Survivors of Childhood Sexual Abuse and Midwifery Practice

CSA, Birth and Powerlessness

Lis Garratt

• Publisher: Taylor & Francis
• Year: 2018
• Print ISBN: 9781846194245
• eBook ISBN: 9781315357287
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Many midwives will care for women who are survivors of childhood sexual abuse (CSA), whether these women disclose this or not. Pregnant and birthing women commonly experience their bodies becoming 'public property', a variety of sometimes intimate medical procedures, and limited choices on where and how care is provided. For CSA survivors, who have suffered loss of ownership over their bodies as children and may experience recurring feelings of powerlessness and loss of control, these factors can combine with impersonal and medicalised settings and practices to deeply traumatic effect. 'Sexual abuse is all about power, not sex.' - interviewee Many midwives also experience powerlessness and loss of control as professionals as a result of these same settings and practices, and those midwives who are themselves CSA survivors bring a particularly acute awareness of this and of the needs of survivor mothers. This unique study sets out to gain a deeper understanding of the needs of these mothers by exploring them alongside the parallel experiences of survivor midwives. It explores the insights and reflections they together bring to midwifery, and the positive results of more collaborative, personal, communicative and ultimately empowering practices for all involved. 'The significance of this book is far wider than its immediate subject, for it offers us the opportunity to rethink our professional coping strategies. If we seek to make all our professional relationships ones of equality and opportunities for growth, as would benefit someone who has suffered abuse, then we can all grow and flourish.' - from the Foreword by Mavis Kirkham

CHAPTER 1

What is childhood sexual abuse?

Before embarking on a book examining the impact of childhood sexual abuse on birth it would be useful to discuss various definitions of it and look at the frequency with which it occurs. It is only relatively recently that CSA has been recognised as a widespread problem affecting many individuals regardless of race, social class or culture. Obviously, it is not a new phenomenon, and in the late 19th century Sigmund Freud published a paper in which he linked ‘hysteria’ with early childhood sexual experiences. This arose out of his clinical practice and observations of his female patients. However, only one year later he reinterpreted his findings, stating that these reported scenarios of seduction were merely sexual fantasies, which had never actually taken place. Tragically, because the work of Freud was so widely respected, the existence of CSA was consequently dismissed for a large part of the 20th century.

During the latter half of the century, however, with the rise of the feminist movement, society’s changing attitudes towards women and new understanding about the impact of trauma on individuals, Freud’s assertions began to be challenged. At last, CSA was acknowledged as a reality and sexual trauma was finally recognised as having long-term psychological consequences comparable to those caused by other horrific events. There are some variations in the definitions of what constitutes CSA, but it is generally agreed that it is any kind of sexual activity which takes place between a child, who is not in a position to resist, consent to or understand the significance of the act, and a sexually more mature individual. A ‘child’ is usually defined as someone under the age of 18,^1,2 although an ‘abuser’ is also understood to be someone who is in a position of power over the child by dint of maturity or role, and is fully aware of what is taking place. Thus, an older ‘child’ could be described as an abuser if his/her victim is significantly younger and less sexually aware. It does not necessarily have to involve sexual intercourse or physical force, but the child may be tricked or manipulated into compliance.³ CSA also encompasses activities such as voyeurism, forcing the child to watch pornography or sexual acts, exposure of genitals and verbal abuse such as erotic talk or accusations of sexualised behaviours.⁴

Sexual abuse of children can be perpetrated by a family member, a blood relative or someone the child believes to be a relative, or by someone outside the family who is often in a position of trust or authority, such as a family friend, a member of the clergy or a teacher.⁵ Sexual abuse by strangers is less common.^6,7,8

What is clear from the literature is that sexual abuse is largely concerned with the misuse of power and the betrayal of trust and does not necessarily have to involve physical force in order to have a damaging effect. A child’s essential dependence is the basis upon which an abuser is able to coerce and maintain power over his victim. Cooperation may be gained through manipulation using promises, threats, gifts or ‘special’ treatment.^4,9 The victim may not understand the significance of what s/he is experiencing, but may feel uncomfortable, frightened or confused about it. Children will often be reluctant to disclose, particularly if their abusers are people whom they look to for care and protection,^10,11 and sadly disclosure may be met with disbelief and dismissal.^9,10,12 Summit¹³ suggests a paradigm to describe the process in which abused children may become trapped which he refers to as ‘The child abuse accommodation syndrome’. He argues that an abused child’s normal coping behaviour may contradict the entrenched beliefs and expectations typically held by adults, laying him/her open to accusations of lying, manipulation and fantasising by the very people who are, theoretically, in a position to help. As a consequence, s/he descends even deeper into self-blame, self-hatred and re-victimisation. Furthermore, some children who do disclose may feel unable to cope with the resultant furore and consequently may recant or minimise what has happened. Some remain silent because of threats (such as physical punishment or removal from the family) made by their abuser.^9,10,11,14 It is known that many cope by suppressing their memories of abuse (see Chapter 8), thus being enabled to continue with everyday life as if nothing were amiss.^10,15,16 As a result, children may become trapped helplessly in abusive situations not only by their abusers but also by the expectations and beliefs of a society, which, until relatively recently, has tended to look upon child sexual abuse as a rarity.

PREVALENCE

It is impossible to arrive at a definitive answer as to the incidence of CSA because this largely depends on how it is defined. If abuse consisted merely of physical contact then it would be relatively easy to define. As we have seen earlier, there are non-physical forms of sexual contact that are widely accepted as abusive; however, there are others which lie on the periphery and are therefore open to question and interpretation. To some extent, the idea of what constitutes CSA is socially and culturally constructed.¹⁷ Conflicting opinions about exactly how to define CSA results in a wide range of prevalence being quoted. For example, drawing on current research evidence, Community Health Sheffield¹⁸ cites a range of 12–51% of females reporting CSA, while the American College of Obstetrics and Gynecology (ACOG)³ puts the figure at approximately 20%. Other authorities suggest numbers may be as high as 54%,⁶ but studies undertaken in Sweden⁸ and Germany² found incidences of 8.1% and 15.9% respectively. It is highly likely, however, that for multiple reasons, CSA is under-reported.^5,19,20,21 Not only are survivors kept silent by their own sense of shame, but, as I previously pointed out, some fail to speak out because of threats made by perpetrators against them or their family.¹⁰ In addition, some individuals are affected by long-term amnesia resulting from the trauma of their early experiences.^15,22 It is possible, then, that up to half of the women passing through the maternity services may have experienced some form of CSA. Given the probable scale of the problem, it is inevitable that midwives, obstetricians and other maternity workers will come into contact with a significant number of survivors during their careers.²³ It is, therefore, disturbing that so little apparent emphasis is placed upon raising professional awareness of the implications of caring for these women.

THE POTENTIAL SEQUELAE OF CSA

Research shows that CSA results in a multitude of adverse short- and long-term effects in those who have been subjected to it. There is no single syndrome or cluster of symptoms that are universally present in survivors, but this kind of abuse has the potential to have an impact on every area of an individual’s life. The work of Finkelhor and Browne²⁴ ha...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Dedication
• Foreword
• About the author
• Acknowledgements
• Introduction
• 1 What is childhood sexual abuse?
• 2 How the research was conducted: the problems and dilemmas of dealing with such a topic
• 3 What we already know about the impact of CSA on childbearing
• 4 A life sentence: the effect of CSA on the interviewees’ daily lives
• 5 The psychological needs of birthing women, post-traumatic stress disorder and traumatic childbirth
• 6 Re-enactment? The women’s experiences of giving birth
• 7 CSA and midwives: the impact on midwives’ practice
• 8 Coping with the inescapable: survivors’ dissociation, ‘professional dissociation’
• 9 What women want from their maternity carers and why the industrial model cannot deliver
• 10 What is the answer? Conclusions drawn from the women’s positive experiences
• 11 What can be done?
• Organisations that can help
• Further reading
• Index