: A Qualitative Study Lotta Halvorsen, RN, RM, MHSc, Hilde Nerum, RN, RM, MHSc, Pa˚l Øian, MD, PhD, and Tore Sørlie, MD, PhD ABSTRACT: Background: Rape is one of the most traumatizing violations a woman can be
subjected to, and leads to extensive health problems, predominantly psychological ones. A large proportion of women develop a form of posttraumatic stress termed Rape Trauma Syndrome. A previous study by our research group has shown that women with a history of rape far more often had an operative delivery in their first birth and those who gave birth vaginally had second stages twice as long as women with no history of sexual assault. The aim of this study is to examine and illuminate how women previously subjected to rape experience giving birth for the first time and their advice on the kind of birth care they regard as good for women with a history of rape. Methods: A semi-structured interview with 10 women, who had been exposed to rape before their first childbirth. Data on the birth experience were analyzed by qualitative content analysis. Results: The main theme was “being back in the rape” with two categories: “reactivation of the rape during labor,” with subcategories “struggle,” “surrender,” and “escape” and “re-traumatization after birth,” with the subcategories “objectified,” “dirtied,” and “alienated body.” Conclusion: A rape trauma can be reactivated during the first childbirth regardless of mode of delivery. After birth, the women found themselves re-traumatized with the feeling of being dirtied, alienated, and reduced to just a body that another body is to come out of. Birth attendants should acknowledge that the common measures and procedures used during normal birth or cesarean section can contribute to a reactivation of the rape trauma. (BIRTH 40:3 September 2013) Key words: birth experiences, birth trauma, content analysis, rape, re-traumatization
Rape is one of the most traumatizing violations a woman can be subjected to, with negative consequences for her health and reproductive life (1–3). It is well documented that a rape can lead to long-term reactions, fear, anxiety, depression, fatigue, chronic pain, sleep or eating disturbances, self-harm, substance abuse, and suicidal thoughts or attempts (3–10). It is the psychological injuries that dominate, and a large
proportion of women develop a form of posttraumatic stress disorder in the aftermath, termed Rape Trauma Syndrome, in which the rape is the stressor (11,12). Sufferers of Rape Trauma Syndrome tend to have more serious symptoms than individuals in which posttraumatic stress disorder is because of other stressors, and the closer their assault is to the legal definition of rape (forced, nonconsenting sexual activity) the stronger the
Lotta Halvorsen and Hilde Nerum are Doctoral students at the University of Tromsø, Norway, and midwives at the Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø. They are equal first authors of the following paper. Pål Øian is a professor in the Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, and Institute of Clinical Medicine, University of Tromsø, Norway. Tore Sørlie is a professor in the Department of General Psychiatry, University Hospital of North Norway, Tromsø, and Institute of Clinical Medicine, University of Tromsø, Norway.
Address correspondence to Lotta Halvorsen, Department of Obstetrics and Gynecology University Hospital of North Norway, Postbox 100, Langnes, 9038 Tromsø, Norway.
Accepted July 9, 2013 © 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc.
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symptoms of Rape Trauma Syndrome (3,13). Features that seem more prominent in victims of rape are shame, guilt, and suicidal ideation (2,6). The rape crisis is assumed to strike a core in the woman that affects her fundamental value as a woman and influences her relationships with other people in the future (6,14). Estimates indicate that 6–36 percent of all women have been subjected to forced sexual activity or sexual violence (1,5,7–9,15). Statistics from the United States show that between 12 and 18 percent of women have been subject to a rape in the course of their lifetimes (9). Several studies indicate that the risk of being subject to sexual assault is highest in late adolescence (6,15,16). In most studies of the association between various forms of sexual assault and subsequent birth outcomes, women with a history of sexual assault have not been found to have higher incidence of medical complications or operative delivery than women without such histories (17–19). A study carried out by our research group has, however, shown that women who were raped as adults were delivered by cesarean, forceps, or vacuum extraction to a much greater degree, and that those who gave birth vaginally had second stages of labor twice as long compared with women with no history of sexual assault (20). Studies have shown that a large proportion of women requesting cesarean for fear of birth have been subject to sexual assault earlier in life, and have experienced their first birth as traumatic (21,22). During the many years of our clinical practice as midwives, we have counseled numerous women with a history of sexual assault and rape, many of whom experienced the care they received during labor as new assaults. The actual birth experience of women who have been subject to rape previously has been little researched or described in the obstetric literature. The aim of this study is to examine and illuminate the way a first childbirth is experienced by women previously subjected to rape, and advice on the kind of birth care they regard as good for women with a history of being raped.
Method Design and Population To examine the women’s experiences, a qualitative semi-structured interview was used. This approach is suitable for sensitive topics, and gives access to human thoughts and experiences (23). The interviews were carried out according to Kvale’s principles for the qualitative research interview (24). This process means that the informants do not merely answer questions posed by the researcher, but that through dialogue with the interviewer they formulate their own experience and
perception of the world they live in. Data were analyzed qualitatively as described by Graneheim and Lundman, a method for systematic identification of variation in the text with regard to similarities and differences (25). Advice on good birth care for women with a past history of rape is summarized and presented in a schematic model. The study population consists of women subjected to rape after the legal age of consent (≥ 16 years) and before giving birth to their first child. The informants were recruited from a cohort of 808 women who had been referred for counseling for various psychosocial problems to a mental health team at the antenatal clinic, University Hospital of Northern Norway, in the period from 2000 to 2007. Of the 808 women, 59 reported having been raped as adults, whereof 50 were part of a study showing primiparous labor outcome (21). All of the women had been subjected to vaginal rape with penetration. The information about the rape was registered as part of a systematic charting of their reproductive and mental health during counseling at the antenatal clinic. The women’s rape history was not known to their caregivers during pregnancy and remained unknown to the birth attendants during the women’s first birth. A strategic sample was chosen using the following criteria: the woman had to speak Norwegian, not be pregnant, and not be suffering from serious mental illness at the time of the interview. The women’s births represented different modes of delivery: vaginal birth, vacuum extraction, and cesarean section. Written requests to participate in the study were sent to 11 women, with information about the aim of the study and what participation entailed. In the letter it was emphasized that there would be an offer of professional help if the interview itself caused problematic reactions. Those who wished to participate posted their consent directly to the researchers. No reminders were sent. Ten women consented to participate, and these comprise the informants for this study. Their ages at the time they were raped and at their first childbirth and the outcomes of those births are described in Table 1. The interviews were carried out in the period 2009 to 2010 jointly by the two first authors (LH, HN), who both have extensive clinical experience discussing sensitive themes with women. Eight of the interviews took place in an undisturbed place at the hospital and two took place in the homes of the informants. The interviews were audio recorded, and lasted on average two hours each. An interview guide had been developed with focus on the following themes: the first birth experience, interaction with birth attendants, what the informants considered “good birth care,” and asking the informants to describe their own mental and sexual health at the time of the interview. The opening question was “Tell us about your first childbirth—in as
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184 Table 1. Informants’ age at time of rape, at time of first childbirth, type of onset of labor, and mode of birth
Informant
Age at rape (year)
Age at birth (year)
1
22
38
Spontaneous
2
18
22
Spontaneous
3 4 5
17 16 26
29 26 29
Induced Induced Spontaneous
6 7
16 16
25 26
Spontaneous Induced
8
19
23
Induced
9 10
16 16
21 23
Spontaneous Induced
Labor onset
Mode of birth Vacuum extraction Vacuum extraction Spontaneous Spontaneous Vacuum extraction Spontaneous Emergency cesarean Emergency cesarean Spontaneous Emergency cesarean
much detail as you can recall.” The subsequent thematic order was dependent on what the individual woman brought up. The interviewees were encouraged to tell freely about their experiences related to the various themes. No direct questions about the rape were included. Clarifying questions were posed as needed. Before ending, the interview guide was checked to ensure that all of the themes had been dealt with. After each interview, individual notes were made that summed up the interviewers’ immediate reflections on the content of the interview. The first six interviews were transcribed consecutively (by LH), and the rest were transcribed by an external person without any connection to the study. The interviews were transcribed verbatim in dialect, as close to the oral form as possible, with noting of laughter, crying, silence, or other forms of nonverbal communication.
the main theme was an ongoing process throughout the entire analysis period. Presenting the material in a clear way was emphasized, without changing the meaning of the women’s comments. Further analysis was discussed by the other two coauthors (TS, PØ) to achieve a greater common understanding of the abstracted material in the text. The entire analysis was carried out manually, without the use of electronic instruments of analysis.
Ethical Approval The study was approved by the Regional Committee for Medical and Health Professional Research Ethics for Northern Norway (Reference 2009/1146-2).
Results Descriptions of the Study Population The informants were aged 21–38 years (Mean 26.2) at the time of their first childbirths (Table 1). Seven were married or cohabiting with partners and three were single. All resided in Northern Norway, and four had Sami ethnic origin. All had completed secondary school and four had university educations lasting more than 4 years. Nine were in full-time employment; one was temporarily disabled as a result of serious somatic illness. At the time of the interview, eight had two children, whereas two had one child each. They had been raped when they were 16–26 years old and the first childbirth occurred 6–16 years after the rape. Nine of the women had experienced attack rapes by strangers, two of them by multiple attackers; one woman had been raped by her partner. In the case of four of the women, the rape was their sexual debut. One rape had been reported to police. Being Back in the Rape
Data Analysis Interviews consisting of 131,261 words were analyzed by the two first authors (LH, HN). Because this study focuses on the first birth experience, only those parts of the text dealing with labor and the advice of the birth attendants were used (98,467 words). To get a comprehensive picture of the experience as a whole, the interviews were listened to and the transcripts re-read several times. Thereafter, the same two researchers reflected together on the main themes of the content. The text was then divided into meaning units that were coded, condensed, and thematized. The development of
In the analysis, one main theme, two categories, and six subcategories were identified. The main theme was “being back in the rape.” The category “reactivation of the rape during labor” had the subcategories “struggle,” “surrender,” and “escape,” whereas the category “retraumatisation after birth” had the subcategories “objectified,” “dirtied,” and “alienated body.” Reactivation of the Rape All of the informants described persistent strong memories of having been back in the rape during their first childbirth, independent of whether they gave birth
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vaginally or by cesarean section. They described it as switching back and forth between scary memories from the rape and conditions during labor that reminded them of the rape. Struggle The informants described having carried on an intense internal struggle during labor, in which the rapist and the birth attendant switched roles as main actor. One of the informants described her fight with the rapist this way: I recall the birth as dark and ominous, a big black hole I was afraid to fall into, because there he stood, the man who raped me and he was grinning this awful grin. I know I fought not to fall down the hole, because if that happened I would lose my mind. It was vital to stay on the edge and not fall in. My husband realized I was struggling in my own world, fighting with someone outside the room. It cannot have been easy to be him while I was battling another man in the midst of the birth of our child. (3)
In the battle with the birth attendants, the women were in conflict with themselves and their own needs, and the ward’s procedures and routines. I was alone against them. All information was given with their hands inside me… I tried to tell myself “Relax! Get a grip!” but it was no use. (10)
The birth attendants’ touching of intimate parts of their bodies was experienced as an invasive procedure, and this intrusion was intensified when the attendants without warning touched them without the women understanding what the attendants were doing, and why. The women tried actively to maintain control over their bodies by protecting themselves with clothes or bedding. They described the feeling of once more being held captive, held forcibly in positions they expressed strongly that they did not wish to be in. Procedures such as vaginal examinations to monitor progress in labor were tied to their experiences of the violent vaginal penetration during the rape. The pain experienced by the lower part of their bodies once again became the main body part, which once again was subject to events reminiscent of the rape. I felt he was brutal, it was just kind of a “whoosh”… felt he just broke my legs apart, and right in and just go ahead and check me. It was such a helpless situation to be lying there… in way like… a bit of a violation really. Even though I tried to tell myself, sort of sensibly that “they do have to do this” and “I guess they need to check that everything is OK.” (4)
The alternating battle with the birth attendant and the rapist was experienced over time as a useless one, in which the women finally simply surrendered.
Surrender The women felt that their physical and emotional reactions were either overlooked or overrun by the birth attendants. Through the unintended unfortunate interaction with the birth attendants, in which they tried in vain to resist, the women gradually allowed themselves to be dominated and finally surrendered. I did not want to be on my back with my legs up, but they held my legs. Something happened to me around that, being held in place. For me, it led to just giving up, they could do whatever they wanted. It was kind of… all the way up to that point, I was protesting. (9) When they laid me on the operating table I felt as if I died. My whole body disappeared. I felt nothing, I was gone, I had no way to get away, I could not get away. (10)
When the woman gave up, the birth attendants interpreted the situation as an inability to give birth, and their next move was an even more active intervention to deliver her. The women perceived this interference as if they were unable to master the task and that their bodies had failed them. When they had surrendered, they saw no other option than to mentally escape out of their bodies. When they put in that “vacuum cup” it was the first time I really had thought about the rape in years. I was back in it, being held down and not being able to move. In any case I was completely naked. I felt a kind of shame too. Up to this point I was kind of angry, in a way. But then it was a little bit like when “he” (the rapist) – it was kind of too late. Nothing left to fight for. Afterwards I felt I’d done such a terribly bad job. (2) Just lying there on your back and you’re in the same position when you again go into the same state as when you were raped, plain and simple. You′re lying there and things happen down there (points between her legs), the feeling of being held down. It was really strange… my body held back and would not do it. I wanted to give birth but my body would not do it. (1)
Escape Both the birth and the rape were experienced by the informants as unavoidable and uncontrollable situations. They let their captive bodies remain, and saw themselves from outside, or from above. I no longer knew I was giving birth. It was very unreal, but so is a rape. I felt that in a way, I left my body, like when I was raped. I did not know where I was, if I was above myself looking down. But it felt very similar. (4) I was stuck in the bed, they could do what they wanted with me. They were saying something about them seeing that I am in pain, but “they will be quick.” They pull away the duvet I
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186 am clinging to for dear life and they pull up my top. Lying in bed, vulnerable, I leave the room; they can just do whatever they have to. (10) Looked down and saw myself from above, like a slaughtered animal lying there that they could do whatever they wanted to. Could not move a muscle, and real scared. I am lying there stunned, and cannot get away. Cannot take in what is happening. I am good at leaving the crime scene. (7)
The informants described the way they experienced being treated as a passive object instead of a participant. Their intention was to collaborate with the birth attendant, something that gradually seemed as an impossible task. They described birth attendants who seemed stressed, and who they felt had no time or inclination to work with them. They experienced their own reactions as deviant and inappropriate, and perceived that the attendants focused exclusively on the baby’s birth, to which the women themselves comprised an obstacle. Re-traumatization after birth The informants had tried to deal with the rape as a “non-event” in their lives. The shame of having been raped was so overwhelming that the trauma remained unspoken and thereby unprocessed. In pregnancy they had thought that the rape might influence the birth, but the thought had been shoved aside. After the birth, they experienced that the same patterns of reaction and the same defense strategies elicited by the rape, also had been activated during labor.
Objectified What they had attempted to communicate to the birth attendants had not been received; their body language had been overlooked and not given consideration—as though they had not even been present. They felt reduced to a “birth machine” and were ashamed that they had not been able to prevent this process from happening. That the midwife did not talk to me, did not address me—and that I was not allowed to be involved. I was just a kind of “robot machine body” that was there to give birth to a baby— where nobody saw “me.” There is something very degrading about being treated like a birth machine that is just something to be repaired. You are not a machine that is going to give birth to a kid, you are there as a person too. You are not just a body that another body is going to come out of. So in a way it is “a body” that gave birth—but it was not me. (2) It was sort of the baby it was all about, not “me” at all. It was so strange really—as if I was not even there—I was not there. I was just—I was not even a patient, really—was actually
nobody. There was just a baby who was going to come out of me. (4)
The women recognized well the same unworthy feeling of being useless, like some random object, and they again assumed the blame for it having turned out that way.
Dirtied The women described the way all forms of touch by unfamiliar hands invaded and dirtied their bodies. “Dirtied” in the sense that the feeling came as a consequence of something they were subjected to from outside themselves, and that had stuck to their bodies. Immediately after the birth or the cesarean section there arose an acute and pressing need to wash themselves clean. Recall that I felt dirty! I felt violated, and I really wanted to brush my teeth. I felt I wanted to brush away something or other. And this has something to do with me feeling really dirty—and those old nightmares about the hands came back. (1) It got so important to get on my feet again, after the cesarean section. Everything had to be washed away, sweat, blood, filth, bits of tape, and most important, hands. All the hands that had been there, had to go. (10) I felt I had to have a shower. Not so much the birth, because I do not know if I was bloody, I have no idea—I am sure I was, and sweaty too, but there was something else I had to shower off. Felt I had to make myself clean in some way or another. After that rape I have always been like that—felt that I had to—all this stuff about cleanliness. (4)
The feeling of being dirtied persisted far into the puerperium; they felt they had bodies they did not recognize as their own, and this feeling made it difficult to carry out the natural tasks of mothering.
Alienated Body The birth became a new assault in which the women experienced being violated in a similar way to when they were raped. They recognized the degradation of having been objectified and reduced to a physical thing that others had made use of. The feeling was not directly tied to how the child was born, but to how the interaction between the women and the birth attendants had developed during the birth. I felt just gross. They shoved me further and further away from myself, just slammed on. They stood there all three with their heads in me, down there. Was not that nobody saw me or talked to me. I was just empty. I hate my body, thinking of
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myself as one thing, my body as something else, and we are not working together. My body is just gross. (10) Well, it feels like certain of your body parts are not yours no more. It is just something someone takes all away from you. You sit there or lie there, just like that, and just ARE like a carcass or a beached whale in my case. I felt like I was just laying there, stuck, and could not come back to my own self. I feel I’m still lying there, when I ought to be lying out to sea, swimming. (9)
The rape trauma had invaded the entire birth experience so that instead of feeling like a proud new mother, this woman remained re-traumatized. Caring in labor for women with a past history of rape Figure 1 shows advice on what kind of care in labor the informants would have liked, and their advice to birth attendants on the kind of care they regard as good for women who have been raped previously. They were very clear that the most important condition for the best possible outcome is good interaction between the woman and her attendants. It is important that the birth attendants understand that routine procedures used during labor or a cesarean section can contribute to a reactivation of the rape trauma. They state that the woman should have enough time and a calm atmosphere in which to give birth to her baby, with as few interventions or disturbances as possible that may remind her of the rape. All of our informants reflected on how giving birth vaginally and spontaneously without operative intervention can give a feeling of self-efficacy and thus contribute to moving forward in processing their attack. Those informants who had given birth twice recounted that the memory of the rape was most prominent during their first childbirth.
Discussion The findings of this study show how our informants during their first childbirth were caught by their bodily experiences and memories from the rape. This experience led to a chaotic mixture of the rape in the past and their labor in the present, and was unrelated to whether the woman gave birth spontaneously, was operatively delivered by vacuum extraction, or was delivered by cesarean section. In the literature this chaotic mixture is described as the person behaving as though the traumatic situation poses a current threat, with a desire to defend herself against the threat in the way she tried in the original situation, without success (10). It has been documented that unprocessed traumatic life events can force themselves on the individual so they experience that the event is occurring again (10,26,27). In the theo-
187 retical model in Fig. 1, the central expressions of how the memories of the rape were triggered in the birth situation are shown. During labor, the informants noted that several of the same reactions and defense strategies as they experienced during the rape were elicited. After birth this phenomenon made them feel as if they had been raped again. It has been described previously that childbirth can reactivate memories of rape (26–30). Rhodes and Hutchinson have described four different extremes of behavioral patterns during labor, which can be associated with posttraumatic stress reactions after sexual abuse or assault: fighting, taking control, surrendering, and retreating (29). The same patterns can be seen in our informants when they describe that in the unintended poor interaction with their attendants, they first tried to resist, but after a while allowed themselves to be dominated and surrendered, and finally ended up feeling that their bodies were alien to them. The informants described how the birth attendants “doing as they pleased” with their bodies, externally and internally, without preparing them for this act, contributed to their being drawn back in time to the rape in their past. The informants described being very disturbed by all of the interventions used during labor. The methods used for pain relief did not help against what they found painful, but rather enhanced the feeling of being paralyzed and out of control. Burgess has described that the immediate reactions that automatically arise during a rape give a surreal feeling in which the body no longer reacts or carries out the orders given by the brain, and the woman becomes physically unable to remove herself from the situation (11). The predominant feeling the informants in various ways communicated, and the feeling they were left with after birth, was a deep shame. They were ashamed that their body once again had been invaded and they had not been able to prevent a new assault. They were ashamed that they had not managed to communicate and cooperate with their birth attendants. The shame of not measuring up as a woman giving birth, nor as a mother, was a burden they carried in silence as they went on with their lives. The most prominent expression of deep shame is silence, and the perception of one’s own worthlessness (31). Being raped is more than experiencing vaginal penetration against one’s will; it involves an injury to the core of the self, a violation of one’s human dignity, and those who have been subjected to it frequently assume the blame for what happened. For our informants, the rape had been such an extreme event that a reactivation during their first childbirth was inevitable. The informants in this study had all been subjected to a violent vaginal penetration; for nine of them, the rape had been part of an attack in which they had feared for their lives. Other studies
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188
Memories of the rape
Rape
Labor
Memories of the rape
Conditions during labor
Lying supine, forcibly restrained
Being placed supine, physically restrained
Brought to the fore during labor
Reminding woman of the rape
Violent approach to the body/genitals
Legs forced apart, placed in stirrups
Painfully forced entry and vaginal penetration
Invasive procedures, not being listened to or seen
Perpetrator takes over control of her body
Invasive vaginal examinations
Struggle, shouting, crying for help
Unfamiliar hands touching body, being overruled
Darkness, blood, semen, sweat, breath
Sight / smell of blood, amniotic fluid, feces, sweat
Feels unclothed, despised
Dimmed lighting/being unclothed
Helpless, degraded
Bodily integrity not ensured
Gives up, lets it happen, feels ashamed,
Being tied to bed or operating table, giving up
leaves her body, disappears
Birth attendants control body, room, time
Reactivation During labor Struggle Escape
Surrender
Being back in the rape
Dirtied
Objectified Alienated from body Retraumatized After birth
Informant’s advice on good birth care for women with past history of rape That birth attendant knows about the rape before labor, shows understanding for her reactions Not talking about the rape during labor Being included in treatment decisions, being addressed directly, with eye contact Being encouraged and supported, helped to stay in the present during labor, “being brought back” to present task Protection of bodily integrity, as little manipulation of the body as possible, fewest possible vaginal exams Help to maintain an upright position, avoid being placed supine Awareness that epidural can give same paralyzed feeling as during rape, and both nitrous oxide and pethidine can give unpleasant fogginess and feeling out of control Informing her in advance of any touching of her body by anyone, allowing time for her to cooperate freely As few unfamiliar people as possible in the labor or operating room Allowing her enough time, especially in second stage Creating a calm space and time for giving birth Understanding her need to wash and freshen up immediately after birth Getting to talk through labor with her birth attendants afterwards
Figure 1. Schematic model of reactivation of the rape during labor, re-traumatization after the birth, and the kind of birth care the informants consider as good birth care for women who have a past history of rape.
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have shown that when rape is associated with mortal fear, and when the attack is not reported, or for other reasons remains hidden by silence, the psychological problems are more serious in the aftermath (3,6,11). Only one of our informants had reported the rape to the police. For most of the women the trauma had been suppressed and unprocessed. Childbirth was for all of them a new and shocking confrontation with their previous trauma. We believe that the degree to which childbirth reactivates a rape trauma depends on, among other things, the quality of the interaction with the birth attendants. This belief, however, poses certain requirements to charting previous trauma, working through this trauma before the birth, and tailoring the birth situation to the woman’s needs. Our informants expressed how important it was to be seen, and to be addressed directly. They wanted help to protect their bodily integrity from the view and touch of those present, and they needed sufficient time to prepare so they could cooperate with necessary procedures such as vaginal examinations. They wished to be encouraged and supported to be present in their bodies during labor, so that they did not surrender and escape mentally from the situation. This approach requires that the birth attendant has knowledge of reactivation of assault, and that the attendant is familiar with the conditions during labor, which may remind the woman of her assault. Birth attendants often lack knowledge about the woman’s history, and the woman may not think that the assault will have any significance during childbirth. One explanation for this lack may be that the theme of assault, and of rape in particular, is laden with shame and therefore surrounded by silence in such a way that it is difficult to approach for the woman and her helpers alike. The shame of having been raped can be overwhelming for the woman, and difficult for her helpers to identify. Health care personnel who provide antenatal care frequently feel they do not have the necessary competence or preparation to take in the woman’s history of assault, and this feeling may be a factor in leaving the theme untouched upon (32). When those caring for pregnant women for various reasons do not give attention to the theme of sexual assault, it can send a signal that burdensome life experiences and psychological problems are not seen as factors of significance for birth. When working with women who have had a traumatic birth experience, one should ask oneself whether she has had other traumatic life experiences, which could potentially be reactivated during the birth. One can imagine the possibility that performing a planned elective cesarean section might be a way to avoid reactivating a rape trauma in labor. However, our informants who were delivered by cesarean
reported similar reactions to those who gave birth vaginally. They described among other things that being touched by strangers’ hands, placed in supine position, anesthetized, and fixed to an operating table reactivated the rape trauma in the same way. They felt just as objectified, dirtied, and alienated from their bodies as those who gave birth vaginally. The informants also reflected on how a planned cesarean section would not be able to prevent a reactivation as it necessarily involves being touched by others as well as insertion of intravenous and urinary catheters, washing of the surgical field, and being tied to necessary equipment. It is also possible to view reactivation of a trauma as an opportunity to connect with the traumatic event and to begin processing it (33). Childbirth holds the potential to enter a dialogue with one’s body, a dialogue that can lead to growth in the longer term. Having a new experience can give a feeling of self-efficacy, which itself is important for the confidence that one can protect oneself in the future. All of the informants reflected on how a vaginal birth without operative intervention would promote an experience of mastery, and the informants in this study who had given birth to subsequent children described the memory of the rape being most intrusive during their first child’s birth. This reflection may be interpreted as performing elective planned cesarean section to protect the woman in the short term may hinder her opportunity for growth in the long term. None of the women in this study wanted a cesarean delivery.
Limitations and Strengths of the Study Our informants were very clear about their main motive to participate in the study. By sharing their experiences they hoped to contribute to increased knowledge of how rape can affect birth, so that both birthing women and their attendants may benefit from this sharing in the future. A limitation of this study is that all of the informants were recruited from the cohort of women who were referred for counseling for psychological problems by a mental health team at a hospital antenatal clinic; these informants’ experiences may not apply to all women with a history of rape. Even though no direct questions were asked about the rape, all of our informants spontaneously gave in-depth descriptions of the attack. The close association between the memories of the rape and the birth experience strengthens the supposition of an internal association between the two. The interviews, however, were performed 1–12 years after the first birth and for the women who had given birth twice, even though they described their labor experiences very clearly and separated the first and sec-
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190 ond ones, the possibility of confusion cannot be ruled out.
Clinical Implications This study presents the way women subjected to rape experience their first childbirth. We know little of how the birth attendants experienced the interaction with the women. More in-depth studies of the relationships between birth attendants and women in labor, seen from both sides, will increase the understanding of the dimension of trauma in their interactions. Provided that there exists a good relationship with the birth attendants, childbirth can also carry the possibility of progress in working through a rape trauma.
Conclusion A rape trauma may be reactivated during the first childbirth, independent of mode of birth. The birth for our informants came as a shock, a confrontation with the past trauma in which the woman was emotionally paralyzed and alienated from her body, feelings that persisted for a long time after birth. Birth attendants should acknowledge that common measures and procedures used in labor and during cesarean section can reactivate the rape trauma. Future research should focus on how best to provide care in labor and birth to women with a past history of rape.
Acknowledgments The study was supported by the North Norway Regional Authority Clinical Research fund, Helse Nord RHF, 8038 Bodø, Norway. We wish to thank our informants for their participation in this study. They based their willingness to participate on their hope that sharing their experiences could help improve care in the future for other women with a history of being raped. We thank Rachel Myr for her translation of this paper.
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Giving Birth with Rape in One’s Past: A Qualitative Study Lotta Halvorsen, RN, RM, MHSc, Hilde Nerum, RN, RM, MHSc, Pa˚l Øian, MD, PhD, and Tore Sørlie, MD, PhD ABSTRACT: Background: Rape is one of the most traumatizing violations a woman can be
subjected to, and leads to extensive health problems, predominantly psychological ones. A large proportion of women develop a form of posttraumatic stress termed Rape Trauma Syndrome. A previous study by our research group has shown that women with a history of rape far more often had an operative delivery in their first birth and those who gave birth vaginally had second stages twice as long as women with no history of sexual assault. The aim of this study is to examine and illuminate how women previously subjected to rape experience giving birth for the first time and their advice on the kind of birth care they regard as good for women with a history of rape. Methods: A semi-structured interview with 10 women, who had been exposed to rape before their first childbirth. Data on the birth experience were analyzed by qualitative content analysis. Results: The main theme was “being back in the rape” with two categories: “reactivation of the rape during labor,” with subcategories “struggle,” “surrender,” and “escape” and “re-traumatization after birth,” with the subcategories “objectified,” “dirtied,” and “alienated body.” Conclusion: A rape trauma can be reactivated during the first childbirth regardless of mode of delivery. After birth, the women found themselves re-traumatized with the feeling of being dirtied, alienated, and reduced to just a body that another body is to come out of. Birth attendants should acknowledge that the common measures and procedures used during normal birth or cesarean section can contribute to a reactivation of the rape trauma. (BIRTH 40:3 September 2013) Key words: birth experiences, birth trauma, content analysis, rape, re-traumatization
Rape is one of the most traumatizing violations a woman can be subjected to, with negative consequences for her health and reproductive life (1–3). It is well documented that a rape can lead to long-term reactions, fear, anxiety, depression, fatigue, chronic pain, sleep or eating disturbances, self-harm, substance abuse, and suicidal thoughts or attempts (3–10). It is the psychological injuries that dominate, and a large
proportion of women develop a form of posttraumatic stress disorder in the aftermath, termed Rape Trauma Syndrome, in which the rape is the stressor (11,12). Sufferers of Rape Trauma Syndrome tend to have more serious symptoms than individuals in which posttraumatic stress disorder is because of other stressors, and the closer their assault is to the legal definition of rape (forced, nonconsenting sexual activity) the stronger the
Lotta Halvorsen and Hilde Nerum are Doctoral students at the University of Tromsø, Norway, and midwives at the Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø. They are equal first authors of the following paper. Pål Øian is a professor in the Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, and Institute of Clinical Medicine, University of Tromsø, Norway. Tore Sørlie is a professor in the Department of General Psychiatry, University Hospital of North Norway, Tromsø, and Institute of Clinical Medicine, University of Tromsø, Norway.
Address correspondence to Lotta Halvorsen, Department of Obstetrics and Gynecology University Hospital of North Norway, Postbox 100, Langnes, 9038 Tromsø, Norway.
Accepted July 9, 2013 © 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc.
183
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symptoms of Rape Trauma Syndrome (3,13). Features that seem more prominent in victims of rape are shame, guilt, and suicidal ideation (2,6). The rape crisis is assumed to strike a core in the woman that affects her fundamental value as a woman and influences her relationships with other people in the future (6,14). Estimates indicate that 6–36 percent of all women have been subjected to forced sexual activity or sexual violence (1,5,7–9,15). Statistics from the United States show that between 12 and 18 percent of women have been subject to a rape in the course of their lifetimes (9). Several studies indicate that the risk of being subject to sexual assault is highest in late adolescence (6,15,16). In most studies of the association between various forms of sexual assault and subsequent birth outcomes, women with a history of sexual assault have not been found to have higher incidence of medical complications or operative delivery than women without such histories (17–19). A study carried out by our research group has, however, shown that women who were raped as adults were delivered by cesarean, forceps, or vacuum extraction to a much greater degree, and that those who gave birth vaginally had second stages of labor twice as long compared with women with no history of sexual assault (20). Studies have shown that a large proportion of women requesting cesarean for fear of birth have been subject to sexual assault earlier in life, and have experienced their first birth as traumatic (21,22). During the many years of our clinical practice as midwives, we have counseled numerous women with a history of sexual assault and rape, many of whom experienced the care they received during labor as new assaults. The actual birth experience of women who have been subject to rape previously has been little researched or described in the obstetric literature. The aim of this study is to examine and illuminate the way a first childbirth is experienced by women previously subjected to rape, and advice on the kind of birth care they regard as good for women with a history of being raped.
Method Design and Population To examine the women’s experiences, a qualitative semi-structured interview was used. This approach is suitable for sensitive topics, and gives access to human thoughts and experiences (23). The interviews were carried out according to Kvale’s principles for the qualitative research interview (24). This process means that the informants do not merely answer questions posed by the researcher, but that through dialogue with the interviewer they formulate their own experience and
perception of the world they live in. Data were analyzed qualitatively as described by Graneheim and Lundman, a method for systematic identification of variation in the text with regard to similarities and differences (25). Advice on good birth care for women with a past history of rape is summarized and presented in a schematic model. The study population consists of women subjected to rape after the legal age of consent (≥ 16 years) and before giving birth to their first child. The informants were recruited from a cohort of 808 women who had been referred for counseling for various psychosocial problems to a mental health team at the antenatal clinic, University Hospital of Northern Norway, in the period from 2000 to 2007. Of the 808 women, 59 reported having been raped as adults, whereof 50 were part of a study showing primiparous labor outcome (21). All of the women had been subjected to vaginal rape with penetration. The information about the rape was registered as part of a systematic charting of their reproductive and mental health during counseling at the antenatal clinic. The women’s rape history was not known to their caregivers during pregnancy and remained unknown to the birth attendants during the women’s first birth. A strategic sample was chosen using the following criteria: the woman had to speak Norwegian, not be pregnant, and not be suffering from serious mental illness at the time of the interview. The women’s births represented different modes of delivery: vaginal birth, vacuum extraction, and cesarean section. Written requests to participate in the study were sent to 11 women, with information about the aim of the study and what participation entailed. In the letter it was emphasized that there would be an offer of professional help if the interview itself caused problematic reactions. Those who wished to participate posted their consent directly to the researchers. No reminders were sent. Ten women consented to participate, and these comprise the informants for this study. Their ages at the time they were raped and at their first childbirth and the outcomes of those births are described in Table 1. The interviews were carried out in the period 2009 to 2010 jointly by the two first authors (LH, HN), who both have extensive clinical experience discussing sensitive themes with women. Eight of the interviews took place in an undisturbed place at the hospital and two took place in the homes of the informants. The interviews were audio recorded, and lasted on average two hours each. An interview guide had been developed with focus on the following themes: the first birth experience, interaction with birth attendants, what the informants considered “good birth care,” and asking the informants to describe their own mental and sexual health at the time of the interview. The opening question was “Tell us about your first childbirth—in as
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184 Table 1. Informants’ age at time of rape, at time of first childbirth, type of onset of labor, and mode of birth
Informant
Age at rape (year)
Age at birth (year)
1
22
38
Spontaneous
2
18
22
Spontaneous
3 4 5
17 16 26
29 26 29
Induced Induced Spontaneous
6 7
16 16
25 26
Spontaneous Induced
8
19
23
Induced
9 10
16 16
21 23
Spontaneous Induced
Labor onset
Mode of birth Vacuum extraction Vacuum extraction Spontaneous Spontaneous Vacuum extraction Spontaneous Emergency cesarean Emergency cesarean Spontaneous Emergency cesarean
much detail as you can recall.” The subsequent thematic order was dependent on what the individual woman brought up. The interviewees were encouraged to tell freely about their experiences related to the various themes. No direct questions about the rape were included. Clarifying questions were posed as needed. Before ending, the interview guide was checked to ensure that all of the themes had been dealt with. After each interview, individual notes were made that summed up the interviewers’ immediate reflections on the content of the interview. The first six interviews were transcribed consecutively (by LH), and the rest were transcribed by an external person without any connection to the study. The interviews were transcribed verbatim in dialect, as close to the oral form as possible, with noting of laughter, crying, silence, or other forms of nonverbal communication.
the main theme was an ongoing process throughout the entire analysis period. Presenting the material in a clear way was emphasized, without changing the meaning of the women’s comments. Further analysis was discussed by the other two coauthors (TS, PØ) to achieve a greater common understanding of the abstracted material in the text. The entire analysis was carried out manually, without the use of electronic instruments of analysis.
Ethical Approval The study was approved by the Regional Committee for Medical and Health Professional Research Ethics for Northern Norway (Reference 2009/1146-2).
Results Descriptions of the Study Population The informants were aged 21–38 years (Mean 26.2) at the time of their first childbirths (Table 1). Seven were married or cohabiting with partners and three were single. All resided in Northern Norway, and four had Sami ethnic origin. All had completed secondary school and four had university educations lasting more than 4 years. Nine were in full-time employment; one was temporarily disabled as a result of serious somatic illness. At the time of the interview, eight had two children, whereas two had one child each. They had been raped when they were 16–26 years old and the first childbirth occurred 6–16 years after the rape. Nine of the women had experienced attack rapes by strangers, two of them by multiple attackers; one woman had been raped by her partner. In the case of four of the women, the rape was their sexual debut. One rape had been reported to police. Being Back in the Rape
Data Analysis Interviews consisting of 131,261 words were analyzed by the two first authors (LH, HN). Because this study focuses on the first birth experience, only those parts of the text dealing with labor and the advice of the birth attendants were used (98,467 words). To get a comprehensive picture of the experience as a whole, the interviews were listened to and the transcripts re-read several times. Thereafter, the same two researchers reflected together on the main themes of the content. The text was then divided into meaning units that were coded, condensed, and thematized. The development of
In the analysis, one main theme, two categories, and six subcategories were identified. The main theme was “being back in the rape.” The category “reactivation of the rape during labor” had the subcategories “struggle,” “surrender,” and “escape,” whereas the category “retraumatisation after birth” had the subcategories “objectified,” “dirtied,” and “alienated body.” Reactivation of the Rape All of the informants described persistent strong memories of having been back in the rape during their first childbirth, independent of whether they gave birth
185
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vaginally or by cesarean section. They described it as switching back and forth between scary memories from the rape and conditions during labor that reminded them of the rape. Struggle The informants described having carried on an intense internal struggle during labor, in which the rapist and the birth attendant switched roles as main actor. One of the informants described her fight with the rapist this way: I recall the birth as dark and ominous, a big black hole I was afraid to fall into, because there he stood, the man who raped me and he was grinning this awful grin. I know I fought not to fall down the hole, because if that happened I would lose my mind. It was vital to stay on the edge and not fall in. My husband realized I was struggling in my own world, fighting with someone outside the room. It cannot have been easy to be him while I was battling another man in the midst of the birth of our child. (3)
In the battle with the birth attendants, the women were in conflict with themselves and their own needs, and the ward’s procedures and routines. I was alone against them. All information was given with their hands inside me… I tried to tell myself “Relax! Get a grip!” but it was no use. (10)
The birth attendants’ touching of intimate parts of their bodies was experienced as an invasive procedure, and this intrusion was intensified when the attendants without warning touched them without the women understanding what the attendants were doing, and why. The women tried actively to maintain control over their bodies by protecting themselves with clothes or bedding. They described the feeling of once more being held captive, held forcibly in positions they expressed strongly that they did not wish to be in. Procedures such as vaginal examinations to monitor progress in labor were tied to their experiences of the violent vaginal penetration during the rape. The pain experienced by the lower part of their bodies once again became the main body part, which once again was subject to events reminiscent of the rape. I felt he was brutal, it was just kind of a “whoosh”… felt he just broke my legs apart, and right in and just go ahead and check me. It was such a helpless situation to be lying there… in way like… a bit of a violation really. Even though I tried to tell myself, sort of sensibly that “they do have to do this” and “I guess they need to check that everything is OK.” (4)
The alternating battle with the birth attendant and the rapist was experienced over time as a useless one, in which the women finally simply surrendered.
Surrender The women felt that their physical and emotional reactions were either overlooked or overrun by the birth attendants. Through the unintended unfortunate interaction with the birth attendants, in which they tried in vain to resist, the women gradually allowed themselves to be dominated and finally surrendered. I did not want to be on my back with my legs up, but they held my legs. Something happened to me around that, being held in place. For me, it led to just giving up, they could do whatever they wanted. It was kind of… all the way up to that point, I was protesting. (9) When they laid me on the operating table I felt as if I died. My whole body disappeared. I felt nothing, I was gone, I had no way to get away, I could not get away. (10)
When the woman gave up, the birth attendants interpreted the situation as an inability to give birth, and their next move was an even more active intervention to deliver her. The women perceived this interference as if they were unable to master the task and that their bodies had failed them. When they had surrendered, they saw no other option than to mentally escape out of their bodies. When they put in that “vacuum cup” it was the first time I really had thought about the rape in years. I was back in it, being held down and not being able to move. In any case I was completely naked. I felt a kind of shame too. Up to this point I was kind of angry, in a way. But then it was a little bit like when “he” (the rapist) – it was kind of too late. Nothing left to fight for. Afterwards I felt I’d done such a terribly bad job. (2) Just lying there on your back and you’re in the same position when you again go into the same state as when you were raped, plain and simple. You′re lying there and things happen down there (points between her legs), the feeling of being held down. It was really strange… my body held back and would not do it. I wanted to give birth but my body would not do it. (1)
Escape Both the birth and the rape were experienced by the informants as unavoidable and uncontrollable situations. They let their captive bodies remain, and saw themselves from outside, or from above. I no longer knew I was giving birth. It was very unreal, but so is a rape. I felt that in a way, I left my body, like when I was raped. I did not know where I was, if I was above myself looking down. But it felt very similar. (4) I was stuck in the bed, they could do what they wanted with me. They were saying something about them seeing that I am in pain, but “they will be quick.” They pull away the duvet I
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186 am clinging to for dear life and they pull up my top. Lying in bed, vulnerable, I leave the room; they can just do whatever they have to. (10) Looked down and saw myself from above, like a slaughtered animal lying there that they could do whatever they wanted to. Could not move a muscle, and real scared. I am lying there stunned, and cannot get away. Cannot take in what is happening. I am good at leaving the crime scene. (7)
The informants described the way they experienced being treated as a passive object instead of a participant. Their intention was to collaborate with the birth attendant, something that gradually seemed as an impossible task. They described birth attendants who seemed stressed, and who they felt had no time or inclination to work with them. They experienced their own reactions as deviant and inappropriate, and perceived that the attendants focused exclusively on the baby’s birth, to which the women themselves comprised an obstacle. Re-traumatization after birth The informants had tried to deal with the rape as a “non-event” in their lives. The shame of having been raped was so overwhelming that the trauma remained unspoken and thereby unprocessed. In pregnancy they had thought that the rape might influence the birth, but the thought had been shoved aside. After the birth, they experienced that the same patterns of reaction and the same defense strategies elicited by the rape, also had been activated during labor.
Objectified What they had attempted to communicate to the birth attendants had not been received; their body language had been overlooked and not given consideration—as though they had not even been present. They felt reduced to a “birth machine” and were ashamed that they had not been able to prevent this process from happening. That the midwife did not talk to me, did not address me—and that I was not allowed to be involved. I was just a kind of “robot machine body” that was there to give birth to a baby— where nobody saw “me.” There is something very degrading about being treated like a birth machine that is just something to be repaired. You are not a machine that is going to give birth to a kid, you are there as a person too. You are not just a body that another body is going to come out of. So in a way it is “a body” that gave birth—but it was not me. (2) It was sort of the baby it was all about, not “me” at all. It was so strange really—as if I was not even there—I was not there. I was just—I was not even a patient, really—was actually
nobody. There was just a baby who was going to come out of me. (4)
The women recognized well the same unworthy feeling of being useless, like some random object, and they again assumed the blame for it having turned out that way.
Dirtied The women described the way all forms of touch by unfamiliar hands invaded and dirtied their bodies. “Dirtied” in the sense that the feeling came as a consequence of something they were subjected to from outside themselves, and that had stuck to their bodies. Immediately after the birth or the cesarean section there arose an acute and pressing need to wash themselves clean. Recall that I felt dirty! I felt violated, and I really wanted to brush my teeth. I felt I wanted to brush away something or other. And this has something to do with me feeling really dirty—and those old nightmares about the hands came back. (1) It got so important to get on my feet again, after the cesarean section. Everything had to be washed away, sweat, blood, filth, bits of tape, and most important, hands. All the hands that had been there, had to go. (10) I felt I had to have a shower. Not so much the birth, because I do not know if I was bloody, I have no idea—I am sure I was, and sweaty too, but there was something else I had to shower off. Felt I had to make myself clean in some way or another. After that rape I have always been like that—felt that I had to—all this stuff about cleanliness. (4)
The feeling of being dirtied persisted far into the puerperium; they felt they had bodies they did not recognize as their own, and this feeling made it difficult to carry out the natural tasks of mothering.
Alienated Body The birth became a new assault in which the women experienced being violated in a similar way to when they were raped. They recognized the degradation of having been objectified and reduced to a physical thing that others had made use of. The feeling was not directly tied to how the child was born, but to how the interaction between the women and the birth attendants had developed during the birth. I felt just gross. They shoved me further and further away from myself, just slammed on. They stood there all three with their heads in me, down there. Was not that nobody saw me or talked to me. I was just empty. I hate my body, thinking of
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myself as one thing, my body as something else, and we are not working together. My body is just gross. (10) Well, it feels like certain of your body parts are not yours no more. It is just something someone takes all away from you. You sit there or lie there, just like that, and just ARE like a carcass or a beached whale in my case. I felt like I was just laying there, stuck, and could not come back to my own self. I feel I’m still lying there, when I ought to be lying out to sea, swimming. (9)
The rape trauma had invaded the entire birth experience so that instead of feeling like a proud new mother, this woman remained re-traumatized. Caring in labor for women with a past history of rape Figure 1 shows advice on what kind of care in labor the informants would have liked, and their advice to birth attendants on the kind of care they regard as good for women who have been raped previously. They were very clear that the most important condition for the best possible outcome is good interaction between the woman and her attendants. It is important that the birth attendants understand that routine procedures used during labor or a cesarean section can contribute to a reactivation of the rape trauma. They state that the woman should have enough time and a calm atmosphere in which to give birth to her baby, with as few interventions or disturbances as possible that may remind her of the rape. All of our informants reflected on how giving birth vaginally and spontaneously without operative intervention can give a feeling of self-efficacy and thus contribute to moving forward in processing their attack. Those informants who had given birth twice recounted that the memory of the rape was most prominent during their first childbirth.
Discussion The findings of this study show how our informants during their first childbirth were caught by their bodily experiences and memories from the rape. This experience led to a chaotic mixture of the rape in the past and their labor in the present, and was unrelated to whether the woman gave birth spontaneously, was operatively delivered by vacuum extraction, or was delivered by cesarean section. In the literature this chaotic mixture is described as the person behaving as though the traumatic situation poses a current threat, with a desire to defend herself against the threat in the way she tried in the original situation, without success (10). It has been documented that unprocessed traumatic life events can force themselves on the individual so they experience that the event is occurring again (10,26,27). In the theo-
187 retical model in Fig. 1, the central expressions of how the memories of the rape were triggered in the birth situation are shown. During labor, the informants noted that several of the same reactions and defense strategies as they experienced during the rape were elicited. After birth this phenomenon made them feel as if they had been raped again. It has been described previously that childbirth can reactivate memories of rape (26–30). Rhodes and Hutchinson have described four different extremes of behavioral patterns during labor, which can be associated with posttraumatic stress reactions after sexual abuse or assault: fighting, taking control, surrendering, and retreating (29). The same patterns can be seen in our informants when they describe that in the unintended poor interaction with their attendants, they first tried to resist, but after a while allowed themselves to be dominated and surrendered, and finally ended up feeling that their bodies were alien to them. The informants described how the birth attendants “doing as they pleased” with their bodies, externally and internally, without preparing them for this act, contributed to their being drawn back in time to the rape in their past. The informants described being very disturbed by all of the interventions used during labor. The methods used for pain relief did not help against what they found painful, but rather enhanced the feeling of being paralyzed and out of control. Burgess has described that the immediate reactions that automatically arise during a rape give a surreal feeling in which the body no longer reacts or carries out the orders given by the brain, and the woman becomes physically unable to remove herself from the situation (11). The predominant feeling the informants in various ways communicated, and the feeling they were left with after birth, was a deep shame. They were ashamed that their body once again had been invaded and they had not been able to prevent a new assault. They were ashamed that they had not managed to communicate and cooperate with their birth attendants. The shame of not measuring up as a woman giving birth, nor as a mother, was a burden they carried in silence as they went on with their lives. The most prominent expression of deep shame is silence, and the perception of one’s own worthlessness (31). Being raped is more than experiencing vaginal penetration against one’s will; it involves an injury to the core of the self, a violation of one’s human dignity, and those who have been subjected to it frequently assume the blame for what happened. For our informants, the rape had been such an extreme event that a reactivation during their first childbirth was inevitable. The informants in this study had all been subjected to a violent vaginal penetration; for nine of them, the rape had been part of an attack in which they had feared for their lives. Other studies
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188
Memories of the rape
Rape
Labor
Memories of the rape
Conditions during labor
Lying supine, forcibly restrained
Being placed supine, physically restrained
Brought to the fore during labor
Reminding woman of the rape
Violent approach to the body/genitals
Legs forced apart, placed in stirrups
Painfully forced entry and vaginal penetration
Invasive procedures, not being listened to or seen
Perpetrator takes over control of her body
Invasive vaginal examinations
Struggle, shouting, crying for help
Unfamiliar hands touching body, being overruled
Darkness, blood, semen, sweat, breath
Sight / smell of blood, amniotic fluid, feces, sweat
Feels unclothed, despised
Dimmed lighting/being unclothed
Helpless, degraded
Bodily integrity not ensured
Gives up, lets it happen, feels ashamed,
Being tied to bed or operating table, giving up
leaves her body, disappears
Birth attendants control body, room, time
Reactivation During labor Struggle Escape
Surrender
Being back in the rape
Dirtied
Objectified Alienated from body Retraumatized After birth
Informant’s advice on good birth care for women with past history of rape That birth attendant knows about the rape before labor, shows understanding for her reactions Not talking about the rape during labor Being included in treatment decisions, being addressed directly, with eye contact Being encouraged and supported, helped to stay in the present during labor, “being brought back” to present task Protection of bodily integrity, as little manipulation of the body as possible, fewest possible vaginal exams Help to maintain an upright position, avoid being placed supine Awareness that epidural can give same paralyzed feeling as during rape, and both nitrous oxide and pethidine can give unpleasant fogginess and feeling out of control Informing her in advance of any touching of her body by anyone, allowing time for her to cooperate freely As few unfamiliar people as possible in the labor or operating room Allowing her enough time, especially in second stage Creating a calm space and time for giving birth Understanding her need to wash and freshen up immediately after birth Getting to talk through labor with her birth attendants afterwards
Figure 1. Schematic model of reactivation of the rape during labor, re-traumatization after the birth, and the kind of birth care the informants consider as good birth care for women who have a past history of rape.
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have shown that when rape is associated with mortal fear, and when the attack is not reported, or for other reasons remains hidden by silence, the psychological problems are more serious in the aftermath (3,6,11). Only one of our informants had reported the rape to the police. For most of the women the trauma had been suppressed and unprocessed. Childbirth was for all of them a new and shocking confrontation with their previous trauma. We believe that the degree to which childbirth reactivates a rape trauma depends on, among other things, the quality of the interaction with the birth attendants. This belief, however, poses certain requirements to charting previous trauma, working through this trauma before the birth, and tailoring the birth situation to the woman’s needs. Our informants expressed how important it was to be seen, and to be addressed directly. They wanted help to protect their bodily integrity from the view and touch of those present, and they needed sufficient time to prepare so they could cooperate with necessary procedures such as vaginal examinations. They wished to be encouraged and supported to be present in their bodies during labor, so that they did not surrender and escape mentally from the situation. This approach requires that the birth attendant has knowledge of reactivation of assault, and that the attendant is familiar with the conditions during labor, which may remind the woman of her assault. Birth attendants often lack knowledge about the woman’s history, and the woman may not think that the assault will have any significance during childbirth. One explanation for this lack may be that the theme of assault, and of rape in particular, is laden with shame and therefore surrounded by silence in such a way that it is difficult to approach for the woman and her helpers alike. The shame of having been raped can be overwhelming for the woman, and difficult for her helpers to identify. Health care personnel who provide antenatal care frequently feel they do not have the necessary competence or preparation to take in the woman’s history of assault, and this feeling may be a factor in leaving the theme untouched upon (32). When those caring for pregnant women for various reasons do not give attention to the theme of sexual assault, it can send a signal that burdensome life experiences and psychological problems are not seen as factors of significance for birth. When working with women who have had a traumatic birth experience, one should ask oneself whether she has had other traumatic life experiences, which could potentially be reactivated during the birth. One can imagine the possibility that performing a planned elective cesarean section might be a way to avoid reactivating a rape trauma in labor. However, our informants who were delivered by cesarean
reported similar reactions to those who gave birth vaginally. They described among other things that being touched by strangers’ hands, placed in supine position, anesthetized, and fixed to an operating table reactivated the rape trauma in the same way. They felt just as objectified, dirtied, and alienated from their bodies as those who gave birth vaginally. The informants also reflected on how a planned cesarean section would not be able to prevent a reactivation as it necessarily involves being touched by others as well as insertion of intravenous and urinary catheters, washing of the surgical field, and being tied to necessary equipment. It is also possible to view reactivation of a trauma as an opportunity to connect with the traumatic event and to begin processing it (33). Childbirth holds the potential to enter a dialogue with one’s body, a dialogue that can lead to growth in the longer term. Having a new experience can give a feeling of self-efficacy, which itself is important for the confidence that one can protect oneself in the future. All of the informants reflected on how a vaginal birth without operative intervention would promote an experience of mastery, and the informants in this study who had given birth to subsequent children described the memory of the rape being most intrusive during their first child’s birth. This reflection may be interpreted as performing elective planned cesarean section to protect the woman in the short term may hinder her opportunity for growth in the long term. None of the women in this study wanted a cesarean delivery.
Limitations and Strengths of the Study Our informants were very clear about their main motive to participate in the study. By sharing their experiences they hoped to contribute to increased knowledge of how rape can affect birth, so that both birthing women and their attendants may benefit from this sharing in the future. A limitation of this study is that all of the informants were recruited from the cohort of women who were referred for counseling for psychological problems by a mental health team at a hospital antenatal clinic; these informants’ experiences may not apply to all women with a history of rape. Even though no direct questions were asked about the rape, all of our informants spontaneously gave in-depth descriptions of the attack. The close association between the memories of the rape and the birth experience strengthens the supposition of an internal association between the two. The interviews, however, were performed 1–12 years after the first birth and for the women who had given birth twice, even though they described their labor experiences very clearly and separated the first and sec-
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190 ond ones, the possibility of confusion cannot be ruled out.
Clinical Implications This study presents the way women subjected to rape experience their first childbirth. We know little of how the birth attendants experienced the interaction with the women. More in-depth studies of the relationships between birth attendants and women in labor, seen from both sides, will increase the understanding of the dimension of trauma in their interactions. Provided that there exists a good relationship with the birth attendants, childbirth can also carry the possibility of progress in working through a rape trauma.
Conclusion A rape trauma may be reactivated during the first childbirth, independent of mode of birth. The birth for our informants came as a shock, a confrontation with the past trauma in which the woman was emotionally paralyzed and alienated from her body, feelings that persisted for a long time after birth. Birth attendants should acknowledge that common measures and procedures used in labor and during cesarean section can reactivate the rape trauma. Future research should focus on how best to provide care in labor and birth to women with a past history of rape.
Acknowledgments The study was supported by the North Norway Regional Authority Clinical Research fund, Helse Nord RHF, 8038 Bodø, Norway. We wish to thank our informants for their participation in this study. They based their willingness to participate on their hope that sharing their experiences could help improve care in the future for other women with a history of being raped. We thank Rachel Myr for her translation of this paper.
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