**5. Pregnancy and the history of sexual abuse**

Body memory can awaken when a woman's body starts to change during pregnancy. When the pregnancy becomes visible, this can be a sign that the body is no longer untouchable, that someone has already crossed the "line". Thus, a woman's gestational belly becomes part of the public arena, where everybody notices and sees it. For a woman without a history of sexual abuse, this can be the most beautiful thing. However, for a woman who has been sexually abused, her body becoming more noticeable and different can be extremely distressing. This is particularly the case if, for years and years, she had hidden every bodily change caused by the sexual abuse - even if only in her feelings and experiences.

Some studies have shown that girls who have been sexually abused in childhood are three times more likely to get pregnant before the age of 18 years [19] than those who have not. Similarly, Saewyc et al. [20] argue that 60% of pregnant underage girls have been victims of sexual harassment, rape or attempted rape in their past. According to other studies, pregnancy (as a consequence of sexual abuse) occurs in 11% to 20% of girls. Furthermore, more than 96% of underage prostitutes who have run away from home have been victims of sexual abuse in their childhood [9].

A study on a sample of 3,128 sexually abused underage girls showed that they engage more often in sexually risky behaviour (promiscuity, prostitution and pornography – seeking contact through sexuality). This study also reported that, compared to girls who had not been sexual abused, these girls were more likely to have had intercourse by the age of 15 years and more than one sexual partner. They were also less likely to use birth control during intercourse. Additionally, they more often used alcohol or other substances before having sexual inter‐ course. Among others, the following variables strongly stood out in this study: lack of parental supervision, presence of physical abuse, higher levels of school absenteeism, less involvement in extracurricular activities and lower grades (in comparison to those who had not been sexually abused). The difference between the two groups was statistically significant. The study also demonstrated that underage girls with a history of either sexual or physical abuse were twice as likely to become pregnant as teenagers, compared to girls without such a history. If they had experienced both sexual and physical abuse, they were four times as likely to get pregnant [21].

Seng et al. [22] found that women who had experienced PTSD during pregnancy were more susceptible to a spontaneous abortion, ectopic pregnancy and hyperemesis. Other studies report that sexually abused women have a statistically significant higher number of compli‐ cations during pregnancy. Among the most common are: bleeding, severe vomiting, x-ray or radiotherapy in the first semester, alcohol, smoking, medications, accidents, infectious diseases, threatened abortions with hospitalization and severe illness [23]. Some abused women report several health complications and a higher use of health care services during pregnancy. However, these women do not experience more obstetric complications during their pregnancies and deliveries [24].

Women with a history of sexual abuse **experiencedepression in the prenatal and the postnatal period much more often** than women who have not been sexually abused. In general, children whose mothers were depressed during pregnancy show changes in their neurological functioning. They are more withdrawn, irritable and inconsolable than children whose mothers were not depressed during pregnancy [25]. Prenatal depression can lead to deficient care during pregnancy and bad eating habits, as well as the abuse of various substances like tobacco, alcohol and illegal drugs.

**Smoking** can lead to spontaneous abortion, as well as increasing the risk of an enlarged thyroid gland in children, low body weight and deformation. It has been recorded that children whose mothers smoked heavily during pregnancy had lower mental abilities measured by the age of 19 months with the Bayley Scales of Infant Development [14]. The foetuses of women who chronically drank **alcohol** during pregnancy exhibited serious morphological (related to the form of the organism) and developmental abnormalities. Not all children exposed to alcohol during pregnancy suffer such serious conditions. However, there is a high probability that they will have neurological and cognitive disorders such as a lower reaction time and reduced attention spans.

**Using illegal drugs** during **pregnancy** is also problematic. Using **marihuana** during pregnancy can lead to a child having lower mental abilities, hyperactivity, impulsiveness, carelessness, inattention, delinquency and the externalizing of problems. **Cocaine abuse** during pregnancy is associated with a weakened, impaired processing of aural informa‐ tion, an increased risk of spontaneous abortion, premature labour pains, a stillborn child and microcephaly (the child having a small head). Heroine abuse and the use of other narcotics can cause a premature birth, the death of the foetus, the child's addiction, low body weight and cognitive and behavioural problems. **LSD and inhalants abuse** can be related to various deficits at birth [26].

In addition to drugs, women often silence their abused bodies with food. Waugh and Bulik [27] have found that women **with eating disorders during pregnancy** are more exposed to a caesarean section and have more problems in maintaining breastfeeding. Often, the disorders continue after the birth, leaving them at a high risk of developing postnatal depression.

Katarina Neff [28], a doula who has a lot of experience with pregnant women who have been sexually abused, believes that when a sexual abuse survivor with PTSD becomes pregnant, she may develop the following symptoms:


someone has already crossed the "line". Thus, a woman's gestational belly becomes part of the public arena, where everybody notices and sees it. For a woman without a history of sexual abuse, this can be the most beautiful thing. However, for a woman who has been sexually abused, her body becoming more noticeable and different can be extremely distressing. This is particularly the case if, for years and years, she had hidden every bodily change caused by

Some studies have shown that girls who have been sexually abused in childhood are three times more likely to get pregnant before the age of 18 years [19] than those who have not. Similarly, Saewyc et al. [20] argue that 60% of pregnant underage girls have been victims of sexual harassment, rape or attempted rape in their past. According to other studies, pregnancy (as a consequence of sexual abuse) occurs in 11% to 20% of girls. Furthermore, more than 96% of underage prostitutes who have run away from home have been victims of sexual abuse in

A study on a sample of 3,128 sexually abused underage girls showed that they engage more often in sexually risky behaviour (promiscuity, prostitution and pornography – seeking contact through sexuality). This study also reported that, compared to girls who had not been sexual abused, these girls were more likely to have had intercourse by the age of 15 years and more than one sexual partner. They were also less likely to use birth control during intercourse. Additionally, they more often used alcohol or other substances before having sexual inter‐ course. Among others, the following variables strongly stood out in this study: lack of parental supervision, presence of physical abuse, higher levels of school absenteeism, less involvement in extracurricular activities and lower grades (in comparison to those who had not been sexually abused). The difference between the two groups was statistically significant. The study also demonstrated that underage girls with a history of either sexual or physical abuse were twice as likely to become pregnant as teenagers, compared to girls without such a history. If they had experienced both sexual and physical abuse, they were four times as likely to get

Seng et al. [22] found that women who had experienced PTSD during pregnancy were more susceptible to a spontaneous abortion, ectopic pregnancy and hyperemesis. Other studies report that sexually abused women have a statistically significant higher number of compli‐ cations during pregnancy. Among the most common are: bleeding, severe vomiting, x-ray or radiotherapy in the first semester, alcohol, smoking, medications, accidents, infectious diseases, threatened abortions with hospitalization and severe illness [23]. Some abused women report several health complications and a higher use of health care services during pregnancy. However, these women do not experience more obstetric complications during

Women with a history of sexual abuse **experiencedepression in the prenatal and the postnatal period much more often** than women who have not been sexually abused. In general, children whose mothers were depressed during pregnancy show changes in their neurological functioning. They are more withdrawn, irritable and inconsolable than children whose mothers were not depressed during pregnancy [25]. Prenatal depression can lead to deficient

the sexual abuse - even if only in her feelings and experiences.

their childhood [9].

122 Sexology in Midwifery

pregnant [21].

their pregnancies and deliveries [24].


"Because birth is so different for every woman," comments Kristina, "women who have dealt with the same trauma may react in completely different ways and have completely different fears. Mostly, they are afraid of dealing with the first trauma again, regardless of if it was an abusive situation or a previous traumatic birth." There are some **specific fears that may manifest for a sexual abuse survivor with PTSD**, such as:


Sometimes the consequences of sexual abuse are not extensive or it does not seem that there are any. However, some women have been surprised and distressed by the feelings or memories that surface once they are pregnant, giving birth or mothering their child.

*"Until I got pregnant, I had no problems or any difficult memories of the sexual abuse I had suffered in my childhood. It seemed to me that those who said it was a serious trauma exaggerated, since my life was quite okay. I don't know what happened afterwards, but I can't even describe the degree of worry, fear and anxiety I started experiencing after I got pregnant, especially after I started showing. A terrifying fear that I'd lose the child because my body was dirty due to the abuse and the child couldn't develop in such conditions...sudden and severe anxiety attacks because I no longer had control over my body, my weight, my belly, which kept growing..."*

*"My pregnancy was nothing special until the moment the child began kicking in my belly. I was overwhelmed by the uncontrollable feelings of panic. Once, I even had to go to the ER. I felt guilty because I just wanted to pull the child right out, since every movement that was not under my control unnerved me intensely. At moments, I even wished for the child to die so that the distress would stop but I knew that, then, another would begin. I was somewhat appeased by being told I was having a girl because I realized that a boy would obviously remind me too much of the perpetrator."*

Clinical practice has shown that many pregnant women who have been sexually abused in the past often experience distress and new traumas in situations where women without a history of sexual abuse do not experience - or to a substantially smaller degree [29]. Even the usual gynaecological examinations can be very unpleasant due to the groping. In this case, it is very important that the gynaecologist is professional and sensitive. Nevertheless, when a woman is pregnant, carrying a developing and growing being, she is all the more sensitive to every touch and procedure related to her womanhood and her body [30].

*"The visit to the gynaecologist reminds me very much of rape. You lie there like a victim, while he shines his light down there and touches you. I think that someone inserting their fingers in your vagina is a matter of sex and I can't imagine what else this action would be good for. I find the stirrups particularly horrible. But, on the other hand, I am also aroused. When I was at the gynaecologist's last year, I had the same feeling as after sex, only without the kissing and petting. Like a rape I myself wanted. I was* *very much aroused when I went home and I was quite ashamed. I felt disgusted with myself and wished that someone would actually rape me. I'd pay him to go to bed with me and treat me really nastily, like his slave."*

*"It's the most horrible doctor's examination in the world. I go there when they send me the third invitation because I have to have regular check-ups. There I am, all stiff, keep my eyes closed and try to think of anything but this dreadful, humiliating, disgusting position I am in. The thought that I will have to go there almost every month when I'm pregnant makes me not want to ever get pregnant."*

*"What bothered me most was that some people touched my baby bump without permission. There were a few times when I had to leave the company and go to the toilet to vomit because I was so disgusted with the touching and, at the same time, angry with myself that I didn't draw the line and say I didn't like it."*

Post-traumatic effects of sexual abuse can be a big problem for survivors and a source of great fear. This is due to the subconscious triggering of traumatic memories during pregnancy (prenatal care) and delivery (the experience of birth). Women may avoid necessary medical care because of these fears. Furthermore, they may be so devastated by their experiences that they have difficulty enjoying and caring for their newborns. With this in mind, it can be highly beneficial if the personnel (midwifes, doctors, doulas, etc.) that a woman encounters during pregnancy, childbirth and the postnatal period are acquainted with her trauma and react appropriately. This ensures an even greater feeling of safety and support for the traumatized woman. Compassion in such hard times accelerates the healing of the reawakened trauma. At the same time, unkindness, roughness and unprofessionalism re-traumatize the pregnant woman and cause her additional distress and pain [29].
