Sex Sexual Violence & Its Impact on Maternal Health

1. Sex Sexual Violence & Its Impact on Maternal Health

2. Agenda • 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

3. 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.

4. ORCC’s Counseling Services LONG TERM COUNSELLLING TELEPHONE CRISIS COUNSELLING • 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 • 24hr, 7 days a week crisis line- • concerned with personal safety • Helps the client identity short-term goals • Helps the client identity her most pressing concern and discusses coping strategies for the immediate or short term

5. What is Sexual Assault? What is Rape?

6. What is Sexual Assault? What is Rape? • Any unwanted sexual act that a person has not agreed to such as; • Street hassling • Obscene calls / texting • Flashing or exposing • Masturbation in front of someone • Pornography • Crowding-invasion of personal space • Physical molestation (groping, touching) • Sexual harassment on the job • 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.

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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 ‘cut-off’ 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.

15. 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?

16. 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’

17. 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

18. Themes of Types of Clients: • 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

19. Clients who are far along in their healing process: • 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 self-advocate

20. 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’

21. 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.

22. 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’

23. Common feelings or signs during pregnancy: • 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

24. 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)

25. Supporting Women: • 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

26. 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/Articles-Handouts/Strategies%20for%20Specific%20Triggers.pdf • 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

27. 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

28. 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’

29. Common Triggers during birth: • Odours • Nausea, gagging and vomiting • Pushing (various pushing positions, directed pushing, stir-ups) • Baby Crowning • Operative birth • Ceserean birth

30. Clinical Presentations: • Long prodromal labour • Hypervigilance • Intense pain • Dissociation • Fear & anxiety • Panic • ‘Switching’ • Flashbacks • Labour dystocia / Delay or failure of descent

31. Supporting the woman: • 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/Articles-Handouts/Clinical%20Challenges%20in%20Childbirth%20Related%20to%20Childhood%20Sexual%20Abuse.pdf

32. Sexual Violence & Postpartum Period: • Survivors may experience issues with: • 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

33. 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)

34. 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

35. Parenting Difficulties: • 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

36. 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’

37. Breastfeeding Issues: • 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

38. 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’

39. 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

40. 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

41. 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’ trauma-related 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 trauma-related 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

42. 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

43. Supporting Women in Lanark: • What supports exist in your community for survivors during pregnancy & postpartum? • What possible collaborations can be made with community partners to better support survivors? • What can you do/organization do to better support women in your community?

44. Thank-you For more information please visit our website at www.orcc.net 613-562-2333 crisis line 613-562-2334