Breastfeeding and the Sexual Abuse Survivor
Abstracts, May 1998, Volume 17, Number 4, pp. 27-28.
One out of five American women has been sexually abused as a child.l-2 Past sexual abuse can affect many aspects of a woman's current level of functioning, including breastfeeding and parenting.3 Only one recent study has specifically considered breastfeeding among sexual abuse survivors.4 The authors found a higher intention to breastfeed among survivors than their non-abused counterparts.
Even with the dearth of directly relevant studies, there is a large body of research on the long-term effects of sexual abuse. This literature can be helpful in identifying some of the issues and concerns that adult survivors face.
Long-term effects of sexual abuse can be divided into seven domains of functioning.3, 5-6 Thus there is a range of possible symptoms that may affect breastfeeding to varying degrees. Sexual abuse survivors may experience any of these symptoms, or none at all.
Post-Traumatic Stress Disorder (PTSD).
Mothers may experience sudden and intrusive flashbacks, hypervigilance, and sleep disturbances. While most do not meet full diagnostic criteria of PTSD, 50% of adult survivors have PTSD symptoms.3,7 Mothers may experience flashbacks of their abuse either during labor and delivery or when they bring their babies to breast. Triggers for these flashbacks may include squirting milk or skin-to-skin contact. Other women may not experience flashbacks but may experience a vague discomfort whenever they breastfeed.7
Mothers may overestimate danger to themselves or their babies, and perceive themselves as weak or helpless. These perceptions can lead to a state of "learned helplessness" that can influence their emotional state and their ability to seek assistance when necessary.3, 5 When they encounter breastfeeding difficulties, they may assume that there is nothing they can do that will help.
Emotional distress includes some of the most common sequelae of sexual abuse: depression, anxiety, panic disorders, and anger. Depression is an especially common symptom; adult survivors have a four-times greater lifetime risk of depression than do their non-abused counterparts.3, 7 This is a concern because postpartum can be a time when many women are vulnerable to depression. Mood disorders can have a negative effect on how mothers interact with their babies.
Impaired Sense of Self.
Mothers may manifest an impaired sense of self by having difficulty separating their emotional states from the reactions of others. They may have difficulties in self-protection, leading to an increased risk of re-victimization.3 More typically, they may not be able to mobilize necessary social support from among their network of friends and family at a time when they really need it.7
Avoidance.Some of the most serious long-term effects of sexual abuse fall into the category of avoidance. Mothers may experience dissociation, which includes alterations in body perception, emotional numbing, amnesia for painful memories, and multiple personality disorder. Other types of avoidant behavior are substance abuse, suicidal ideation and attempts, and "tension-reducing activities" including indiscriminate sexual behavior, bingeing and purging, and self-mutilation.3-5 A mother may suddenly recover memories of abuse in the puerperium, or she may have an eating disorder, or she may be a substance abuser. All of these situations require intervention by a mental health provider.
Not surprisingly, adult survivors may also have problems with interpersonal relationships. They may adopt an "avoidant" style, characterized by low interdependency, self-disclosure, and warmth. Or they may adopt an "intrusive" style, characterized by extremely high needs for closeness, excessive self-disclosure, and a demanding and controlling style. These styles can affect relationships with friends, partners, and their children. Both styles are problematic and generally result in loneliness.3, 6 For the breastfeeding mother, these ineffective styles may blunt her ability to read and respond appropriately to her baby's cues.
Physical Health and Susceptibility to Illness.
This is the newest area of study in sexual abuse. Findings from these studies indicate that a relatively high percentage of sexual abuse survivors are at increased risks for health problems,8 especially those with a strong mind-body component such as irritable bowel syndrome and fibromyalgia.5, 9-10 These can affect the overall health and energy level of the mother, increasing her vulnerability to breast infections, and compounding the stresses of the postpartum period.
There are some other symptoms that practitioners may encounter that should alert them to the possibility of past sexual abuse. For example, some mothers cannot tolerate the feel of the baby on the breast. They may indicate that the baby is "biting," even when there is no evidence of this. Others may make inappropriate jokes or comments about breastfeeding and the needs of the baby (e.g., "like all men"). Still others may appear to be ashamed of their breasts. Some of these comments may be from nervousness or may be the result of living in a culture that is ambivalent about breastfeeding, and have nothing to do with sexual abuse. For others, these comments should at least raise the possibility of sexual abuse in the mind of the practitioner.
There are a number of positive steps that professionals can take to assist a sexual abuse survivor with breastfeeding. It is important to keep in mind that every mother is different. Approach each situation with an open mind. What may be an issue or problem for one mother may not be for another.
Offer suggestions that will make breastfeeding more comfortable. Try to find out which situations make a mother uncomfortable. Some potential problem areas include (but are not limited to) skin-to-skin contact, playful older babies and nighttime breastfeeding. Help mothers work within their comfort level, and find a solution that works for them. If a mother might be a sexual abuse survivor, always ask permission before touching her. This gives her the chance to control the amount of contact.
Make a referral.If a mother mentions that she has been sexually abused, talk with her about the importance of seeing a professional who can help (if she is not already doing so). While breastfeeding professionals want to be sympathetic and supportive, they must avoid becoming the main source of emotional support for issues that are only tangentially related to breastfeeding. For a mother experiencing serious difficulties, or difficulties outside the realm of breastfeeding, referral is a must.
Educate care providers about the normal course of breastfeeding, including breastfeeding on demand, co-sleeping and late weaning. This is an area where professional expertise in breastfeeding can make a significant difference. Many professionals in the sexual abuse field feel that attachment-parenting practices, such as co-sleeping and demand feeding, are a negative result of the sexual abuse experience. Breastfeeding advocates can educate mental health providers, either directly or via the mother, about the normality of these practices, especially from a global perspective.11
Some survivors cannot even consider breastfeeding, while others may find it healing. Still others are somewhere in between. By approaching each mother with gentleness and respect, we can help women who want to breastfeed have a positive breastfeeding experience.
Kathleen Kendall-Tackett is a Research Associate at the Family Research Laboratory, University of New Hampshire in Durham, New Hampshire. She is the author of Postpartum Depression: A Comprehensive Approach for Nurses and is an active La Leche League Leader.
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