**6. Childbirth and the history of sexual abuse**

"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**

**•** Fear that the child will be born dead (i.e., as punishment, wish fulfilment or self fulfilling

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

*"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*

*"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*

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

*"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*

*realized that a boy would obviously remind me too much of the perpetrator."*

touch and procedure related to her womanhood and her body [30].

memories that surface once they are pregnant, giving birth or mothering their child.

**manifest for a sexual abuse survivor with PTSD**, such as:

**•** Fear that the child will be born deformed (like her)

**•** Fear of the intensity of her feelings

**•** Fear of being an incompetent parent

*body, my weight, my belly, which kept growing..."*

**•** Fear of being an abusive parent

prophesy)

124 Sexology in Midwifery

It is normal for every pregnant woman to be afraid of giving birth. Evidence suggests that the fear of childbirth exists in a psychological domain of its own. For some women, the fear is of a very low level but for others, it can be extremely high [31]. Extreme fear of childbirth has been estimated to effect around 2.4% to 5% of pregnant women [32].

Numerous studies report that a great fear of childbirth is strongly related to negative sexual experiences in childhood and youth [33]. Fear may manifest itself by tearfulness, sleepless‐ ness, nightmares, preoccupation with fear and the objects of fear, restlessness, nervous‐ ness and tachycardia. Fear of childbirth may include fear of any of the following: the labour and delivery process, labour pain, lack of care by health professionals, the health of the baby or mother, surgical procedures, damage to the vagina and perineum, loss of control, not performing well, panic attack, physical exposure, uncertainty about the process of labour and becoming a parent [34].

In addition to the fear of childbirth, other fears may also be present. For example, the fear of vaginal examinations, health professionals noticing that you are damaged even if you don't have scars, being touched without consent and loss of control.

A study that included 2,365 pregnant women reported that a history of sexual abuse significantly increased the risk of experiencing severe fear of childbirth among primipar‐ ae. Fear of childbirth among multiparae was most strongly associated with a negative birth experience [35].

Similar conclusions can be found in a study that included 1,452 pregnant women (at 18 weeks of gestation) and measured their fear of childbirth (with the W-DEQ questionnaire) and anxiety (with the STAI questionnaire). In this study, the serious fear of childbirth effected 5.5% of the women. The fear of childbirth is not associated with the mode of delivery. However, sexual or physical abuse in childhood is negatively associated with the mode of delivery [32]. A small number of studies have shown that a history of child abuse has a minimal effect on the complications of labour and mode of delivery [36]. Having said this, the majority of studies have shown the opposite [37-39].

An experimental study, which used the cold pressor test, has shown that women who are afraid of childbirth have a reduced level of pain tolerance during and after pregnancy, compared to women who are not afraid of childbirth [40]. Other studies have shown that pregnant women who fear childbirth are prone to report fear during the actual labour and postpartum [41]. Fear of childbirth has been associated with elective CS, hyperemises gravi‐ darum, induction of labour, use of EDA and prolonged labour [42].

Compared to women with no history of sexual abuse, women with a history of sexual abuse are significantly more likely to be transferred to hospital due to complications. Furthermore, they use more medical pain relief, while primiparae are more likely to give birth with a CS [39].

A Norwegian study has shown that only half of women who report having an experience of physical and sexual abuse in childhood have a vaginal delivery without complications, as opposed to the 75% of non-abused women.

Similarly, a study in which 103 women were interviewed four weeks after giving birth showed that women who have been sexually abused are 12 times more likely to experience the childbirth event as traumatic [43].

The traumatic experience of childbirth is particularly associated with the subconscious awakening of the trauma of sexual abuse. This manifests through flashbacks and body memory. The most frequent triggers are vaginal examinations or other procedures (e.g., enema, shaving etc.). Additionally, pain during or after the childbirth itself can be a trigger, particularly in the woman's vagina, stomach, back, breasts or crotch. It is the person who a woman should trust the most during childbirth who can subconsciously remind her of the perpetrator who abused her trust as an authority figure (e.g., teacher, parent, stepfa‐ ther, coach, priest, etc.). The woman then (re)experiences the feelings of powerlessness, humiliation, shame and horror [29].

During the labour pains, a woman with a history of sexual abuse can start to feel that she no longer controls her own body - just as she did during the abuse. This is why, for an abused woman, having no control often feels like she is no longer emotionally and physically safe and that something bad is about to happen. This is why she feels stronger and safer if things are structured – if she knows what will happen during labour, how it will roughly take place, what is normal and what she can expect. This information will help her to take a break from the constant control, worrying and waiting for what is to come. It is precisely these feelings that are very strongly related to the abuse they have suffered. Abuse teaches a person that it is "safer" to be constantly alert. Furthermore, the feeling of being endangered can lead to extreme behaviour, e.g., aggression, submission, rituals, constant crises, etc. [44].

A study that included 2,365 pregnant women reported that a history of sexual abuse significantly increased the risk of experiencing severe fear of childbirth among primipar‐ ae. Fear of childbirth among multiparae was most strongly associated with a negative birth

Similar conclusions can be found in a study that included 1,452 pregnant women (at 18 weeks of gestation) and measured their fear of childbirth (with the W-DEQ questionnaire) and anxiety (with the STAI questionnaire). In this study, the serious fear of childbirth effected 5.5% of the women. The fear of childbirth is not associated with the mode of delivery. However, sexual or physical abuse in childhood is negatively associated with the mode of delivery [32]. A small number of studies have shown that a history of child abuse has a minimal effect on the complications of labour and mode of delivery [36]. Having said this, the majority of studies

An experimental study, which used the cold pressor test, has shown that women who are afraid of childbirth have a reduced level of pain tolerance during and after pregnancy, compared to women who are not afraid of childbirth [40]. Other studies have shown that pregnant women who fear childbirth are prone to report fear during the actual labour and postpartum [41]. Fear of childbirth has been associated with elective CS, hyperemises gravi‐

Compared to women with no history of sexual abuse, women with a history of sexual abuse are significantly more likely to be transferred to hospital due to complications. Furthermore, they use more medical pain relief, while primiparae are more likely to give birth with a CS [39].

A Norwegian study has shown that only half of women who report having an experience of physical and sexual abuse in childhood have a vaginal delivery without complications, as

Similarly, a study in which 103 women were interviewed four weeks after giving birth showed that women who have been sexually abused are 12 times more likely to experience the

The traumatic experience of childbirth is particularly associated with the subconscious awakening of the trauma of sexual abuse. This manifests through flashbacks and body memory. The most frequent triggers are vaginal examinations or other procedures (e.g., enema, shaving etc.). Additionally, pain during or after the childbirth itself can be a trigger, particularly in the woman's vagina, stomach, back, breasts or crotch. It is the person who a woman should trust the most during childbirth who can subconsciously remind her of the perpetrator who abused her trust as an authority figure (e.g., teacher, parent, stepfa‐ ther, coach, priest, etc.). The woman then (re)experiences the feelings of powerlessness,

During the labour pains, a woman with a history of sexual abuse can start to feel that she no longer controls her own body - just as she did during the abuse. This is why, for an abused woman, having no control often feels like she is no longer emotionally and physically safe and that something bad is about to happen. This is why she feels stronger and safer if things are

darum, induction of labour, use of EDA and prolonged labour [42].

experience [35].

126 Sexology in Midwifery

have shown the opposite [37-39].

opposed to the 75% of non-abused women.

childbirth event as traumatic [43].

humiliation, shame and horror [29].

*"I had a problem with gynaecological examinations as long as I can remember. I can never completely relax. Having to spread my legs in front of a man that's not my partner instantly puts me in situations that I experienced as a child. I also faced traumas during childbirth. My subconscious spewed memories from the past and, even though I suffered painful labour pains, I couldn't help myself. The cervical exam...Horror, despair, panic, tears, anger...At that moment, I couldn't calm myself and make myself understand that the obstetrician was only going to examine me. Despite the labour pains and big belly, I lifted my backside from the bed and sought refuge at the wall. My husband and the nurses tried to calm me down, but I didn't care. The simple fact that someone wanted to examine me in the middle of my labour pains seemed extremely intrusive and horrible!"*

During the sexual abuse of their bodies, some women are threatened. This can be not only verbally and psychically, but also physically (e.g., with a weapon). "*The labour pains intensified so quickly that I felt the gradual loss of control. I became more and more afraid. The pains got stronger and more intense. The body started contracting. My mind was full of thoughts and pictures of a rape that happened when I was two and a relative on my mother's side tore my vagina..."*

Thus, the midwifery care or the midwife's attitude, demeanour and responses are extremely important during childbirth. The body of a sexually abused woman has already been violated and tortured once. As a result, she may experience the midwife's care as additional torture and violation. Additionally, phrases spoken by the midwife, e.g., "relax", "nothing to worry about, I'll just feel around a bit to see what the situation is", "it will soon be over, hold on a bit longer" etc., are likely to awaken the subconscious organ memory of the same or similar words being spoken by the perpetrator, under different circumstances – during the sexual abuse [45]. This is why it is highly important that the midwife knows how to ensure safety and that she follows the reactions of the pregnant woman. The midwife needs to be open and accessible for a possible conversation in which she can reassure the mother-to-be that no abuse is taking place and that everything is normal. Above all, she must be respectful. In such moments, it is even better to have someone beside the pregnant woman who knows of her abuse and whom she fully trusts. This person can reassure her that what she is experiencing are reawakened feelings pertaining to her abuse; that the abuse is no longer happening and that it is safe. This double recognition and distinction between the past and the present is extremely important for the mother-to-be [46, 29, 47]. "Flashbacks" can be triggered and reawakened by a touch, words, the position of the woman or the care professional at the maternity hospital or a gynaecological clinic. The woman can react in various ways. She can freeze, become rigid, apathetic, her breathing or facial expressions can change and she can even exhibit signs of panic.

Women who are aware of their abuse and are consciously prepared for these feelings will be able to more easily control the situation. Furthermore, such women will be able to discern that their feelings do not originate in the here and now, but have only been reawakened it is safe [29, 48].

*"My first childbirth was a real nightmare because I couldn't cope with what I was feeling and with my body that failed me completely. When I should have pushed out my baby, I failed, despite numerous attempts, and so the child was born with a CS. When I got pregnant the second time, the push-out was what I was afraid of most. I feared that the same psychical and physical pain would repeat. I started going to therapy and I was set at ease when my therapist helped me understand what transpired during my first childbirth. The pain I felt in my vagina subconsciously reminded me of the pains I felt when, after practice, my coach would grope me and shove in my vagina everything - from his fingers and various objects to his penis. I always considered that part of my body the most dirty and disgusting. When I should have pushed my little baby girl through that space, I was repulsed and couldn't do it, even though time was running out. As long as she was in my belly, she was still pure but then I had the feeling that she would have to swallow all the sperm and all the disgust the coach had given me. With this awareness and strongly determined that my body was clean, while the perpetrator was dirty, I went to give birth for the second time; this time, my son. I gave myself strength with words that my body could not be dirty, ugly and damaged if it was going to give birth to a new life. The birth itself would finally heal old wounds and give me back my dignity as a woman. Although my brain knew all this, the moment the midwife announced that I was fully dilated and ready for the push-out, I started feeling the same horror and anxiety as the first time. As if an invisible force wanted to drag me away again to the world of abuse. I couldn't believe my body would fail me again. I started calling to God for help. And he actually answered. In my mind, I heard the words of my therapist calmly and tenderly resounding: "You are safe now. The earthquake is over. This is only a reawakening of the feelings you were not allowed to feel during abuse...Your uterus is a place where life is born and your body has a remarkable power," she said. "Bring it back into a place of power and life-giving..." And that's how I managed! Prouder than ever in my life, I heard the cry of my second-born child!"*

It is much more difficult when a woman is not aware of her abuse. This is because the psyche and body experience are precisely what the woman has suppressed and unprocessed (fear, shame, anxiety, panic, despair, disgust powerlessness, anger, etc.). Clinical practices have shown that many victims of sexual abuse freeze during the abuse itself (a subconscious defence mechanism that helps them survive the difficult events). This is why many victims feel that experiencing the consequences (e.g., flashbacks during pregnancy, childbirth, etc.) is even more traumatic than the original trauma (the abuse). In situations that are subconsciously reminiscent of their past experiences, the flashbacks awaken what they were not allowed to feel during the abuse itself due to apathy and dissociation. This often happens to victims who experience severe pain during their abuse. Consequently, such women may experience dissociation during childbirth. Here, their minds may wonder and they may not feel the pain. They are subconsciously fighting the pain. This can prolong and hinder the course of childbirth. In moments like these, it is very important that the woman can be "present" during childbirth. To do this, her midwife or partner (if he is beside her) need to "calls her back" with words, calm her, tell her she is safe and to believe that all will be fine with her body [45, 29, 47].

*"Until the strongest labour pains started intensifying, I was really proud of how well I was doing because I was very afraid of giving birth. But the more the pain grew, the less present I was emotionally. I* *suddenly felt I had tuned out into another world even though I didn't want to, but it was as if I had no power or influence any more. Only now and then I still managed to look around and the only thing I remember is the doctor coming to me and calling me by my name. When I heard my name, it seemed as if my brain had realized that I was safe but the body would not obey me. As if it had detached from me. The doctor suggested epidural analgesia and, even though my birth plan said I didn't want it, at that moment, I clung to every kind of help. Truly, the epidural helped me come back and also be emotionally present when my son was born. Having the possibility to decide at the most crucial moment has been one of the most powerful and most positive experiences in my life so far."*

that their feelings do not originate in the here and now, but have only been reawakened -

*"My first childbirth was a real nightmare because I couldn't cope with what I was feeling and with my body that failed me completely. When I should have pushed out my baby, I failed, despite numerous attempts, and so the child was born with a CS. When I got pregnant the second time, the push-out was what I was afraid of most. I feared that the same psychical and physical pain would repeat. I started going to therapy and I was set at ease when my therapist helped me understand what transpired during my first childbirth. The pain I felt in my vagina subconsciously reminded me of the pains I felt when, after practice, my coach would grope me and shove in my vagina everything - from his fingers and various objects to his penis. I always considered that part of my body the most dirty and disgusting. When I should have pushed my little baby girl through that space, I was repulsed and couldn't do it, even though time was running out. As long as she was in my belly, she was still pure but then I had the feeling that she would have to swallow all the sperm and all the disgust the coach had given me. With this awareness and strongly determined that my body was clean, while the perpetrator was dirty, I went to give birth for the second time; this time, my son. I gave myself strength with words that my body could not be dirty, ugly and damaged if it was going to give birth to a new life. The birth itself would finally heal old wounds and give me back my dignity as a woman. Although my brain knew all this, the moment the midwife announced that I was fully dilated and ready for the push-out, I started feeling the same horror and anxiety as the first time. As if an invisible force wanted to drag me away again to the world of abuse. I couldn't believe my body would fail me again. I started calling to God for help. And he actually answered. In my mind, I heard the words of my therapist calmly and tenderly resounding: "You are safe now. The earthquake is over. This is only a reawakening of the feelings you were not allowed to feel during abuse...Your uterus is a place where life is born and your body has a remarkable power," she said. "Bring it back into a place of power and life-giving..." And that's how I managed! Prouder than*

It is much more difficult when a woman is not aware of her abuse. This is because the psyche and body experience are precisely what the woman has suppressed and unprocessed (fear, shame, anxiety, panic, despair, disgust powerlessness, anger, etc.). Clinical practices have shown that many victims of sexual abuse freeze during the abuse itself (a subconscious defence mechanism that helps them survive the difficult events). This is why many victims feel that experiencing the consequences (e.g., flashbacks during pregnancy, childbirth, etc.) is even more traumatic than the original trauma (the abuse). In situations that are subconsciously reminiscent of their past experiences, the flashbacks awaken what they were not allowed to feel during the abuse itself due to apathy and dissociation. This often happens to victims who experience severe pain during their abuse. Consequently, such women may experience dissociation during childbirth. Here, their minds may wonder and they may not feel the pain. They are subconsciously fighting the pain. This can prolong and hinder the course of childbirth. In moments like these, it is very important that the woman can be "present" during childbirth. To do this, her midwife or partner (if he is beside her) need to "calls her back" with words, calm her, tell her she is safe and to believe that all will be fine with her body [45, 29, 47].

*"Until the strongest labour pains started intensifying, I was really proud of how well I was doing because I was very afraid of giving birth. But the more the pain grew, the less present I was emotionally. I*

it is safe [29, 48].

128 Sexology in Midwifery

*ever in my life, I heard the cry of my second-born child!"*

Women in therapy often say that, when dissociation occurs, what helps them the most is someone calling them by their name. In the above described case, the epidural analgesia helped because the physical pain (the labour pain), which was reminiscent of the pains during her abuse, triggered dissociation. In other cases, the epidural may cause dissociation or a panic attack. This is because the pregnant woman may feel that she is not in control of her body or that she is, in a way, tied, captured and cannot escape. As a result, she may experience feelings similar to those she experienced during the sexual abuse when her body froze.

Dissociation is strongly associated with the feeling of not being safe: "*I felt as if I followed the entire delivery from outside my body, looking down from the ceiling to the bed where I lay. This made me feel safer. But when contracting and dilating began, I started pushing and crying out for my mother...In my mind, I tried to escape to a safe place...I know it sounds weird, but I couldn't manage being present. I was exhausted from the touches..."*

**Physical sensations**, such as the stretching of the pelvis, tensions in the body, etc., can strongly remind a woman of, and reawaken, the sexual abuse recorded in her somatic memory – in her body. This impact is stronger and greater if the abuse she suffered involved painful penetra‐ tions or rape. General anaesthesia, especially the feeling of losing control over her body, can also arouse fear in a woman with a history of sexual abuse. However, in some cases, general anaesthesia facilitates a woman's ability to cope with childbirth [44].

*"My partner and I really looked forward to the childbirth, although we were also afraid about how everything would unfold. I had heard a lot of stories, read a lot of literature, but despite all this I was still completely unprepared for such intense triggers and memories which seemed like a bolt out of the blue. All the horror began when I heard the screaming, bellowing and quick and loud breathing of a woman giving birth in the next room. My chest stung with pain and my heart began pounding with all its force. My legs froze. The more I was supposed to cooperate with the personnel, the more I began to fail. All the old feelings – lying in bed with my legs spread, shouting, panting, pain, the feeling of having no control – and the people around me, whom I was supposed to trust and who were supposed to take care of me, reminded me of the rape I had experienced when I was 12..."*

Flashbacks can also be triggered by the **position of the body**, for example lying in bed. A woman who has been sexually abused night after night before sleep, while having to lie on her back in her bed, can experience bad and unpleasant feelings in this position [47].

*"The most disgusting thought about giving birth was having to lie naked on my back with my legs apart because, for me, it's the same as rape, with the addition of people walking by and looking into my crotch. The moment I found out who my midwife was going to be, I took a risk and told her what I was most* *afraid of and what worried me most. Thank God she was understanding and even thanked me for telling her. Her words that I could give birth also standing up or squatting calmed me so much that there were no more problems or complications because I could relax and believe that it really was safe."*

*"Until I got into a darkened delivery room, I was fine. But then I suddenly couldn't breathe anymore and the familiar panic and feeling that I'd simply die began intensifying. At that moment, they gave me sedatives so I could cooperate at least somewhat and hear what everyone who came into my room wanted from me. When I was almost completely calm, a bearded older doctor came into the room and my distress began again, but not as intensely. I can't believe that my body failed me again and it seemed as if I was falling into an abyss..."*

In therapy, it transcribed that the above mentioned woman had, during her childhood, been sexually abused by her stepfather (man). This man had a beard similar to the doctor and would come into her room in the dark. During her labour, the health professionals entered without knocking or in any other way announcing their entrance, similar to how the perpetrator had come "unannounced".

Most often, the medical personnel is not even aware that they have the power to re-traumatize a woman who has been sexually abused. At the same time, with kindness and professionalism, they can help her experience the delivery as something beautiful. Sometimes a sentence is enough to calm a woman down or, quite the opposite, enough for everything to fall to pieces. Most abused women undergoing therapy report that they find it immensely difficult to tell their midwives or doctors that they have been sexually abused. This is because they are too afraid that the personnel might then look at them funnily or treat them differently. Further‐ more, it is likely that some of them have never told anyone about their experience, not even their partner. Many women say that it would be most helpful if, during pregnancy, they had a person (perhaps a doula, a chosen midwife, a determined partner, etc.) who they could communicate their worries and fears to. This person would then be present at delivery. For a mother with a history of sexual abuse, it can be highly reassuring to have someone beside her who knows how she is feeling and understands her reactions to situations which reawaken painful memories. If the mother struggles, this person can speak to the personnel instead of the mother, making the situation "safe" again. When the abuse took place, there was nobody there to protect the girl and provide safety; to speak for her and draw the line or just reassure her that everything would be fine. This is why such a positive experience can be very healing for the victim.

### **7. Motherhood and the history of sexual abuse**

The child is born. Even before giving birth, some mothers are afraid and worry about whether they will be competent mothers, whether they will feel the child, whether they will know how to protect it from dangers, etc. In this section, we explore the studies and clinical experiences relating to sexual abused mothers and their child (during breastfeeding, caring for the child and in their attachment to the child). Furthermore, how they raise their children and how sexual abuse can manifest in subsequent generations.

The first contact after birth is most commonly related to breastfeeding. This involves not only the connection between the mother's and the child's body, but also a very strong emotional bond accompanied by the most varied experiences. If a sexually abused mother feels an aversion to breastfeeding; perhaps this reawakens feelings relating to abuse and reminds her body that someone has been disrespectful to it, then she needs to be given as much support as possible and not be pressured to breastfeed at any cost. Even though her body is completely ready to breastfeed, this does not necessarily mean that her psyche is. This is why emotional contra-indicators need to be taken into account [30].

*afraid of and what worried me most. Thank God she was understanding and even thanked me for telling her. Her words that I could give birth also standing up or squatting calmed me so much that there were*

*"Until I got into a darkened delivery room, I was fine. But then I suddenly couldn't breathe anymore and the familiar panic and feeling that I'd simply die began intensifying. At that moment, they gave me sedatives so I could cooperate at least somewhat and hear what everyone who came into my room wanted from me. When I was almost completely calm, a bearded older doctor came into the room and my distress began again, but not as intensely. I can't believe that my body failed me again and it seemed as if I was*

In therapy, it transcribed that the above mentioned woman had, during her childhood, been sexually abused by her stepfather (man). This man had a beard similar to the doctor and would come into her room in the dark. During her labour, the health professionals entered without knocking or in any other way announcing their entrance, similar to how the perpetrator had

Most often, the medical personnel is not even aware that they have the power to re-traumatize a woman who has been sexually abused. At the same time, with kindness and professionalism, they can help her experience the delivery as something beautiful. Sometimes a sentence is enough to calm a woman down or, quite the opposite, enough for everything to fall to pieces. Most abused women undergoing therapy report that they find it immensely difficult to tell their midwives or doctors that they have been sexually abused. This is because they are too afraid that the personnel might then look at them funnily or treat them differently. Further‐ more, it is likely that some of them have never told anyone about their experience, not even their partner. Many women say that it would be most helpful if, during pregnancy, they had a person (perhaps a doula, a chosen midwife, a determined partner, etc.) who they could communicate their worries and fears to. This person would then be present at delivery. For a mother with a history of sexual abuse, it can be highly reassuring to have someone beside her who knows how she is feeling and understands her reactions to situations which reawaken painful memories. If the mother struggles, this person can speak to the personnel instead of the mother, making the situation "safe" again. When the abuse took place, there was nobody there to protect the girl and provide safety; to speak for her and draw the line or just reassure her that everything would be fine. This is why such a positive experience can be very healing

The child is born. Even before giving birth, some mothers are afraid and worry about whether they will be competent mothers, whether they will feel the child, whether they will know how to protect it from dangers, etc. In this section, we explore the studies and clinical experiences relating to sexual abused mothers and their child (during breastfeeding, caring for the child and in their attachment to the child). Furthermore, how they raise their children and how

*no more problems or complications because I could relax and believe that it really was safe."*

*falling into an abyss..."*

130 Sexology in Midwifery

come "unannounced".

for the victim.

**7. Motherhood and the history of sexual abuse**

sexual abuse can manifest in subsequent generations.

Accounts of clinical experiences have shown that this often happens to women whose breasts were groped during abuse. As a result, the baby's suckling can act as a trigger that reawakens their fear, anxiety and disgust. Nudity reminds them of how it felt to be exposed and unpro‐ tected during abuse. Thus, the first contact between the mother and the child in the maternity hospital, when the baby is laid on the mother's breasts, is extremely important.

*"When they laid the child on my breasts immediately after the delivery and tenderly neared its head to the nipple so it began suckling, I felt very comfortable. It meant a lot that the midwife was nice and didn't do anything by force. But the second day in the ward, it was completely different: an unkind nurse grabbed my breast with one hand and the baby's head with the other and pressed the baby on my breast so roughly that it only chocked, while I cried and couldn't say anything, I just froze. In addition, she said that breastfeeding was no science since every animal knew how to feed its young. I was furious with myself for not being able to say anything back to her but I felt so helpless and vulnerable that I cried long after this incident, blaming myself for being a worthless mother who can't protect her newborn child."*

Some mothers feel that their milk is dirty because it comes out of their breasts (that were "dirtied" by the perpetrator during abuse). Many mothers feel more relaxed if they have had a daughter, as opposed to a son (because a man abused them and now a "man" is suckling). Other mothers still limit the breastfeeding to daytime. At night they only bottle-feed the baby with pumped milk.

*"Strange, but true, I couldn't feed my baby at night because I would find it hard to breathe and I saw in the baby someone who wanted to hurt me. I organically couldn't press it to my bosom. During the day, I didn't experience these feelings at all and I felt like a horrible mother, guilty for having such feelings towards someone completely innocent. Even if I turned on the lights, moved from the bedroom to the living room, it didn't help. Only when I became aware that this was related to my being abused at night; when my father would come to sleep with me because my mother worked the night shift, did the guilt lessen a bit. As long as I breastfed, I was not calm as a mother. I felt much better when the child gradually began eating solid foods and didn't wake up as often during the night."*

Clinical experiences show that a similar or an even greater distress is caused by an abused woman's partner's jealousy of their child. This happens during breastfeeding in particular. During breastfeeding, the mother tenderly gives the baby all of her attention. With this, the mother establishes contact through feeding and changing her child, putting it to sleep and cuddling it. A partner who is jealous of this most likely demands attention, exclusively for himself. He may oppress the mother, even when she wants to get up in the middle of the night to comfort and calm the crying baby. He may stand in front of the door, for example, or not allow her to go so as not to "spoil" the child. Even worse, he may demand that she be sexually available to him, perhaps even before her check-up six weeks after the birth and before she is psychically ready.

Women in abusive relationships much more often have an unplanned pregnancy a few months after the birth [49]. Many other studies [18, 50, 51, 44] report that CSA survivors are less content in intimate partner relationships. Overall, there is more discord and violence. Furthermore, there is a higher probability of divorce.

In such a distressful situation, if the mother is lonely and has nobody to support her, she can lose her milk. Furthermore, in order to have some peace from her partner or her awakened feelings, she may decide not to breastfeed anymore. It is extremely important that her envi‐ ronment and medical personnel (the visiting nurse, paediatrician, gynaecologist, etc.) do not judge such a mother or guilt-trip her as this could be devastating for her. This reaction to breastfeeding does not make her a bad mother. If she were to breastfeed, the extreme anxiety she would experience would harm her relationship with her child - far more than not breast‐ feeding.

*"If only I had at the time one person to tell me that I wasn't to blame and that I was a good mother, for I did my best, but I just couldn't manage. Due to the violence I was subjected to daily by my partner and due to his jealous outbursts if I cuddled our child, I stopped breastfeeding because I had constant problems. My baby girl cried because she waited for me to press her to my bosom, but I had to "calm" him first to gain the "right" to breastfeed the child. I was so relieved when he went to work. When the same thing repeated with the second child, I couldn't manage anymore and I got help. I feel better today when he's not here because he went elsewhere. I prefer not to remember that difficult period."*

Heightened sensitivity, hormonal changes, sleepless nights, possible discords in the partner relationship, adaptation to the rhythm of feeding and putting the baby to sleep, crying and comforting – any of these strongly affect a mother's wellbeing. However, if the mother has an experience of sexual abuse, it is even harder for her to trust her body and intuition. If she experienced her body already failing her during childbirth, she is even more afraid to trust herself afterwards. She is not sure that she is right about what the child needs when it cries, cannot sleep or refuses to breastfeed. This is precisely why feelings of shame, guilt and anxiety frequently manifest in a sexually abused mother.

All of these feelings are even more present if the woman grew up in a family living in utter chaos or in which everything was wrong and there was no safety. If this was the case, she may develop an intense need to do everything right as a mother. Endeavouring to raise her child differently can lead to extremes – to perfectionism. This can manifest in selfless devotion, that is, in her putting all the child's needs above her own, while suppressing a lot of anger and frustration deep inside her. Such a mother will probably be very critical of how other parents raise their children. She will see herself as different, often stigmatized (as a little girl, she already felt different and stigmatized due to abuse) [49].

The results of a study [52] that measured the parenting characteristics of female survivors of childhood sexual abuse have highlighted some prominent traits: difficulties in setting clear generational boundaries between parents and children, two extreme parenting styles – either permissive parenting or the use of harsh physical discipline. Mothers with a permissive parenting style may avoid invoking parental authority because of their own negative experi‐ ences as victims of adult power [53]. They may feel less efficient and "in control" in the parental role. Consequently, they have less confidence in setting appropriate boundaries [54]. More‐ over, because they are emotionally more wounded due to the sexual abuse, they have less energy to enforce discipline or appropriate behaviour of their children. They can be easily manipulated by crying children, presumably due to an over-identification with their children's unhappiness [55].

to comfort and calm the crying baby. He may stand in front of the door, for example, or not allow her to go so as not to "spoil" the child. Even worse, he may demand that she be sexually available to him, perhaps even before her check-up six weeks after the birth and before she is

Women in abusive relationships much more often have an unplanned pregnancy a few months after the birth [49]. Many other studies [18, 50, 51, 44] report that CSA survivors are less content in intimate partner relationships. Overall, there is more discord and violence. Furthermore,

In such a distressful situation, if the mother is lonely and has nobody to support her, she can lose her milk. Furthermore, in order to have some peace from her partner or her awakened feelings, she may decide not to breastfeed anymore. It is extremely important that her envi‐ ronment and medical personnel (the visiting nurse, paediatrician, gynaecologist, etc.) do not judge such a mother or guilt-trip her as this could be devastating for her. This reaction to breastfeeding does not make her a bad mother. If she were to breastfeed, the extreme anxiety she would experience would harm her relationship with her child - far more than not breast‐

*"If only I had at the time one person to tell me that I wasn't to blame and that I was a good mother, for I did my best, but I just couldn't manage. Due to the violence I was subjected to daily by my partner and due to his jealous outbursts if I cuddled our child, I stopped breastfeeding because I had constant problems. My baby girl cried because she waited for me to press her to my bosom, but I had to "calm" him first to gain the "right" to breastfeed the child. I was so relieved when he went to work. When the same thing repeated with the second child, I couldn't manage anymore and I got help. I feel better today*

Heightened sensitivity, hormonal changes, sleepless nights, possible discords in the partner relationship, adaptation to the rhythm of feeding and putting the baby to sleep, crying and comforting – any of these strongly affect a mother's wellbeing. However, if the mother has an experience of sexual abuse, it is even harder for her to trust her body and intuition. If she experienced her body already failing her during childbirth, she is even more afraid to trust herself afterwards. She is not sure that she is right about what the child needs when it cries, cannot sleep or refuses to breastfeed. This is precisely why feelings of shame, guilt and anxiety

All of these feelings are even more present if the woman grew up in a family living in utter chaos or in which everything was wrong and there was no safety. If this was the case, she may develop an intense need to do everything right as a mother. Endeavouring to raise her child differently can lead to extremes – to perfectionism. This can manifest in selfless devotion, that is, in her putting all the child's needs above her own, while suppressing a lot of anger and frustration deep inside her. Such a mother will probably be very critical of how other parents raise their children. She will see herself as different, often stigmatized (as a little girl, she

The results of a study [52] that measured the parenting characteristics of female survivors of childhood sexual abuse have highlighted some prominent traits: difficulties in setting clear

*when he's not here because he went elsewhere. I prefer not to remember that difficult period."*

psychically ready.

132 Sexology in Midwifery

feeding.

there is a higher probability of divorce.

frequently manifest in a sexually abused mother.

already felt different and stigmatized due to abuse) [49].

Contrary to this, using physical violence and other harsh parenting methods are likely indicate that the parent is repeating what they were subject to as children. In this, they must not feel the child's pain, for this would mean that they would first have to face the pain they had experienced with their parents. Thus, they subconsciously preserve contact with their parents, albeit in a negative sense, and transmit the patterns of violence [46]. Zuravin et al. [56] suggest something similar. They claim that the maternal history of sexual abuse involving intercourse is related to the increased chances of physical abuse, sexual abuse or neglect in the second generation.

*"I remember my aunt telling me once that my mother had been raped as a teenager. I can't understand how this experience didn't make her protect me from the abuses of my father and brother. As if she didn't know what it meant for someone to dirty you like that and seal your fate?! Once, when she came into my room, she saw what my father was doing to me, but she just closed the door, went away and never said anything. THIS hurt me even more than everything I experienced from my father and brother. And I felt guilty, as if I was stealing her husband. I feel sick just thinking about it. She was so cruel as a mother. I fear whether I'll know how to protect my daughter so that nothing like that ever happens to her."*

Additionally, children of abused mothers are often parental, taking care of the emotional needs of their mothers who are, in a way, emotionally dependent on them (no healthy boundaries). Compared to their peers, these children look much more grown up. Howev‐ er, in the long term, their own development can suffer [57]. Clinical experiences show that mothers often treat their children as confidants and friends. This is particularly the case if they do not get along with their partner. Mothers reporting a history of incest were more likely to interact with their sons in a subtly seductive manner, considered to be indicative of generational boundary dissolution [58].

*"Until recently, my mother and I were best friends. She confided everything in me, even the sexual problems they had with my father. How I felt or what went on with me never interested her. She often even said that if she hadn't had me, she'd have rather died. She was jealous of my friends who were never good enough for me. I thought all this was normal, even more, it seemed a special privilege that not all daughters were entitled to. But when I was treated for bulimia, I discovered what she did to me. She attended the sessions a few times and the therapist discovered that just like she overstepped all emotional limits with me, so a man in her childhood overstepped all limits with her, also in the sexual sense."*

In general, children of sexually abused mothers show a more helpful, protective, managing and controlling behaviours towards family members. On the other hand, children of nonabused mothers show significantly more trusting, deferring, relying and submitting behav‐ iours [59]. Grocke, Smith and Graham [60] have found that, compared to children of nonabused mothers, children of CSA survivors are more prone to interpreting ambiguous pictures of children and strangers as negative or frightening. They also believe that sexually abused mothers teach their children about the male and female sexual development and contracep‐ tion-related topics in more detail. Such mothers find this increased communication essential. This is because they presume that it will protect their children from a experiencing a similar sexual abuse. On the contrary, Douglas [61] reports that mothers with a history of sexual abuse are more anxious in child care, requiring intimate contact such as changing, bathing and putting to bed. Even though these activities, as such, are not "sexual", they may indicate that, because of the mother's unease, sexuality and intimacy will be taboo topics in the child's growing up.

Women who are aware of having been sexually abused may often fear that they will themselves **abuse** their child. The fact that the mother is afraid is a sort of safeguard and it is, therefore, quite unlikely that she would sexually abuse her child. However, there can be situations in which she feels aroused. For example, during the changing, bathing or breastfeeding of her child. Her body tells her that what is happening is not natural, that it is perverted. Particularly, this can happen if she, herself, has been sexually abused on the changing table. In this case, she may not even have the images in her explicit memory, that is, she cannot recall the event of the abuse. It suffices that her body remembers it, that the abuse is recorded in the organ memory - in implicit memory. If arousal or disgust occur, it is important that the mother controls herself, that she takes time to evaluate her feelings. In other words, it is necessary that she sets boundaries and becomes aware that it is her abuse reawakening; that her child deserves pure love. She has to feel able to withdraw, go to her partner and communicate these feelings if she is unable to process them herself. When this does not work, it is necessary that the mother seeks the help of a professional who will assist her in going through the emotions of abuse (disgust, shame, etc.) and help her work through them. It is not necessary for inappropriate touching to occur during the changing or bathing of the child, the atmosphere can already become terrifying and abusive when the mother feels aroused by the child's innocent and powerless body (just like someone who sexually abused her as a little girl was aroused by her as an innocent and powerless child). At the same time, the mother feels contempt for and disgust with herself for having these feelings. These feelings and real bodily sensations are unfair, both on the mother who experiences them and on the child who, through the projectionintrojection identification, senses and feels her distress or, even more, when the child drinks these feelings of abuse on her bosom [29]. In such an atmosphere, it is more likely that the unresolved feelings (perhaps even the action itself) will lead to an intergenerational transmis‐ sion of the trauma of sexual abuse, which we will discuss in the next section.
