Providing Care for Survivors of Sexual Abuse During Childbirth

“Humiliating and Traumatic,” these are the words from a survivor of sexual abuse when asked to describe her labor and delivery. All too often, women who have been sexually abused carry their wounds into the delivery room. And, all too often, these unresolved traumas rear their ugly heads and cause complications, from labor dystocias, to full blown anxiety attacks that result in a woman completely shutting down. These are some of the more challenging labors to manage.

According to the U.S. Department of Health, one in four girls and one in five boys will be sexually abused before they turn 18. One in five women and one in 71 men will be raped at some point in their lives. This is in many ways a silent epidemic. Sometimes victims don’t disclose their abuse to their care providers. The reasons vary, and can range from  ongoing suffering of the traumatic effects of the abuse and  avoiding  reliving it, to a continuing sense of shame that victims  may have never come to grips with.

What are some possible signs of sexual abuse?

According to When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women, having a constellation of these symptoms can indicate a history of abuse. Having one or more of the following should trigger a red flag and considerations for a woman’s  care during childbirth:

  • Not able to feel fetal movement. Some women have “numbed” that part of the body
  • Hyperemesis gravidarum
  • Chronic pelvic pain
  • Missed prenatal appointments
  • Panic with vaginal exams
  • Extreme anxiety with IV starts
  • Disassociation that manifests as if she’s going into a trance

Many of these symptoms can understandably occur in women who don’t have a history of sexual abuse, but when a woman has two or more, it’s reasonable to suspect that such a history is possible. These symptoms can stem from PTSD, which is triggered by a woman’s perception of loss-of-control, as well as the physical sensations that occur during pelvic exams, labor, and birth. By rushing through procedures, and not allowing the woman time to process (if possible), understand, and consent to what is happening to her body, we can inadvertently trigger a posttraumatic reaction.

Admittedly, the discussion of sexual abuse is a tough topic for those on either end of the conversation. We often just touch on the subject while reviewing women’s admission histories, and then move on. Fortunately, we don’t need the admission of abuse to employ strategies developed for survivors. It’s actually much more common for caregivers to pick up on non-verbal cues and then tailor their care. A real tragedy is the guilt and shame survivors can feel after giving birth. So, like we would do for any woman,  it’s best to acknowledge the struggle of labor and birth, the strength a woman demonstrated, and the effort and precious reward she  achieved.

What are interventions that nurses and other caregivers can provide?

  • Explain as much as you can in advance, for example “If we run into an emergent situation there might be unfamiliar nurses coming in to help. I know this can cause anxiety, but I want to prepare you ahead of time in case it happens.”
  • Always start with asking permission. From starting an IV to turning on the overhead lights, make sure to obtain permission before doing any procedures or making changes to the environment
  • Go slowly with everything you do–this can be helpful in relation to a woman’s  fear of losing control. Fast movements can be triggers. This is especially important when uncovering a woman or assisting her with positioning.
  • Limit vaginal exams. These are especially traumatic and should be minimized. If a woman is having difficulty in relaxing enough to complete an exam, try making an agreement about when and why you can perform one. If a woman understands that the exams are being performed only when necessary, and with her consent, her anxiety is often more controllable during exams.
  • Minimize people in her room. She might have issues with nursing students or residents, especially if they are male. Obtain her permission before any new staff come into the room, unless there’s an emergent situation.

What are things not to say?

  • Intrusive interest-prying for details or descriptions of the abuse
  • Minimizing the abuse: “Well, that’s over now.”
  • Exaggerated concern
  • Shock or disgust
  • Pity

What are good things to say?

  • “I can imagine that was very hard to share that with me. It takes a lot of courage to talk about and I respect you for doing that.”
  • “Sometimes talking about these episodes can trigger strong feelings. How are you feeling right now?”
  • And, it’s always essential to assess the woman’s current well-being “Do you feel unsafe in any aspect of your life?”

Not all survivors of sexual abuse have difficulty with pregnancy or childbirth, for some it can be empowering. For those who do struggle, recognize that we have a powerful opportunity to help them. We can communicate therapeutically to help  change the woman’s focus from feeling out-of-control.  We can employ care practices to avoid the woman feeling re-traumatizatized.  And we can set the stage to promote healing and bonding with the newborn. In many instances it’s our tacit recognition and respectful and supportive care that facilitates healing, more than any words we could utter or medicines we could administer.

Where can I learn more?

What are resources for my patients?

  • National Sexual Abuse Hotline: 1800-656-HOPE
  • RAINN: Rape, Abuse, Incest National Network, www.rainn.org

Tasha-poslaniecTasha Poslaniec has been a registered nurse for 17 years. She has been working in obstetrics for over a decade and is currently a Perinatal Quality Review Nurse and Childbirth Educator.

She also writes about nursing and childbirth and has been published in the Huffington Post and the American Journal of Nursing. Pain control in childbirth has long been a topic of study and research for her.

Human Trafficking in the US is Real! Here’s How Nurses Can Help

by, Leith Merrow Mullaly, RN, MSN, IBCLC

Sex trafficking is a form of modern slavery that exists in our own backyard. Traffickers resort to violence, threats, lies and other forms of intimidation to force both adults and children to take part in sexual acts against their will. Sex trafficking can occur anywhere, even in your very own community.

In 2016, the National Center for Missing & Exploited Children estimated that 1 in 6 endangered runaways reported to their Center were likely sex trafficking victims.  The Urban Institute estimated that the underground sex economy ranged from $39.9 million in Denver, Colorado, to $290 million in Atlanta, Georgia.  Prostitutes are victims of these crimes.

Yet, sadly, since 2007 the National Human Trafficking Resource Center Hotline has received only 145,764 calls*  (1-888-373-7888).  Why is this? Many of the victims of sex trafficking have no knowledge that such a resource even exists.  To make a phone call to get help is not possible for most victims as communication is strictly controlled and monitored by the pimp who has all the power.  Perhaps, we nurses should have this phone number posted in areas where women in your care can see it.  Nurses should also be aware of the warning signs associated with trafficking, and  when we suspect our patient/client may be such a victim, we should hand them a phone!

Commercially exploited children in our country have almost universally been sexually abused and enter prostitution with a history of complex trauma.  Their families have been absent or dysfunctional.  Several young women with whom I work were identified by teachers as abused (eg, a 7 year old who wouldn’t change gym clothes because of bruises all over her body).  There  were mixed reaction from teachers.  Some did follow up with local child protective services.  Some called parents.  One young woman told me “My teacher was concerned but my mother denied any sexual abuse but then said ‘well, she is so suggestive around my husband’; I was 6 years old!”  Many girls tried to tell an adult but many were afraid.  Some shared “I have told people and nobody believed me”.  Some were placed in foster homes, and believe it or not, they were molested and recruited by their pimps from the foster care system.

What can nurses do?  This may seem so much bigger than what we can do as individuals. But we can develop a more acute awareness about the realities of human sex trafficking right in our own environment.   When you hear or suspect human sex trafficking may be occurring to the patient sitting before you, believe them!  They very frequently display a fearful, distrusting affect because many times they have tried to tell and NOT been believed.  Offer them your belief.   Former President Jimmy Carter wrote an editorial in the Washington Post (May 31, 2016) entitled: “Curb prostitution, punish those who buy sex rather than those who sell it”.  I recommend reading this. Carter describes the “Nordic Model” which is a system that treats purchasing and profiting from sex as major serious crimes.  That might be something for which nurses in small or large groups, such as an AWHONN  Chapter or Section, can advocate for at their own local or state level.  Just imagine the impact it could have if the men in your community who are purchasing sex were prosecuted and exposed in public as the criminals they actually are.  We have heard “but he is a pastor” and “but he is on city council” and “ their reputations would be destroyed”.  Women and children who are sold for sex face more than ruined reputations, they face ruined lives!

As health care providers and patient advocates we must begin to work vigorously with our own elected officials to change the unacceptable and shocking status quo.  Did you know that trafficked children are treated as criminals in many jurisdictions even though under Federal law those under 18 years old are classified as victims?

My state, the Commonwealth of Virginia, was the last state in the country to pass a stand-alone human sex trafficking law (2015).  Now, anyone assisting, or working to traffic, sell or purchase prostitution can be arrested and charged.  This law came about because of the incredible tenacity and diligent work of a very few advocates working with their local legislators.  They provided both Representatives and their constituents with education on this issue.

Health education has always been a strong focus for nurses.  The public looks to us to educate them and the public trusts nurses to provide solid, honest information.  My “own public” sat in disbelief when we first started talking about sex trafficking right here where we live and work.  I heard comments like “No way, this is a lovely community.  Not here!”  As they learned the realities they were initially horrified, but now are very energized to help in any number of ways.  We also can’t  forget to educate parents.  They need to know that when young teens, girls and boys, meet other “youth” on the internet they are often opening themselves to traffickers.  When middle and high school kids sext and post photos they can and do become easy prey to predators.

If your community doubts the very idea of sex trafficking in your town, send them to a website called “Backpage”.  It is a trafficking website that lists ads for prostitution.  In my small size city there are more than 20 ads a day!  “Plenty of Fish” is another site that purports to be a dating site. We have had some of our trafficked victims “hooked up” on this site with “clients” purchasing sex.  If a nearly naked woman is advertising to come to a hotel room to provide a “massage”, read between the lines.  If the face is blurred, it most likely means the girl is a young minor.  If you look…unfortunately you will find human sex trafficking right in your own backyard.

Overwhelmingly the young women with whom I work had dreams of growing up to be moms or lawyers or teachers or doctors or nurses.  One girl had seriously and sincerely wanted to be an astronaut.  No one ever dreamed of growing up to be a prostitute!  They were brought into the “life style” as young minors.    They did not choose the life and do NOT benefit financially (a common misconception).  Once used, these victims are humiliated, shamed, embarrassed and trapped in a system they despise but have no idea how to escape.  Many seem to know of a girl who tried to escape who either “disappeared” or who was re-captured with her photo posted on line with her head shaved and tattooed by  her pimp.

NURSES CAN MAKE A HUGE DIFFERENCE if we just start working together to: 

  • Learn the facts about Human Sex Trafficking in our own communities
  • Work more closely with local and state law enforcement
  • Provide vitally-needed education to our peers, friends, organizations and parent groups
  • Advocate with legislators to enforce the law and explore alternatives such as the “Nordic Model” which is now used in Canada, France and Sweden
  • Believe a patient who trusts you enough to share their situation
  • Post the National Human Trafficking Resource Center Hotline – 1-888-373-7888—in a visible location in your setting
  • Be hyper-alert to telltale signs such as :
    • Tattoos or branding
    • Very unclear past history and no stable address
    • STD’s, especially repeated episodes
    • Wearing scanty clothes – often 2 sizes too small
    • Presence of cotton or debris in vagina and/ or rectum
    • Problems with jaw or neck
    • Inability to keep appointments
    • No identification
    • Accompanied by a person who does not allow the patient to speak or does not want to leave them alone during interview and/or care
    • Inconsistent stories (conflicting stories or misinformation)
    • Lack of documentation of age- appropriate immunizations and health care encounters

There are 3 million nurses in our country.  I believe that together we have the power to change hearts and minds so that our local communities and our nation understand the realities of human sex trafficking.  I serve on the Foundation Board of a home for victims. Our motto is: “Changing one life at a time and changing the world for future generations”.  I have seen the first goal come true with individual young women.  Won’t you join me in meeting both goals?

AWHONN believes Nurses are ideally positioned to screen, identify, care for, provide referral services for, and support victims of human trafficking. Therefore, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) supports improved education and awareness for nurses regarding human trafficking. Learn more about AWHONN’s position on this critical topic.

Resources:


References

*Number of calls reported to the Human Trafficking Hotline as of December 2016 for more information visit https://humantraffickinghotline.org/

Estimating the Size and Structure of the Underground Commercial Sex Economy in Eight Major US Cities

National Center for Missing & Exploited Children

Urban Institute


leithLeith Merrow Mullaly, RN, MSN, IBCLC
Leith Mullaly is a past president of AWHONN and has served at all levels of the organization. Leith has a passion for both nursing and the specialty of Women’s Health and Newborn care. Her focus within AWHONN has always been to mentor future leaders and encourage nurses’ participation in their professional association. She has experience as a Staff Nurse, Staff Educator, MCH Director, Clinical Faculty Member, Certified Lactation Consultant and Author. She is a nationally ranked speaker on topics such as Postpartum Depression, Breastfeeding, the Image of Nursing, Service Excellence, Perinatal Loss and Bereavement, Mature Primiparas. Her interest in care for Victims of Human Sex Trafficking has been a major focus for the past several years.

Human Trafficking in Our Own Backyards

by, Leith Merrow Mullaly, RN, MSN, IBCLC

Learn more about AWHONN’s position on this critical topic.

Slim and obese, tall and short, strikingly beautiful and very plain, black, Asian and white…literally the girls who live next door.  These are the young women I support and with whom I work.  They are all victims of sex trafficking right here in the “good ole U.S.A.”

Most of us think of sex trafficking as something that occurs in Africa, Southeast Asia, the Middle East, Russia or South America.  Unfortunately it is estimated that there are almost 300,000 women, children and even men who are trafficked for sexual purposes in our own country.  I have been told by multiple young women that there is not a single hotel or motel in the United States where a prostitute cannot be obtained!  This includes the most expensive and elegant big city hotel to the most humble rural establishment.

Prostitution is much more lucrative than drug dealing.  A single pimp can earn more than $1.5 million every six months with 6 women or children in their “stable”.  The chances of being apprehended are fairly small and there is often no one to testify against the pimp.  I have worked closely with a young woman who finally agreed to testify against her pimp only when the F.B.I. put her into hiding.  Two previous potential witnesses had “disappeared” and are assumed to have been killed.  (It is most distressing to learn that this pimp is a husband and father with children in an elite private school.  He is a highly respected businessman who owns several companies and is known for his charitable giving!)

My husband and I serve on one of the few Foundation Boards in our nation that is providing real hands-on help to these young women.  This sheltered home, provided by  the county and located in a small city,  offers not only a safe escape away from their dangerous traffickers/pimps but most importantly, individual and group trauma-based counseling  because many of our residents are suffering from PTSD, dissociative and other personality disorders.  Most of our residents were on the street by age 14!   Many of our young women are pretty badly damaged and not easy to handle initially. They are combative and angry and extremely defensive.  They cannot TRUST!  They express profound shame and state “I feel so dirty”. We take them to free clinics to treat their STDs and obtain medications for their anxiety disorders, which are often severe.  We help them finish their GED certification and work closely with our community college on educational opportunities.  We offer classes on body image.  We try to introduce them to what a healthy male-female relationship should be via “Pizza Night”. One or two married couples, who really care, bring pizza and spend the evening eating and visiting.  Sadly, for some of our young women, this is a totally new experience. Things that you and I accept as common and expected, these women have never known.  We held the very first birthday party for a twenty year old!

One day a young woman decided she really wanted to move forward.  She asked if we thought there was a “thrift shop for prostitutes” where she could donate all her clothes “because some of these outfits were very expensive”! Instead, we had a big bon fire!  Today she is in college, hoping to become a nurse.  As nurses, we have seen and experienced so many facets of life.  We know about child sexual abuse.  Yet, have we really considered what happens to them long term?  Certainly many children receive help, counseling and appropriate adult love and support.   I must confess that I had not consciously made the direct connection between abused children and victims of sex trafficking.  Men in prison have bragged that they can spot a vulnerable young person in less than 2 minutes!  I was truly ignorant about the scope and size of sex trafficking…right here in our own backyard.  This is the impact and outcome for many victims of childhood physical and sexual abuse.  I sincerely hope that I may open your eyes and hearts so that when you see a prostitute, you see a victim and not a criminal.

When you see a young woman “on the street” or in your clinic, L&D or E.D. be alert to signs and indicators of possible human trafficking.  While not all signs prove human sexual trafficking, some of the following should be “red flags”:

  • No stable address & no family, community connections
  • Very unclear past history
  • An overbearing male companion
  • A “beaten-up” body, often with healing scars
  • A number tattoo (pimp’ s ID)
  • Emaciated, starved appearance
  • STD (almost 100%)
  • Scanty clothes (often 2 sizes too small & often animal prints)

When you encounter these kinds of signs we need to at least think “sex traffic victim”.  Yes, victim!  Most, if not all young women and to a lesser degree, young men, end up on the street because they are victims of repeated child sexual abuse at home.  Pimps brag that they can spot a “vulnerable prospect” in 2 to 10 minutes!

As nurses we need to grasp the pervasive nature of this problem…NOT in some far off country, but rather, right here at home…in our own backyards.  I was naïve about all this until I became involved with one of the very few homes in the United States offering a safe haven for these young women.  We work with the state police, the F.B.I. and Homeland Security to get sex- trafficked women off the street.  It is estimated that there are only 100 beds nationally for sex trafficked women over the age of 18 and only another 100 beds for those less than 18 years old.

I’ll be writing more about this topic and what we can all do to help these victims in upcoming AWHONN Connections blogs.

_______

AWHONN believes Nurses are ideally positioned to screen, identify, care for, provide referral services for, and support victims of human trafficking. Therefore, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) supports improved education and awareness for nurses regarding human trafficking. Learn more about AWHONN’s position on this critical topic.

leithLeith Merrow Mullaly, RN, MSN, IBCLC
Leith Mullaly is a past president of AWHONN and has served at all levels of the organization. Leith has a passion for both nursing and the specialty of Women’s Health and Newborn care. Her focus within AWHONN has always been to mentor future leaders and encourage nurses’ participation in their professional association. She has experience as a Staff Nurse, Staff Educator, MCH Director, Clinical Faculty Member, Certified Lactation Consultant and Author. She is a nationally ranked speaker on topics such as Postpartum Depression, Breastfeeding, the Image of Nursing, Service Excellence, Perinatal Loss and Bereavement, Mature Primiparas. Her interest in care for Victims of Human Sex Trafficking has been a major focus for the past several years.

Intimate Partner Violence

Journey of Motherhood Under the Shadow of Abuse During Pregnancy

by, Ann Bianchi, PhD, RN

Intimate partner violence (IPV) has devastating effects on a pregnant woman and her unborn child.

Intimate partner violence may be more severe and more frequent during pregnancy which poses health risks to the mother and her baby. The effects on a woman’s health due to IPV during pregnancy may extend long after the pregnancy and post-partum period. One in four women are victims of IPV and 324,000 pregnant women experience IPV each year and 1600 maternal deaths each year are the result of intimate partner violence.

This blog post is part of our IPV series and covers the effects on mother-infant bonding, maternal and fetal outcomes, and our role as nurses.

The last in our blog series coming out in winter 2015 will cover screening details for nurses. Continue reading

Intimate Partner Violence

Intimate Partner Violence (IPV)

by, Ann L. Bianchi, PhD, RN

What is Intimate Partner Violence?

Intimate Partner Violence (IPV) affects women of all ages, races, ethnic backgrounds, religions, educational levels, and economic levels. Abuse is inflicted upon a current or former partner or spouse, or boyfriend, or dating partner. Intentional behaviors are used by the abuser to induce fear, terror, coercion, and threats to gain power and control over the other person and the relationship.

Abusive behaviors, according to Centers for Disease Control and Prevention National Center for Injury Prevention and Control, may include physical abuse such as: hitting, pinching, shoving, grabbing, pushing, being kicked, thrown, or shaken, even punched, slapped, or strangulated. Depending on the severity of the assault it may lead to death. Continue reading