I thought for a long time that I’d never be able to carry a child. As a survivor of sexual trauma, the idea of losing control of my body in that way was terrifying. In medical settings, I had a tendency to shut down, to lose my voice. I would recoil at any touch, and spend the entire time worried about and wondering where my care provider would touch me next.
But as the years passed, I fell in love and got married. My husband and I decided we wanted to have a child. When we first found out I was pregnant in October 2013, I was overjoyed to know that our baby was growing inside of me. But it wasn't long before that happiness was replaced by fear.
My first appointment with my new obstetrician started out in the same way as all my doctors' visits. I began by telling her that I am a survivor of sexual trauma and suffering from post traumatic stress disorder, or PTSD. What I’ve discovered about my past is that it’s always relevant to my medical history. It often affects me in unexpected ways, and I wasn’t sure how it would manifest during my pregnancy.
My provider seemed unaware of the importance of my revelation and how to handle my case differently. In an ideal world, a doctor who knows about a patient’s history of sexual violence can and should be prepared to offer resources and support. I received none of those, and as my due date got closer, I left each appointment feeling disempowered and deflated.
I was beginning to fear that I would be steamrolled during labor and delivery and wasn’t sure I could handle that.
I know that I’m not alone in being someone who has experienced sexual violence and went on to carry a baby. Estimates from the National Sexual Violence Resource Center say that 1 in 5 women will be raped in her lifetime and 1 in 4 girls will experience sexual abuse before the age of 18. A 2011 national study by FORGE, a nonprofit that provides peer support to predominantly those on the female to male transgender spectrum, found that at least 50 percent of transmasculine individuals — who were female at birth but identify as male or somewhere in between — have experienced sexual violence. What this means is that there is a large overlap between people who have experienced some kind of sexual trauma and people who get pregnant. I assumed that would mean that my (purposely chosen, female) provider would know how to handle my disclosure. My assumption was incorrect.
Pregnancy can be one of the most daunting challenges for survivors of sexual trauma. Given the sexual nature of pregnancy and birth, having to be in a vulnerable position on your back and endure vaginal exams during routine checkups, plus dealing with rapid changes in your body that are not in our control, some of the anxiety, depression or fear that many of us thought we had conquered long ago can come rushing back.
During those scary months, I found help in a book, "When Survivors Give Birth," by Penny Simkin. A physical therapist, childbirth educator and a doula, when Simkin first began looking into what information was out there regarding the overlap between sexual abuse and pregnancy, she says she found nothing. When she asked her psychiatrist friends about it, they told her there was no connection because there was nothing in the literature about it. But Simkin was not swayed by the literature or, rather, lack thereof.
“All I knew was what women were telling me, and I chose to believe them," she said.
Simkin wrote about how few providers get training on this topic and, when patients bring it up, physicians often get uncomfortable. “They may proceed to do things that, if you’re a survivor, can feel an awful lot like retraumatization,” she said. In my case, I became despondent that my obstetrician was being dismissive of my experience. She failed to explain everything she was doing to my body and seemed to be unable to ask me if I had any questions without leaving room for the answer. Since it was my first pregnancy, I didn’t know what kinds of potential PTSD triggers I should be looking out for, and my doctor didn’t offer any information.
Simkin said she also learned from working with survivors of sexual trauma that while each person’s triggers and experience are different, there are some common themes that often come up for them. For many, the need to be in control of their bodies is very important. But during pregnancy, when the body is changing rapidly, and during labor, when the body (or doctors) take over, they may feel out of control which can cause panic or anxiety.
Others may cope with trauma triggers through dissociation, or mentally “checking out.” That felt familiar to me, too. Dissociation is a huge part of my PTSD, and it manifested during my pregnancy as a feeling of numbness about the pregnancy itself — which to people who didn't know about my past may have looked like a lack of enthusiasm about having a child. My dissociation also meant that I often felt very out of touch with how my body was changing because I was unable to feel anything.
Simkin said another potentially triggering aspect of pregnancy or birth can be the feeling of vulnerability or dependence, particularly upon an authority figure. For survivors who were abused by someone in a position of power over them, being at the mercy of a doctor can bring back those feelings of helplessness.
For many people who experience these symptoms, they may not make the connection between their history of sexual abuse and the way they’re experiencing their pregnancy. Not everyone is necessarily aware that what they went through was abuse, which makes the screening process by providers even more important. It’s hard to provide support to someone who may not know they need it. If I hadn’t openly told my care provider about my history, it probably wouldn’t have been addressed. I checked a box on the intake form, but Simkin says those forms aren’t enough. “Most abuse survivors may be afraid to disclose on a piece of paper because they’re not sure who is going to see it or why it’s relevant to their current condition,” she explains.
Simkin feels strongly that there needs to be a screening process in place, but that it shouldn’t happen during the first appointment as it may take several visits to build up the trust required to share that kind of information. Simkin says the least threatening and most reassuring way of phrasing it is, “Many people have experienced abuse or assault in their lives. Since it is so common, I want to ask you about that, because sometimes a history of abuse can have an effect on labor and birth, and we can do something about it if we know.” She says the patient may become defensive or think there’s something wrong with them if they’re asked point blank, but the provider can reassure them by sharing that it’s common. “It’s helps them to understand why they're being asked,” she explained.
Simkin and her co-author, Phyllis Klaus, now offer workshops in the Seattle area for providers, midwives, and doulas so they can better support their patients with sexual trauma history. Simkin also has a counseling practice where she sees a lot of women who are anxious about birth or who are dissatisfied with their care. She suggests that people who are feeling triggered by their pregnancy or birth seek out counseling or therapy but recommends people go to a trauma therapist because “what abuse survivors have is a form of PTSD,” though she concedes that many mental health professionals do not know much about birth.
New programs to address this need are being launched in other parts of the country. The Signature Strong Start For Mothers and Newborns program in St. Louis, for example, works to ensure that physicians receive training in providing trauma-sensitive care to pregnant patients. The program, which is federally funded through a grant from the Centers for Medicare and Medicaid Innovation, uses an interdisciplinary approach to work with nine OB/GYN physician groups throughout the state to provide coordinated and trauma-informed care for their pregnant Medicaid beneficiaries, of whom many have experienced some level of trauma, including sexual trauma. One of the wonderful things about the program is that social workers, physicians and nurses work together to provide comprehensive care so that kind of support is built in. Maribeth Hollinshead, the program director and nurse navigator for Signature Strong Start, says that her team is helping “physicians take steps to see their patients through a trauma-informed lens.”
At Strong Start, Hollinshead says, they are shifting toward practices similar to universal precautions in screening their patients for trauma, which means assuming all patients have been exposed. “Therefore, we have changed the language we use with our patients. Now, our physicians ask, ‘What has happened to you?’ rather than ‘What is wrong with you?’ and then take it one step further, by next asking ‘How can we help?’” Hollinshead says these subtle shifts in language can go a long way to making a patient feel safe and willing to disclose.
In my case, one of the best decisions I made was to switch to a new care provider during my second trimester. I ended up finding a midwife who was incredibly receptive to my disclosure and worked with me every step of the way.
I was surprised that after finding the right support, my pregnancy and birth experiences changed completely. I ended up feeling powerful and superhuman. Watching my body do incredible things — like create and sustain human life — gave me positive associations with it and helped me feel like my body could bring joy, not just pain.
My husband and I are now the proud parents of a wonderful daughter who is one-and-a-half years old. There were no complications during her birth, and we are now trying for our second child.
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