• Sex
Sexual Violence
&
Its Impact on Maternal Health
Agenda
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Introductions and Background on the ORCC
Overview of Sexual Violence in Canada
Impact of sexual violence on pregnancy
Impact of sexual violence on labour
Impact of sexual violence during postpartum
A little background on the ORCC…
OTTAWA RAPE CRISIS CENTRE
•Founded by a group of feminist women in 1974
•Values are based on principles of feminist practice; which recognize that
violence is a social issue and a product of the society we live in
•Feminist principles included in our practice support a wide variety of values
that encompass social justice, anti-oppression, and anti-racism.
ORCC’s Counseling Services
TELEPHONE CRISIS COUNSELLING
• 24hr, 7 days a week crisis line• concerned with personal safety
• Helps the client identity shortterm goals
• Helps the client identity her most
pressing concern and discusses
coping strategies for the
immediate or short term
LONG TERM COUNSELLLING
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3-6 crisis appointments
42 sessions
concerned with personal safety
Focuses on past and present issues
Over an extended period of time,
helps the client identify short- and
long term goals
Helps the client identify her most
pressing concerns with a view to
creating permanent change
What is Sexual Assault?
What is Rape?
What is Sexual Assault? What is Rape?
Any unwanted sexual act that a person has not agreed to such as;
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Street hassling
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Obscene calls / texting
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Flashing or exposing
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Masturbation in front of someone
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Pornography
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Crowding-invasion of personal space
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Physical molestation (groping, touching)
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Sexual harassment on the job
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Date, acquaintance, stranger rape, rape with physical violence
A term used to refer to all incidents of unwanted sexual activity, including sexual
attacks and sexual touching.
Statistics
Sexual assaults are commonly committed by someone known to the survivor.
Statistics Canada, Canadian Centre for Justice Statistics, Incident-based Uniform
Crime Reporting Survey, 2011
Casual acquaintance or friend 45%
Intimate partner 17%
Non-spousal family member 13%
In 2011 25% of police-reported sexual assaults against women were committed by
a stranger.
According to the 2009 Statistics Canada, General Social Survey there was a rate of
34 sexual assault incidents for every 1,000 women in the previous 12 months.
Nine in ten sexual assaults against women (90%) were never reported to police.
Statistics
According to Statistics Canada 2009 GSS ;
38% of women who were victimized by their spouse used formal victim service
12% of women victims of non-spousal violence contacted formal victim service
formal victim service are identified as crisis lines, community centres, shelters,
women's centres, and support groups
The ORCC crisis line receives 1540 calls a year
Impacts of Sexual Assault
Physical symptoms:
Headaches
Abdominal cramps
Chronic Fatigue
Distorted Thinking:
It’s all my fault
I cant trust anyone
I am inherently shameful/bad
Emotional Difficulties:
Depression
Guilt/ Self-Blame
Anger/Rage
Numbing
Relationship Issues:
Challenges communicating needs
Challenges identifying healthy relationships
Attachment issues
Challenges with boundaries
Presenting Concerns for Survivors
Emotional reactions; shock, self destructive thoughts and behaviors, attempts to
manage emotions through addictive or compulsive activities, self injury or self
stimulation
Self –perception; low self esteem, self-loathing, shame, self blame and stigma
Physical and somatic effects; direct physical reactions, medical conditions and
illness, post traumatic stress, dissociative manifestations
Sexual effects; anxiety and physical or psychological trauma
Interpersonal impacts; mistrust and conflict, non-nurturing relationships with
friends, co-workers, partners, parents, Loss of power and control
Impact on Maternal Health
•Approximately 400,000 babies are born every year in Canada
•Approximately 1-4 women will be sexually assaulted in their
lifetimes
•51% of women over16 have experienced at least one incident of
physical assault
Soooo...
•Theoretically approximately 200,000 women giving birth have
experienced at least one incident of physical assault &
approximately 100,000 women giving birth every year can be
survivors of sexual assault
Impacts on Maternal Health
• Women with a history of abuse can experience many challenges in
their childbearing year.
• 40% of domestic violence began during pregnancy
• In one study, approximately 10 percent of respondents disclosed
their abuse history (when they were asked about their abuse
history) to their maternal care provider.
• Reasons for not disclosing included not being aware how their
abuse histories impact their maternal health, fear, shame, fear of
not being believed, lack of trust and not remembering the abuse.
• Women may exhibit experience :
– higher rates of chronic pain
– ‘high risk behaivour’
– poorer health perceptions
– report more physical symptoms of pain
– have higher rates of PTSD, anxiety, depression
• Women may have a harder time seeking and receiving services.
• Unwanted sexual contact & lack of control over repro. choice
• Rates of addiction & mental health issues four times higher for
survivors
Case Study
Elizabeth James arrives in your office. She is having her first baby. Elizabeth is a twenty-four,
white, able-bodied woman and has a common-law male partner. Elizabeth has completed high
school and currently works at a call centre making minimum wage. Her partner is a long-distant
truck driver. They have an average household income.
The pregnancy was not planned and she discovered she was pregnant at four months. Despite
this, she did not see a healthcare provider for her pregnancy until she was 28 weeks pregnant.
Elizabeth lives in a rural area and is 30 minutes from the closest hospital. Elizabeth has a few
support people in her life and has some contact with her immediate family but they live in
another part of Ontario.
As a child Elizabeth was sexually assaulted by her uncle from the age of 6 to 10. She did not
disclose to anyone until she was 16 years of age. When she disclosed her immediate family ‘cutoff’ ties with her uncle and that side of the family. Elizabeth has never gone to counselling for
sexual assault but has talked to her partner about the abuse. When she was a teenager she had
an eating disorder from the age of 13 to 18 years of age but has recovered from it. During a
prenatal PAP smear Elizabeth was triggered and experienced a flashback of the abuse. Elizabeth
sometimes has issues with anxiety and takes medication as needed.
Elizabeth is planning on breastfeeding and has not read a lot about pregnancy, childbirth or
postpartum.
Case Study Questions:
• What are some issues Elizabeth could
potentially be dealing with?
• What are some issues that may affect
pregnancy, labour and postpartum?
• How might Elizabeth’s experience of sexual
assault impact her pregnancy, labour and
postpartum?
How does sexual violence impact the prenatal period?
• Experiencing ‘monumental change’ can bring up issues of the
abuse
• Women may feel like their bodies are damaged (especially if
they have had recurrent pregnancy losses, issues with fertility
etc)
• Women may feel empowered through pregnancy ie. my body
can do this right
• Women may feel out of control of their bodies
• Women may feel disconnected or disassociated from their
bodies as a result of feeling their body has been ‘taken over’
How does sexual violence impact the prenatal period?
• May deny or attempt to hide the pregnancy
• Issues around providing safety during pregnancy and after the
birth of their child may emerge
• Reluctance to seek prenatal care or continue with prenatal care
• Manifestation of physical symptoms or intense feeling of physical
symptoms ie. groin pain
• Fear, anxiety, depression, emerging memories of abuse
Themes of Types of Clients:
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Clients that are far along in their healing process
Clients who are not safe
Clients who are not ready to discuss the sexual violence
Clients who do not know
1) Clients who are far along in their healing
process:
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Usually more likely to disclose to a care provider
Wants to understand how SV may impact her birth
experience
May seek support regarding the impacts of SV on birth
May be more actively involved in her care, can selfadvocate
2) Clients who are not safe:
• May currently be experiencing abuse
• Not living in conditions that allow them to leave/ discuss
psychosocial issues
• Pregnancy may be as a result of sexual coercion
• May or may not disclose the abuse is occurring
• May have issues with addictions/self-harm behaivour
• May seek out health care services to ‘get safety’
3) Clients who are not ready to discuss SV
• May exhibit signs of trauma
• May hint that they are survivors but not disclose the abuse
• May be avoidant to discuss any childhood/past issues around
parenting
• May be very anxious over birth, pain control etc.
4) Clients who do not know
• May exhibit behaivours of trauma but the woman is not
aware of these behaivours
• Have disjointed memories or no memories of childhood
• Have strong desires for particular care during prenatal and
birth but ‘does not know why’
• Has body memories that she is unaware of
• May not recognize abuse as ‘abuse’
Common feelings or signs during pregnancy:
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Feeling like your body is ‘being invaded’
Feelings of a loss of control
Feelings of inadequacy
Feeling that her body is damaged & not capable of giving birth
Feeling that she may ‘replicate the abuse’
Avoiding prenatal appointments
Avoid discussing abuse
Increased amount/new flashbacks and or memories around
abuse
• Being overwhelmed
• Avoiding things like vaginal exams, GBS swab etc.
• Having a strong desire to be in control ie. birth plan, pain
relief
• Anxiety, depression, PTSD, self-harm behaivour
• Increased physical manifestations despite the lack of a
physiological cause
• Mismatching of physical symptoms to current situation
(feeling extreme pain during VE)
Supporting Women:
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Create safe-space for women to discuss abuse
Ask women about their experience
Acknowledge the impacts of SV on pregnancy
Recognize signs & behaivours
Fully explain all procedures, tests etc.
Allow more time during appointments
Help her seek out additional resources for support- pre and
post-natal support
• Understand her/common ‘triggers’ and avoid/find different
ways of working
• Create ‘plan’ on how she will deal with certain things such as
vaginal exams https://www.pennysimkin.com/download/ArticlesHandouts/Strategies%20for%20Specific%20Triggers.pdf
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Educate women on prenatal, birth & postpartum issues
Encourage women to write a birth plan
Encourage women to ‘hire’ a doula/birth companion
Encourage women to take childbirth classes/ provide
educational resources
Sexual Violence and Birth:
• Birth can replicate the physical sensations of the abuse
• Common birthing procedures can be perceived as triggering
and disempowering
• It can make women feel out of control
• Women may be avoidant of pain
• Women may feel ‘on display’
• Birth can trigger PTSD symptoms
• Women may feel like their bodies failed them if they don’t
achieve their desired birth outcome
Common Triggers during birth:
• Directions such as ‘just relax’, ‘open your legs’, ‘stop fighting
me’
• Pain- increased pain
• Vaginal exams & being ‘on display’
• Male care providers
• Epidural insertion
• Having blood taken, IV insertion, urinary catheter insertion
• Being ‘strapped down’
Common Triggers during birth:
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Odours
Nausea, gagging and vomiting
Pushing (various pushing positions, directed pushing, stir-ups)
Baby Crowning
Operative birth
Ceserean birth
Clinical Presentations:
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Long prodromal labour
Hypervigilance
Intense pain
Dissociation
Fear & anxiety
Panic
‘Switching’
Flashbacks
Labour dystocia / Delay or failure of descent
Supporting the woman:
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Acknowledge: validate what she is feeling
Ask permission: let her know what you are doing
Explain: All procedures & why something needs to be done
Advocate: to achieve the birth she wants
Support: provide on going one-on-one support
Educate: on labour, various positions
Clinical Challenges & Solutions (Penny Simkin)
https://www.pennysimkin.com/download/ArticlesHandouts/Clinical%20Challenges%20in%20Childbirth%20Related%20to%20Childhood%20Sexual%20Abuse.pdf
Sexual Violence & Postpartum Period:
• Survivors may experience issues with:
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breastfeeding/feeding child
Feeling disconnected to child
Triggered by child/gender of child
Prone to mental health crisis such as post-traumatic stress &
Postpartum Anxiety/Depression
Overwhelming anxiety for safety of baby/protecting baby
Avoidant or overprotective attachment
Parenting difficulties
Feeling impact of birth especially if birth was traumatic
Post-traumatic Stress:
• Approximately 30% of women will experience PTS following
childbirth (one to two week post-birth)
• Survivors & women who have had/perceive that they had a
traumatic birth are prone to developing PTS symptoms
• Feelings of intense fear, helpless, loss of control or horror
• Symptoms may include: flashbacks, nightmares, intrusive
thoughts, dissociation etc.
• Symptoms lessen overtime & few women actually develop
PTSD (3.4% at one year)
Postpartum Depression/Anxiety:
• Rates vary between 5-25%
• Symptoms include: fatigue, sadness, anxiety around going
outside, taking the baby outside, crying, irritability etc
• Survivors may experience these symptoms more frequently &
have a hard time adjusting to parenting
• PPD impeding life (onset can be up to one year PP)
• Few women develop postpartum psychosis
Parenting Difficulties:
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Difficulty with changing baby, cleaning baby (esp. genitals)
‘Connecting’ with the baby
Avoidant or overprotective attachment to baby
Disconnected with ‘motherhood’
Feeling overwhelmed by responsibilities
Having issues around gender
Viewing child as perpetrator
Feeling out-of-control
Breastfeeding & Sexual violence:
• Healthcare provider’s attitude will directly impact a women’s
choice on how to feed her child
• WHO indicates: 14.4% of women in Canada will breastfeed
beyond 6 months
• One study: childhood survivors were 2.6% more likely to
initiate breastfeeding but 10x less likely to continue beyond
one month
• Survivors that chose not to breastfeed/discontinue
breastfeeding often cited ‘not wanting to’ vs. ‘not able to’
Breastfeeding Issues:
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Being triggered
Flashbacks to abuse
Baby perceived as abuser
Disassociation
Feeling ‘like a failure, body broken’
Feeling disgusted by breastfeeding
Feelings like she is ‘abusing’ her child
Issues around physiological response to breastfeeding such as
arousal
Supporting Women in Postpartum:
• Recognize signs & symptoms of PTS & PPD
• Provide space after the birth and within 6 weeks postpartum
to discuss her birth & her experience of the birth
• Provide non-judgmental information and support
• Connect women with resources in the community that
support women in the postpartum such as breastfeeding
support, peer support, financial support etc.
• Validate, validate, validate
• Discuss normal transitions to ‘life with a newborn’
Supporting Women in Postpartum:
• Empower her to make choices that are right for her and her
situation
• Recognize potential situations that may lead to abuse/neglect
& provide support for the women & family
• Provide her with grounding exercises
• Reframe what she is doing
• Ask her what she needs
Supporting Survivors
• ASK about abuse history, about how it is affecting her generally and in pregnancy, about
what she needs from you, and, at each visit thereafter, ask truly open-ended questions and
allow open time to discuss how she is doing with regard to posttraumatic stress concerns (eg,
“How are you?”)
• ACKNOWLEDGE that trauma has long-term effects on some people, that she is not the only
one, and that you are willing to work with her to address trauma-related needs or are able to
refer her to a more appropriate provider.
• ASSESS repeatedly her risk for associated problems that are critical to perinatal outcomes:
substance use, revictimization (current abuse), high-risk sexual practices, disordered eating,
self-harm, postpartum mood and attachment disorders, and safety for her infant.
• ASSUME, in the absence of disclosure but in the presence of posttraumatic stress reactions,
that the client could be a survivor and respond to her therapeutically but without forcing the
issue.
From: ABUSE-RELATED POSTTRAUMATIC STRESS AND DESIRED MATERNITY CARE PRACTICES: WOMEN’S PERSPECTIVES
Julia S. Seng, CNM, PhD, Kathleen J. H. Sparbel, FNP, MS, Lisa Kane Low, CNM, PhD, FACNM and Cheryl Killion, RN
Journal of Midwifery & Women’s Health • Vol. 47, No. 5, September/October 2002 p 364
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AVOID triggering posttraumatic stress reactions by learning individual clients’ triggers
specifically and by increasing awareness of aspects of maternity care that are generally
triggering (eg, pelvic examinations, being touched without permission, feeling out of control).
ARRANGE more extensive contact that meets her needs via longer or more frequent visits
with the main care provider or appointments with team members, and be ready to arrange
connections to domestic violence programs, substance abuse treatment, or mental health
services as appropriate.
ADVOCATE for appropriate program and financial resources to meet these clients’ traumarelated needs, and consider using a secondary diagnosis of posttraumatic stress (or other
appropriate related disorder) for clients who meet diagnostic criteria.
ASCERTAIN by follow-up of individuals and evaluation of practice over time whether traumarelated outcomes are being met in concert with perinatal goals.
From: ABUSE-RELATED POSTTRAUMATIC STRESS AND DESIRED MATERNITY CARE PRACTICES: WOMEN’S PERSPECTIVES
Julia S. Seng, CNM, PhD, Kathleen J. H. Sparbel, FNP, MS, Lisa Kane Low, CNM, PhD, FACNM and Cheryl Killion, RN Journal of Midwifery &
Women’s Health • Vol. 47, No. 5, September/October 2002 p 364
Resources
Books:
When Survivors Give Birth- Penny Simkin
The Birth Partner- Penny Simkin
Websites:
Penny Simkin Website: www.pennysimkin.com
La Leche League: www.llli.org
A Safe Passage: http://www.asafepassage.info/intro.shtml
Supporting Women in Lanark:
1. What supports exist in your community for survivors during
pregnancy & postpartum?
2. What possible collaborations can be made with community
partners to better support survivors?
3. What can you do/organization do to better support women
in your community?
Thank-you
For more information please visit our website at
www.orcc.net
613-562-2333 crisis line
613-562-2334