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Jewish Survivors of Sexual Violence and Pregnancy Issues

(Incest, Childhood Sexual Abuse, Sexual Assault, Clergy Sexual Abuse, Professional Sexual Misconduct)

There are so many issues when it comes to incest, childhood sexual abuse, sexual assault, clergy sexual abuse and pregnancy, yet The Awareness Center is having a difficult time locating resources to address theml. If you know of resources for Jewish survivors who were pregnant as a result of their abuse/assault, or if you have resources for survivors who were a product of abuse or assault, please forward it to: vickipolin@ theawarenesscenter.org

We are also looking for information to help survivors of abuse deal with their own pregnancy if they find the process difficult.

Dear Friends,

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The Awareness Center is a non-profit, certified 501 (c) (3) organization.  Our goals include reaching out to Jewish survivors of sexual violence, parents of sexually abused children, family members of alleged and convicted sex offenders, rabbis, cantors and other community leaders. We also serve as a clearinghouse of information, and offer advocacy for those in need and educational seminars.

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Disclaimer: Inclusion in this website does not constitute a recommendation or endorsement. Individuals must decide for themselves if the resources meet their own personal needs.

Table of Contents:  

  1. Jewish Resources
  2. Secular Resources

Also see:  

  1. The Awareness Center's Brochure  

  2. Rabbis, Cantors and Other Trusted Officials

  3. Offenders: Problems Our Parents Wouldn't Speak Of

  4. Recidivism of Sex Offenders  (U.S. Department of Justice: Center for Sex Offender Management)

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Medical Professionals sensitive to issues related to sexual victimization

New York

Abortion in Jewish Law

by Daniel Eisenberg, M.D.

Aish HaTorah - Sunday, May 30, 2004

http://www.aish.com/societyWork/sciencenature/Abortion_in_Jewish_Law.asp

The traditional Jewish view of abortion does not fit conveniently into any of the major "camps" in the current debate over abortion.

As abortion resurfaces as a political issue in the upcoming U.S. presidential election, it is worthwhile to investigate the Jewish approach to the issue. The traditional Jewish view of abortion does not fit conveniently into any of the major "camps" in the current American abortion debate. We neither ban abortion completely, nor do we allow indiscriminate abortion "on demand."

A woman may feel that until the fetus is born, it is a part of her body, and therefore she retains the right to abort an unwanted pregnancy. Does Judaism recognize a right to "choose" abortion? In what situations does Jewish law sanction abortion?

To gain a clear understanding of when abortion is permitted (or even required) and when it is forbidden requires an appreciation of certain nuances of halacha (Jewish law) which govern the status of the fetus.1

The easiest way to conceptualize a fetus in halacha is to imagine it as a full-fledged human being -- but not quite.2 In most circumstances, the fetus is treated like any other "person." Generally, one may not deliberately harm a fetus. But while it would seem obvious that Judaism holds accountable one who purposefully causes a woman to miscarry, sanctions are even placed upon one who strikes a pregnant woman causing an unintentional miscarriage.3 That is not to say that all rabbinical authorities consider abortion to be murder. The fact that the Torah requires a monetary payment for causing a miscarriage is interpreted by some Rabbis to indicate that abortion is not a capital crime4 and by others as merely indicating that one is not executed for performing an abortion, even though it is a type of murder.5 There is even disagreement regarding whether the prohibition of abortion is Biblical or Rabbinic. Nevertheless, it is universally agreed that the fetus will become a full-fledged human being and there must be a very compelling reason to allow for abortion.

As a general rule, abortion in Judaism is permitted only if there is a direct threat to the life of the mother by carrying the fetus to term or through the act of childbirth. In such a circumstance, the baby is considered tantamount to a rodef, a pursuer6 after the mother with the intent to kill her. Nevertheless, as explained in the Mishna,7 if it would be possible to save the mother by maiming the fetus, such as by amputating a limb, abortion would be forbidden. Despite the classification of the fetus as a pursuer, once the baby's head or most of its body has been delivered, the baby's life is considered equal to the mother's, and we may not choose one life over another, because it is considered as though they are both pursuing each other.

It is important to point out that the reason that the life of the fetus is subordinate to the mother is because the fetus is the cause of the mother's life-threatening condition, whether directly (e.g. due to toxemia, placenta previa, or breach position) or indirectly (e.g. exacerbation of underlying diabetes, kidney disease, or hypertension).8 A fetus may not be aborted to save the life of any other person whose life is not directly threatened by the fetus, such as use of fetal organs for transplant.

Judaism recognizes psychiatric as well as physical factors in evaluating the potential threat that the fetus poses to the mother. However, the danger posed by the fetus (whether physical or emotional) must be both probable and substantial to justify abortion.9 The degree of mental illness that must be present to justify termination of a pregnancy has been widely debated by rabbinic scholars,10 without a clear consensus of opinion regarding the exact criteria for permitting abortion in such instances.11 Nevertheless, all agree that were a pregnancy to causes a woman to become truly suicidal, there would be grounds for abortion.12 However, several modern rabbinical experts ruled that since pregnancy-induced and post-partum depressions are treatable, abortion is not warranted.13

As a rule, Jewish law does not assign relative values to different lives. Therefore, almost most major poskim (Rabbis qualified to decide matters of Jewish law) forbid abortion in cases of abnormalities or deformities found in a fetus. Rabbi Moshe Feinstein, one the greatest poskim of the past century, rules that even amniocentesis is forbidden if it is performed only to evaluate for birth defects for which the parents might request an abortion. Nevertheless, a test may be performed if a permitted action may result, such as performance of amniocentesis or drawing alpha-fetoprotein levels for improved peripartum or postpartum medical management.

While most poskim forbid abortion for "defective" fetuses, Rabbi Eliezar Yehuda Waldenberg is a notable exception. Rabbi Waldenberg allows first trimester abortion of a fetus that would be born with a deformity that would cause it to suffer, and termination of a fetus with a lethal fetal defect such as Tay Sachs up to the seventh month of gestation.14 The rabbinic experts also discuss the permissibility of abortion for mothers with German measles and babies with prenatal confirmed Down syndrome.

There is a difference of opinion regarding abortion for adultery or in other cases of impregnation from a relationship with someone Biblically forbidden. In cases of rape and incest, a key issue would be the emotional toll exacted from the mother in carrying the fetus to term. In cases of rape, Rabbi Shlomo Zalman Aurbach allows the woman to use methods which prevent pregnancy after intercourse.15 The same analysis used in other cases of emotional harm might be applied here. Cases of adultery interject additional considerations into the debate, with rulings ranging from prohibition to it being a mitzvah to abort.16

I have attempted to distill the essence of the traditional Jewish approach to abortion. Nevertheless, every woman's case is unique and special, and the parameters determining the permissibility of abortion within halacha are subtle and complex. It is crucial to remember that when faced with an actual patient, a competent halachic authority must be consulted in every case.

  1. 1 While there is debate among the Rabbis whether abortion is a Biblical or Rabbinical prohibition, all agree on the fundamental concept that fundamentally, abortion is only permitted to protect the life of the mother or in other extraordinary situations. Jewish law does not sanction abortion on demand without a pressing reason.

  2. Igros Moshe, Choshen Mishpat II: 69B.

  3. Shulchan Aruch, Choshen Mishpat, 423:1

  4. Ashkenazi, Rabbi Yehuda, Be'er Hetiv, Choshen Mishpat 425:2

  5. Igros Moshe, ibid

  6. Maimonides, Mishneh Torah, Laws of Murder 1:9; Talmud Sanhedrin 72B

  7. Oholos 7:6

  8. See Steinberg, Dr. Abraham; Encyclopedia of Jewish Medical Ethics, "Abortion and Miscarriage," for an extensive discussion of the maternal indications for abortion.

  9. Igros Moshe, ibid

  10. See Encyclopedia of Jewish Medical Ethics. P. 10, for references.

  11. See Spero, Moshe, Judaism and Psychology, pp. 168-180.

  12. Zilberstein, Rabbi Yitzchak, Emek Halacha, Assia, Vol. 1, 1986, pp. 205-209.

  13. Rabbi Shlomo Zalman Aurbach and Rabbi Yehoshua Neuwirth cited in English Nishmat Avraham, Choshen Mishpat, 425:11, p. 288.

  14. Tzitz Eliezer, Volume 13:102.

  15. Rabbi Shlomo Zalman Aurbach and Rabbi Yehoshua Neuwirth cited in English Nishmat Avraham, Choshen Mishpat, 425:23, p. 294.

  16. See excellent chapter in English Nishmat Avraham, Choshen Mishpat, 425 by Dr. Abraham Abraham, particularly p. 293.

Author Biography:

Dr. Daniel Eisenberg is with the Department of Radiology at the Albert Einstein Medical Center in Philadelphia, PA and an Assistant Professor of Diagnostic Imaging at Thomas Jefferson University School of Medicine. He has taught a weekly Jewish medical ethics class for the past 10 years. He moderates the monthly Jewish medical ethics study group at Albert Einstein Medical Center and lectures internationally on topics in Jewish medical ethics.

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Secular Articles

Childhood Sexual Abuse as an HIV Risk Factor in Women

Treatment Issues, Vol 11, No 7/8; July/August 1997

Risa Denenberg, R.N., F.N.P., M.S.N.

http://www.aegis.com/pubs/gmhc/1997/GM110710.html

In doing HIV/AIDS work, it is critical to operate with the awareness that a large proportion of adolescents and adults were sexually abused as children and that abuse has had a profound and devastating effect on their consequent psychosocial development. Childhood sexual abuse has been strongly associated with numerous disturbing behavioral and psychological outcomes in adolescent and adult women. Among them are further domestic violence, adolescent pregnancy, child abuse, drug and alcohol abuse, bulimia, sexually transmitted infections, depression, prostitution, self-mutilation, running away from home and dropping out of school (Rosenfeld, 1993; Boyer, 1992). The emotional trauma of childhood sexual abuse is compounded by the fact that the perpetrator of the violence is usually a close, male family member. In most cases, sexual abuse occurs in a family atmosphere of silence, secrecy, protection of the perpetrator and disbelief or blaming of the child victim.

The link between child sexual abuse and risk for HIV infection has been proposed by several authors (Caseese, 1993; Paone, 1993; Rosenfeld, 1993; Zierler, 1991), and recent research strongly confirms that association. Large, prospective, multisite studies of cohorts of women with and at high behavioral risk for HIV have uncovered striking data by conducting structured interviews with participants. Of 771 women enrolled in HIV Epidemiology Research Study (HERS) sites in Baltimore, Detroit, and the Bronx, 43% had been sexually abused as children and 45% had been sexually abused as adults (Vlahov, 1996). In this cohort, 28.3% of the women reported having witnessed a murder.

In the Women's Interagency HIV Study (WIHS), data from 1560 women enrolled in New York City, Chicago, Washington, DC, and Los Angeles revealed that 40% reported a history of childhood sexual abuse (Cook, 1997) For these women, a history of sexual abuse, physical abuse or domestic abuse was highly correlated with engaging in risk behavior for HIV. In particular, childhood sexual abuse was significantly associated with: use of IV drugs; exchange of sex for drugs, money or shelter; higher number of sexual partners; and having had a sexual relationship with a person at high risk for HIV. Additionally, childhood sexual abuse was significantly related to adult domestic violence as well as adult sexual abuse.

HIV and Increased Domestic Violence

A review of the first 138 deaths at Chicago's Cook County Hospital program for HIV-positive women and children provided further evidence of the extent to which HIV and violence are interrelated. The review discovered that only 80% of the deaths were due to AIDS. Substance abuse, cardiac disease and other chronic illnesses accounted for most of the remaining 20%. Significantly, 3% of the deaths in this group were due to domestic homicide (Cohen, 1996). Childhood sexual abuse may be emerging as a primary risk factor for HIV infection, but violence is a major risk factor for mortality in HIV-positive women.

For HIV-positive women, there is increased risk of domestic violence related to HIV status. The decision to test for HIV, disclosure of HIV status to family and partner, partner notification and mandatory newborn HIV screening (as in New York State) are all situations that may increase the risk for violence. There is evidence that women have been beaten, abandoned, shot, and even murdered by domestic partners after revealing their HIV-positive status (North, 1993; Lester, 1995). It has been shown that when physical abuse has occurred in the past, it is even more likely to occur during a pregnancy (Amaro, 1990). Thus, HIV testing during pregnancy, and newborn screening for HIV may set women up for further violence.

Abuse Survivors and Their Care Providers

Childhood sexual abuse may also set the stage for unsatisfactory relationships with health care providers. In general, clinicians fail to screen for a history of childhood sexual abuse or current risk for domestic abuse. Symptoms of domestic abuse may be easily misread. Often an abused woman will miss appointments and be considered noncompliant. Or she may report injuries, falls, forgetfulness and clumsiness. Women who have histories of childhood sexual abuse often have numerous physical complaints, including: digestive upsets, headaches, joint and muscle pains and chest pains (AMA, 1992). When clinicians are unable to find underlying medical causes for these symptoms, they become frustrated and often label the patient a "malingerer."

Sexual trauma can also result in post-traumatic stress syndrome with symptoms such as anxiety, phobias, hypervigilence and isolation. Common coping behaviors in sexual abuse survivors are denial, dissociation and repetition compulsion (Caseese, 1993). Denial and repetition compulsion (repeating behaviors that lead to trauma) are major mechanisms operating when engaging in risk behaviors, or staying in an abusive situation. Dissociation (pushing painful experiences and emotions out of conscious recognition) often occurs when survivors are asked about the trauma. They may respond blankly or without any emotional affect. Care providers often interpret dissociative reactions as the patient being "not too bright," "spaced out" or "on drugs."

The available data on the incidence of sexual trauma and domestic abuse in the U.S. is staggering. It is estimated that more than 30% of all females and nearly 15% of all males in the U.S. have been victims of childhood sexual abuse. Seventy-five percent of sex workers (female and male) have experienced sexual abuse. One in four women have been raped, and one in five women have experienced domestic abuse. During pregnancy, it is estimated that one in six women is sexually or physically assaulted by her partner.

Investigation and data regarding the prevalence, consequences and relationship to risk for HIV of the sexual abuse of boys are nearly absent in the literature. There are currently no clinical recommendations regarding incorporating what is known about childhood sexual trauma into HIV prevention efforts or into principles for forming therapeutic alliances with HIV-positive clients who are trauma survivors.

In most cases in which a history of trauma is uncovered, the individual should be referred to a competent therapist, with the message that recovery, healing and relief of symptoms is possible. A woman who is currently in an abusive situation needs a counselor who is trained in crisis intervention and domestic abuse. In addition, the following guidelines may be useful in approaching and working with individuals with a history of sexual or other trauma (adapted from Denenberg, 1993):

References

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Childhood Sexual Abuse and Its Effects On Childbirth

by Regine Spindler

http://www.gentlebirth.org/archives/abusepaper.html

INTRODUCTION

At the dawn of a new millennium, many caregivers are asking themselves and the healthcare system, why a high technological environment, surrounding such a natural event like childbirth, is not preventing a rising rate of cesarean sections, contrary to certain other European countries such as Holland, where homebirths are the rule and where the rate of cesarean sections is one of the lowest in the world. However, a certain number of medical interventions in childbirth are due to anatomical abnormalities or emergencies .

The caregiver should be aware that these abnormalities are rare. But this is not the topic of this study , and I will concentrate on childhood sexual abuse, which can be the cause of labor dystocia and its symptoms, such as failure to progress (FTP). I will also focus on the consequences of childhood sexual abuse on pregnancy, and on the relation with the caregiver.

In this paper, I used testimonies of sexual abuse survivors obtained on a support group maintained on Internet and researches having being completed already on the subject.

I will first try to define sexual abuse, its components, its background, and the signs and symptoms that a caregiver should recognize.

I will then proceed in quoting several excerpts of the testimonies I have obtained and will analyse their content to outline what happens to those survivors during pregnancy and childbirth.

In the next section, I will describe some symptoms which should help the caregiver in forecasting what could be expected from a survivor, and will suggest approaches to facilitate the relation between the caregiver and the survivor during pregnancy and childbirth, as well as describing other proposals of prevention and healing .

Even though this paper is primarily designated to be read by Gyn Doctors, Midwives, Doulas, and Childbirth Educators of my area (Catkill NY), I hope that facilities such as the family planning, rape crisis centers etc., will understand the necessity of reading this study, in order to start detecting the problem even before the onset of pregnancy, if possible, and start the healing process way before the survivor comes to the healthcare provider for the birth.

WHAT IS SEXUAL ABUSE?

Definition: In the USA, childhood sexual abuse is defined as having any kind of imposed sexual activity under the age of 18 years old. It is usually performed on a child, male or female, by an older person, male or female, having some power or authority on the child. It can happen in any family, regardless of its social-economical background. A member of the family or a neighbor can perform the abuse. It can be a rape, caresses, exhibitionism, sex talk etc. (Simkin, 1994).

Several researches show that 1 woman in 3 is a survivor of childhood sexual abuse, but it is very difficult to make a correct estimate, due to the fact that many women suffer from amnesia until they are much older, or they feel too traumatized to admit what happened. (Holtz, 1994).

Signs and symptoms: Some survivors can demonstrate behavioral symptoms such as: poor grooming, addictions of any kind, eating disorders, teen pregnancies, (Holtz, 1994; Frye, 1998) Psychosomatic symptoms such as pelvic pains, headaches, G I track disturbances are common. Women can experience over exaggerated gag reflexes, neck pains and endless nausea. Survivors who have not recovered any memory from the past abuse, usually experience at least some of these symptoms.

SEXUAL ABUSE AND CHILDBIRTH

Analysis of testimonies

One of the very first thing that I could gather after reading those "confessions", was a general fear of losing control, expressed by all these women during their pregnancy and childbirth. It is not surprising, during an or several continuous episodes of abuse, the individual have no control whatsoever on what is happening to them, many of them being sometimes under physical threats such as weapons.

"The labor was progressing so fast that I felt out of control and scared, and my baby hurt a lot.... My body began pushing. The pain became so intense that I found myself retreating out of my body.... My mind was full of images of the rape I endured when I was 2 years old, when my mother's older relative tore me open from the top of my clitoris down to my urethra." (Rose, 1992)

"I hated pushing and that was a big let down, since I had hoped that it would be easier than the dilating stage. I have a hard time coping with anything that my body does that I cannot control, like pushing out a baby, vomiting, menstruating etc." (E-mail).

"The less I am `messed up with' during childbirth, the better I do. Any time the control is taken out of my hands and put in to the hand of a medical professional, it brings back the terror and the powerlessness of the abuse all over again." (E-mail)

On the other hand, some women let others take control over them: "I managed to enter in an emotionally abusive relationship with doctor who attended the birth. I found that one physician who did home births, and went with him regardless of the fact he made me feel 3 inches tall every time I saw him." (E mail)

They also feel that there is no place safe, so they slip away somewhere else. "In fact, I felt as if I were viewing the whole scene from outside my body, up near the ceiling and to my left, about 10 feet away from where I lay. (Rose, 1992). "But when the contractions came I lost it and just pushed and screamed that it hurt, I cried for my mommy.... I just went someplace else, someplace safe in my mind. I know it sound strange but I just could not handle it, and I was so tired of being touched. " (E mail).

Being touched or examined by the caregiver can trigger traumatic flashbacks and therefore putting an obstacle in a healthy relationship between the mother and caregiver. "And I had talked about not even getting checked during labor before." (E-mail). "Hospitals only mean pain, humiliation, and illness to me." (E-mail). "If I could not endure this vaginal exam on my first prenatal visit, how was I ever going to birth a baby? But I did not trust my body, would not, could not let myself push without her permission {the Midwife}" (E-mail).

Not feeling safe, mistrusting oneself and the caregiver seem to be a constant element, and is demonstrated by refusing exams and especially vaginal exams. Dissociation and flashbacks are also very frequent and play a determinant influence not only in the relation with the caregiver but during the labor itself.

Understanding and recognizing the symptoms

Pregnant women do often reenact unconsciously the abuse or the rape during prenatal exams and birth. They feel, as seen in the precedent section, totally under the control (imaginary or not) of the caregiver and can react to careless interviews, or exams, during their pregnancy and birth. Triggered memories can surge in forms of flashbacks, difficult to handle during labor (Kitzinger, 1992). Women need to feel safe and not disturbed for a good and efficient labor. Mammals are always looking for a retired and dark place in order to give birth. If they feel threatened the survival reflex predominates, and labor stops or is slowed down due to the influx of catecholamines insuring the fight or flight response (Odent, 1999). This is also true for women and this is one of the reasons, in my opinion, why so many survivors experience labor dysfunction, especially in first stage (Tallman & Herring, 1998).

List of symptoms (Simkin in Frye, 1998)

The author advises to avoid generalizations and being conscious of the fact that not every woman displaying several of those symptoms may have been abused.

WHAT CAN THE CAREGIVER DO?

Labor dysfunction will most frequently occur during the first stage, whether the abuse episode has been shared or not with the caregiver (Tallman & Hering, 1998), and is due to unconscious maneuvers from the woman in childbirth, who cannot control the pain anymore, as well as feelings of fear and the stress triggered by the fight for survival.

Establishing a basic bond between the caregiver and the patient during early pregnancy

Since one of the symptoms described previously is a basic mistrust in caregivers, it becomes obvious that step #1 is establishing a minimum level of trust with the client. It will enable the caregiver to recognize further down the road, possible problems and establish tentative of solutions. It is however challenging since symptoms of abuse may not be obvious at first sight.

Anne Frye suggests that disclosure of abuse is possible if the client is aware and remembers the episode(s). Questions such as: "Did you experience sexual abuse in your life", is a direct and healthy way to start the issue. Some women will be comfortable enough to admit it if this is the case. However, some others do not because they cannot admit it due to feelings of guilt even if they remember, and some do not remember the events at all.

This is where the caregiver skills are challenged not only to recognize symptoms, but also to establish a relation where the client will feel safe. It is important to recognize them early in pregnancy, in order to allow sufficient time for the caregiver to assess data and organize a plan of care according to the highest possibilities of the client. (Fusco, 1998)

The room environment where both parties meet is essential : decoration, furniture, examination tables, clothes worn by the care giver etc...Permission should be asked before entering the client's personal and intimate space and explanations should be given during pelvic exams, along with a constant preoccupation of letting the client know that it could be stopped at any time and resumed when the client feels safe enough (Holtz, 1994).

This is also the time where one will recognize non-verbal clues, such as rigidity of the body, grimacing or inappropriate behavior such as laughing or withdrawal.

Flashbacks can be experienced during exams and interviews and it is important to validate them whether the patient is verbalizing them or not (Frye, 1998).

Jennifer Burian (1995), labor nurse advises:

  1. "Consider what your response would be if a woman disclosed a history of sexual abuse to you.

  2. Provide an emotionally and physically safe environment for survivors.

  3. Establish an atmosphere of openness and unhurried listening.

  4. Be aware of your language. False intimacy in a soothing voice may trigger memories of perpetrator's demeanor during the original abuse.

  5. Be aware of the discomfort of body exposure

  6. Remember that a vaginal exam can feel like a repeat of the abuse. Let the woman choose the timing and talk through it, stopping if she appears at all physically and emotionally unable to continue.

  7. Assure her that she is safe, and affirm her strength through labor and birth.

  8. Above all honor the emotions that she is feeling."

During labor

It is crucially important that during the first stage of labor, continuity should be given to what may have been started during pregnancy, by the caregiver, the childbirth educator, and the doula. Ideally, the three parties should have remained in constant communication and interaction during the client pregnancy. Survivors in childbirth do need a maximum of compassion and understanding in order to allow themselves to express what they would feel during this time. The doula is essential to bring the extra support and care that will make the difference in the labor. She can advocate, interpret, and be the interface between the laboring woman and the nurses if they are not aware of the situation. We know that most of the caregivers do not stay during the whole duration of labor, which can be sometimes very long. The doula will be soothing, reinsuring, listening to the survivor as much as needed.

It is essential to remember that past the first stage, and when women get into transition, flash backs or dissociation are frequent, women may slip somewhere else refuse to push or dilate. They may even go back to an early stage of dilatation. The doula and the caregiver will have to continue to reinsure and keep eyes contact with the survivor to get the maximum of her strength and energy (Courtois & Courtois Riley, 1992). Its is also the moment to validate her feelings and emotions as well as her possible physical manifestations, screaming, closing her legs, refusing to be touched, etc. (Simkin, 1992).

Post Partum

Even though all of the above may have been provided, several problems may arise after the birth of the baby. Depression, difficulty in bonding with baby, problems in breastfeeding such as milk retention or repulsion to have the baby suck at the breast (Grant, 1992).

Seeking a solution

I borrowed the title of this section from an article from Nora Tallman and Cammie Hering, a midwife and a counselor, in which they explain that even after having done everything described above, they were still noting that survivors were having more medical interventions during childbirth than the regular patient. They concluded that it was already too late for the survivor at childbirth and that despite of all the measures they had taken, survivors were still experimenting labor dysfunction as early as the first stage, mostly FTP (failure to progress).

They are suggesting setting up a special prenatal preparation, with a support group: "We designed a prenatal support group to help SOCAs (survivor of child abuse) heal their wounded sense of self. Its purpose is to develop psychological and emotional tolls for coping with the challenges of pregnancy, labor, and parenting. Although we do discuss past traumas, the group is primarily focused on the practical aspects of their upcoming birth experience and the challenges of parenting. Topics include dissociation and flashbacks, dealing with pain and fear, control, communication, and relationship issues. By limiting the group to SOCAs, a midwife and a counselor, participants feel safe to discuss painful subjects and to experience both giving and receiving support with others who have experienced similar traumas. Above all, we hope these women experience their empowerment and self-respect."

Sheila Kitzinger (Midwife archives, 1990) encourages the educators counselors midwives to create a birth crisis network where women as women, "could support each other, question obstetrics policies and practices, and get involved in the politics of birth."

Jan Stanton, director of Heart to Heart, headquartered in Chicago, is especially concerned with the rate of teen moms having been raped prior to their pregnancy and the average age of their first sexual abuse (9.7 – 12 years old), and the fact that 50% of these abuses were committed by family members. She also states that violence and weapons were involved in 75% of these cases.

She believes in teen parental education prevention in the form of workshops, such as knowing how to protect themselves and their children from sexual abuse, with an extensive support and information from community network (Sue LaLeike, midwife archives).

CONCLUSION AND DISCUSSION

Why concluding on such a note, after describing extensively what could have been done between the survivor and the caregiver? Many researches have been done already, and many things have been tried, therefore there must be something good in them, despite statistics showing bigger figures in labor dysfunction .

So should we solely turn and focus on prevention and forget the role of the caregiver in the story? It seems obvious, that as presented earlier in a previous section, prevention plus an extremely tight connection between all the parties involved, seems crucial in order to offer the survivor, the highest chances for empowerment, healing, and feelings of success and self realization during their birth, post-partum period, and parenting

I would like to mention that this paper will be offered to the Family Planning, the Reach Center, Columbia Memorial Hospital (Hudson NY), Domestic Violence Program, as well as to the local Midwives Gyn Doctors, in Columbia and Greene County NY and to any childbirth educator and doula interested in it.

Finally, I would like to address my very warm thanks to the survivors who were willing to share with me their stories, through the internet support group, and to Marsha Fusco who, very trustfully, offered her own paper on the subject.

REFERENCES

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Childhood Abuse & Household Dysfunction Associated With Higher Risk Of Unintended First Pregnancy

By Patricia M. Dietz, DrPH

The Journal of the American Medical Association (JAMA) - October 19, 1999

Patricia M. Dietz, DrPH, from the Centers for Disease Control & Prevention in Atlanta, Ga, & colleagues analyzed the results from surveys of adult women to assess whether unintended pregnancies are associated with exposure during childhood to psychological abuse, physical abuse, sexual abuse or household dysfunction. To determine exposure to household dysfunction, the participants were questioned about physical abuse of the mother by her partner, substance abuse by a household member & mental illness of a household member. The researchers found that 45.4% of 1193 women surveyed reported that their first pregnancy was unintended & 65.8% of the women reported exposure to at least 2 types of abuse or household dysfunction. Psychological & physical abuse were the most common types of childhood abuse reported by the respondents.

After adjusting for marital status & age at the time of first pregnancy, the researchers found the following associations between unintended pregnancies & different types of abuse:

The authors also found that women who reported experiencing 4 or more types of abuse during their childhood were 1.5 times more likely to have an unintended first pregnancy than women who did not report experiencing abuse during childhood & that 1 in 5 unintended first pregnancies was associated with reported exposure to childhood abuse.

The authors believe additional research is needed to determine the cause of the association between childhood abuse & unintended pregnancy. The authors write: "Abuse or household dysfunction may influence a woman's feelings of control or power in sexual relationships & may lead to difficulty in negotiating contraceptive use with a partner."

The study reports the results of a survey of adult women enrolled in the Kaiser Permanente Medical Care Program who had received a standardized medical examination between August & November 1995 or January & March 1996. The questionnaire included questions about childhood psychological abuse, childhood physical abuse, childhood sexual abuse & childhood exposure to household dysfunction. Childhood was defined as the first 18 years of life.

The women included in the study were 20- to 50-year-olds who had had their first pregnancy at or after the age of 20 years old; most were white (61.0%), had some college education or had graduated from college (80.6%) & were married at the time of their first pregnancy (72.8%).

Citing other studies, the authors write: In 1994, 49% of US pregnancies were unintended (ie, unwanted or occurring before the woman had intended to become pregnant). Approximately half of all unintended pregnancies result in abortion & those that result in live births are associated with more maternal complications & poorer infant outcomes than intended pregnancies. Several studies have identified exposure to sexual or physical abuse during childhood as a risk factor for teenage pregnancies, most of which are unintended. Adolescents who have been sexually abused are more likely to have a greater number of sexual partners & not to use contraception, behaviors that increase their risk of unintended pregnancy.

"The pathways though which childhood abuse & household dysfunction affect sexual behavior in adulthood are complex & not fully understood," according to the authors. "Nonetheless, our findings suggest that medical providers need to be aware that a history of abuse or household dysfunction is common among adult women & may be affecting their patients' ability or motivation to prevent an unintended first pregnancy."

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Childhood Sexual Abuse and the Potential Impact on Maternity

By Andrya Prescott, Independent Midwife

MIDWIFERY MATTERS, Issue No.92, Spring 2002 - Association of Radical Midwives

At the ARM meeting in Chichester I offered to run a workshop on how sexual abuse in childhood can impact on the experience of becoming a mother. I wanted to provide an insight into why acknowledging childhood sexual abuse is important to midwifery. I focused on ways of broaching the subject with women and offering empathetic and appropriate care. I believe that it is important that midwives should be able to identify good attitudes and behaviours in themselves as well as recognising where there is need for improvement.

Ideally midwives should be able to find ways of bringing the issue into the open, allowing women to discuss their experience if they choose. Midwives can thus empower women and minimise the potentially negative impact of previous abuse on childbearing and parenting. Definitions of abuse can range from, "any unwanted touching" (Finney, 1992) to considering the experience itself and not by physical acts alone (Bass and Davies 1988). Often the literature distinguishes between a victim - a person who is still in abusive relationship, and a survivor - a person who has physically survived and is no longer in the relationship.

I would like to add that some people find that they are not ready to be called a survivor even though they are out of the original abusive relationship. Classification belongs to the woman! Child abuse is divided into many different boxes - ritualistic, emotional, physical, sexual and so on, but women may not feel they fit into any category.

Different effects are experienced by different women, some may find it very emotionally traumatic, some may be in denial, where one woman tells everyone and anyone who will listen, another will cope by not talking about it. There are no hard and fast rules, many extremes are prevalent, exceptionally loud women or exceptionally meek, quiet women may be survivors. Women can be at radically different stages of the healing process if indeed they have found that pathway at all. Why ask?

Why should we ask women if they have experienced abuse? The fact that anything between one in ten and four in ten women have been abused is compelling enough for me. Parratt (1994) found that 65-70% of women who had been abused were "permanently damaged". All midwives will encounter abused women. By asking we can affirm that it is not OK to have been abused, the pain and anguish often caused by abuse is then validated. In the early days of awareness of abuse, people need to hear over and over again from many sources that abuse is not something they deserved or asked for. It is the manipulation by adults who were responsible for their actions. Not asking reinforces society´s attitude that abuse is not to be discussed and is not or should not be of any consequence. If an affirmative answer is given then the midwife can offer appropriate help or referral.

Even when women do not talk about abuse, or where they may not be aware of it, it is not uncommon for women to have memories triggered by the changes that occur to their body, certainly as they start to consider the birth or even during the birth itself. If they have been asked about abuse in some way then they have the opportunity to talk at any time. It implies a supportive and safe atmosphere.

Midwives should be aware that the pregnancy itself may be as a result of the abuse, in which case the woman may need support from the social services and, if she is young, then the help of the child protection service as well as emotional and psychological support from appropriate people.

I have listed some of the issues that arise during pregnancy and into motherhood and it is self-evident that we should ask in a sensitive and caring way. Not asking does not mean the issue will not arise.

Factors to consider:

Control Control is essential. Abused women have learnt that losing control is dangerous physically and emotionally and they may structure their life to feel strong. Such a woman may be unable to risk anything that compromises her perception of control; she may need help to find a chink in her defences and take down the wall, must be sure of yourself and what you can offer, honesty is essential.

A woman's perception of control is often maintained by extremes – aggression – submission – ritual – living in state of crisis.

Confidentiality. If a woman discloses a history of abuse, document it only with her consent.

Midwifery care. The woman's body has been violated once already; she may experience midwifery care as further violation. Ask for consent for your actions! Remember your language, words like "relax" and "sweetie" may have been used before in very different circumstances.

Body image Body memories can emerge as a woman's body changes in pregnancy. Moreover, as the pregnancy becomes visible, taboos on body boundaries are lifted. The woman's belly appears to become part of the public arena.

Screening and blood tests Many women who have been abused have an overwhelming terror of needles. They need to know how appropriate blood screening is for them and must be able to make a truly informed choice. The midwife must be very sensitive in the way she takes any blood.

Routine examination is routine only to maternity professionals! Palpation, especially of baby's head, may be extremely uncomfortable. The need for extreme sensitivity in speculum examination or vaginal examination goes without saying.

Flashbacks Vivid memories of abuse may be triggered by any aspect of treatment. An abused woman may experience an extremely vivid memory of something that has happened to her in the past, or she may panic while being totally unaware that her present experience mirrors the past in some way. Help her to feel safe – she may not know what happened. Flashbacks can be triggered by touch, language, and the position of woman or caregiver. Her reaction may be to go rigid, to tell you, or her breathing or facial expression may change, she may show signs of absolute panic. She may speak to someone who isn't physically in the room with you or may appear suddenly terrified.

You may be able to help her by asking, "Can you tell me what was going through your mind during the last contraction?" You could also try asking her to reframe the current experience, differentiating it from her previous experience; if she says felt sharp like a knife, suggest smooth like a spoon.

Dissociation Many survivors cope with the after effects of abuse by `dissociation', a way of distancing themselves from their body and or mind, a numbness. A midwife may be impressed with how a woman is coping with the pain, by not feeling anything, but the woman may need to be helped back into the present. The midwife can use clear verbal directions to achieve this, asking the woman to focus herself into the room, to focus on the birth here and now. It may help to get her up and moving, reassuring her that this is safe environment, helping her to trust her body.

Physical sensations During the birth other specific factors come into play. The pelvic area being stretched can simulate feelings of abuse – the midwife should help her to empower and reclaim her body. Talk her through the pain speak of the stretching as a 'coming out' not a 'going in'.

Procedures Monitors and straps and VEs may be reminders of past abuse. Informed choice and honest discussion must play a large part in considering how appropriate each procedure is for an individual woman.

Positions Lying on a bed really may not be OK for a woman who was abused every night when she tried to go to sleep!

Slow progress It is often the unconscious mind that stalls labour. Fear of becoming a mother releases adrenalin thereby stopping progress. The midwife should work towards creating a feeling of safety using the power of imagery and visualisation and by her actions. Laughter is a great help in dissipating fear if you can find some humour.

Hands off the perineum Practise helping women to birth their babies by themselves with no meddling. Consider the impact of an episiotomy, tearing and suturing. A woman may have scarring from the abuse so antenatal advice about caring for the skin using Vitamin E oil and or perineal massage might be appropriate.

Lithotomy Does any woman like this position? If it becomes a necessity then try to work out what she needs to stay in control and in the present – if that is what she needs!

A general anaesthetic may provoke fear that a woman is totally out of control; other women may need a general anaesthetic in order to cope.

Elective caesarean There is no guaranteed safe path to travel through childbirth. It takes a lot of courage to face natural childbirth in our society, particularly for abused women, but the rewards are great. For some women, however, an elective caesarean is the only means of retaining control over the birthing process.

Postnatal care In the postnatal period many issues surrounding parenthood may arise. Constructive help from specialist groups could be appropriate to the needs of a woman who has been abused.

Overprotecting or underprotecting her children may be an issue that develops long after the midwife has discharged her.

Breastfeeding carries much emotional baggage for many women in our society which overemphasises the sexual appeal of the breasts at the expense of their physiological function. Midwives must be sensitive and aware that although, physically, a woman is likely to be able to breastfeed, emotionally it may not benefit her or her baby. The laudable desire to achieve 100% breastfeeding rates must not blind us to any emotional contra-indications. While I would be the first to advocate supporting all women as positively as possible about the benefits of breastfeeding, physically and emotionally this aspect must be considered.

Fear of their child being abused and the fear of abusing their own child is commonly something women will have come up for them. It would be sensible to encourage women to seek support if they feel that they may lose control and endanger their baby. Women can also be encouraged to develop openess with their children as they grow so the children will feel able to talk about anything uncomfortable happening to them.

Signs of abuse Many articles about childhood sexual abuse contain lists of characteristics and ways of spotting women who have experienced abuse. These can be very useful if used appropriately. However, they should not be taken as positively indicative of past abuse. You may recognise some of these signs in yourself while knowing that they are not the result of trauma in your childhood! Use the list to aid your intuition.

Helping women who may have been abused

Language. Think about the language you use: spoken, body and especially written. Are you using shallow phrases? Are you showing her the respect she deserves? When discussing procedures available to her be aware of her response to different words – 'relax' is a favourite for causing tension before an internal examination!

Reclaiming one's body. Encouraging perineal massage can help a woman to reclaim that part of herself as well as all the physical benefits.

Informed consent. We should be asking all women for informed consent and we should respect their decisions. When a woman consents to any intervention it may be helpful to explain what you are doing as you do it. Ask what she is comfortable with.

Education. An abused woman may welcome information on what behaviour most people would consider normal and what behaviour is not generally acceptable within a relationship.

Listening and focusing. Some women will present you with an impossibly long list of problems and concerns; encourage them to take control and select the most important things to deal with.

Flashbacks. When a woman is experiencing a flashback – remind her that this is a memory not the abuse. Stay close to her, don't let her go away without support.

Reassurance. Reinforce the fact that the woman is not to blame, it is not her fault; incest is not an act of love, it is never OK. Physical arousal during abuse does not constitute consent, it is merely a reflex bodily response to stimulation and does not imply emotional acceptance of the abuse. Children need love and affection not abuse and sex. Emphasise the fact that she is allowed to say no if she needs to - it is her body.

Avoid internal examinations. Minimise or avoid internal examinations altogether – use other ways to assess progress, for example watch out for the red line, use your excellent observational skills.

Minimising harm. If a VE is necessary, consider asking the woman to take up a position which she finds less threatening and is likely to trigger fewer memories.

Informed choice.

Epidural anaesthesia may make women feel invaded or it may remove them from pain.

Breastfeeding support should be hands off.

Avoid further abuse. Don't do anything you would find personally abusive.

Disclosure. Consider what your response would be if a woman disclosed abuse to you?

Provide a safe environment.

Listen to women in an unhurried environment.

Assure a woman that she is safe and affirm her strength.

Honour the emotion women are feeling.

Get some support for yourself. Ask your Supervisor or an ARM member.

Refer on. If you feel unable to help her directly then find an appropriate midwife, recommend counselling, homeopathy or therapy.

Provide a resource list of helpful books and organisations.

Conclusion

We are not always going to know which women have been abused. So how do we care for them? Why do we treat women who have been abused especially differently from women who have not? Don't all women deserve to be treated and cared for with respect, kindness, and tolerance? Don't all women need to be well informed and have autonomy and control of their bodies and babies? We do not always get the feedback; however, when you have helped to break the cycle of abuse for a woman, you may well have planted the seed for her to start her recovery and gain control over her body and life. Don't underestimate yourself or your actions. Next time you go to do something as a part of your routine consider how relevant it is and of what benefit it will be for the woman you are with.

REFERENCES AND FURTHER READING

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Dear Abby

Pregnant 14-year-old covering for teacher at school

Universal Press Syndicate - Dec. 17, 2003, 5:17PM

http://www.chron.com/cs/CDA/ssistory.mpl/features/2303396

DEAR Abby: I am 14 and pregnant. My baby's father is a 35-year-old teacher at my school. He doesn't know I'm pregnant, and I'm afraid if I tell him, he'll be mad.

My parents know I'm pregnant, and they are devastated. But they do not know who the father is.

I am having trouble sleeping, and I'm sick most mornings. What should I do? Please help.

-- Pregnant in Milwaukee

Dear Pregnant: You MUST tell your parents who the father is. You need their emotional support, and I'm sure you'll receive it once they understand what has happened. You should not have to tell this teacher about your pregnancy alone. Your parents, the principal and the local police should do it with you. If he does get mad, it should be at himself for betraying his trusted role as an educator and committing statutory rape. Please do not be afraid to speak up, and don't blame yourself. What your teacher did is criminal.

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Genital Anatomy in Pregnant Adolescents: "Normal" Does Not Mean "Nothing Happened"

Kellogg ND, Menard SW, Santos A.

Pediatrics 2004 Jan; 113(1):E67-E69.

Many clinicians expect that a history of penile-vaginal penetration will be associated with examination findings of penetrating trauma. A retrospective case review of 36 pregnant adolescent girls who presented for sexual abuse evaluations was performed to determine the presence or absence of genital findings that indicate penetrating trauma. Historical information and photograph

documentation were reviewed. Only 2 of the 36 subjects had definitive findings of penetration. This study may be helpful in assisting clinicians and juries to understand that vaginal penetration generally does not result in observable evidence of healed injury to perihymenal tissues.

Departments of Pediatrics. Family Nursing Care, University of Texas Health Science Center, San Antonio, Texas. Alamo Children's Advocacy Center, San Antonio, Texas.

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Link between rape and pregnancy

BBC - June 20, 2001

http://news.bbc.co.uk/1/hi/health/1398894.stm

It may be that ovulating women attract unwelcome attention

Scientists have made a disturbing finding about rape which they believe may explain why the crime has been so common throughout history.

They have found that a single act of rape may be more than twice as likely to make a woman pregnant than a single act of consensual sex.

This suggests, they say, that in a strictly biological sense, rape is a successful way for a man to spread his genes.

In our experience rape is used in domestic violence to exert power and control, and not necessarily to spread one's genes

But such a theory fails to take account of either the emotional trauma that rape causes, or the fact that for rape to be a successful evolutionary strategy the benefits of the crime have to outweigh the potential costs for the rapist if he is caught.

Psychologists have also warned that it may be misinterpreted by those seeking to justify the unjustifiable.

Violence study

New Scientist magazine reports that researchers Jon and Tiffany Gottschall, from St Lawrence University in Canton, New York, looked at data from a major study of violence against women.

They found that, of 405 women who had been raped between the ages of 12 and 45, some 6.4% became pregnant.

When women who had been using some form of contraception were removed from the calculation, the figure jumped to nearly 8%.

They compared this finding with a separate study which found the proportion of women in a similar age group who got pregnant from a one-night stand or other one-off act of consensual sex was just 3.1% despite the fact the women were not taking precautions.

The Gottschalls believe one possible explanation is that women feel more attractive and sexy when ovulating and unconsciously give off signals that rapists might pick up.

Another possible explanation is that rapists target attractive and healthy-looking women.

Difficult conclusions

Rape is complex behaviour which is often associated with power, control and sadism

Ged Bailes, head of forensic clinical psychology at the Norvic Clinic in Norwich, told BBC News Online, it was very difficult to draw any firm conclusions from a one-off study.

He said: "Rape is complex behaviour which is often associated with power, control and sadism.

"How do things like that fit into an evolutionary theory? And if this was the case why would some rapists want to kill their victim?

"We have to be very careful about making inferences of this type because there is a danger that they will reinforce some people's views about the myths surrounding rape."

Myra Johnson, communications manager for the Women's Aid Federation, a charity which helps women who have been the victims of domestic violence, warned against drawing the wrong conclusions from the report.

She said it was vital that any notion of a possible evolutionary basis for rape should not detract from the personal responsibility that a rapist had for the devastating impact of his actions.

She also told BBC News Online: "In our experience rape is used in domestic violence to exert power and control, and not necessarily to spread one's genes."

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Most Teens First Had Sex at Home

By LAURA MECKLER

The Associated Press - September 26, 2002

WASHINGTON (AP) - Parents wondering if their teenagers are having sex might look upstairs or down the hall. New research finds most sexually active teens first had sex in their parents' homes, typically late at night.

The findings, being released Thursday, should dispel myths that teens are most often having sex after school, when parents are still at work, researchers said. The message for parents, experts say, is nothing new: Be aware of what your kids are up to.

``Kids no longer need to drive to lookout point to have sex,'' said Sarah Brown, director of the National Campaign to Prevent Teen Pregnancy. ``The data suggest the adults may be in the house.''

By the time students are in the ninth grade, 34 percent have had sexual intercourse. That rises to 60 percent by 12th grade.

The report, by researchers at Child Trends, is based on a national teen survey that has been tracking about 8,000 teens since 1997. The ages of the teens ranged from 12-16 when the survey began, and researchers have interviewed the same group every year since then. This report looks specifically at the 664 teens who reported having sex for the first time between 1999 and 2000.

Of those surveyed in 2000, 56 percent said they first had sex at their family's home or at the home of their partner's family.

Another 12 percent had their first sex at a friend's house; 9 percent at a teen's own home; 4 percent in a truck or car; 3 percent at a park or other outdoor place and 3 percent at a hotel or motel. Ten percent said someplace else.

The findings reinforce earlier research that parents can have a significant impact on their children's decisions about sex, Brown said.

``This notion that it's impossible to supervise kids is ludicrous if a lot of them are having sex in the rec room,'' she said.

Earlier this month, researchers reported that teen girls who are close to their moms are more likely to stay virgins. That report, by researchers at the University of Minnesota, also found that half of mothers of sexually active teens didn't realize their children were having sex. Further, while the vast majority of mothers strongly disapprove of their teenager's having sex, large numbers of teens don't realize how their moms feel.

``Parents need to know where their children are and what they're doing,'' Brown said. ``This is not a new idea.''

As for timing, Thursday's report found 42 percent of teens said their first sexual encounter was at night, between 10 p.m. and 7 a.m. Another 28 percent said it was in the evening, between 6-10 p.m.

Just 15 percent said it was in the late afternoon, between 3-6 p.m.

That cuts against the conventional wisdom among parents and policy makers alike that teens are more ``at risk'' of sex after school, said Jennifer Manlove, a researcher at Child Trends.

Research has shown that teens are more likely to commit crime during the after-school hours, Brown said. But people have wrongly assumed that the same goes for sex, she said.

The National Longitudinal Survey of Youth did not look at whether teens were having sex on weeknights or weekends. And it did not ask if parents were home at the time. Although the survey has been interviewing teens since 1997, this was the first year the questions about where and when teens first had sex were asked.

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What Do These Women Have in Common?

Murder and Pregnancy

By April Greer. Evelyn Hernandez. Carol Stuart. Laci Peterson.

http://incestabuse.about.com/cs/domesticabuse/a/pregnantmurder_p.htm

What do all of these women have in common?

They were all pregnant when they were murdered.

A 2001 study by the Journal of the American Medical Association showed that homicide was the most common cause of death among pregnant women in Maryland. This study is easily extrapolated to the rest of the United States, and this number is probably higher in reality because only 17 states and New York City list on death certificates whether or not a woman was pregnant at the time of death. This study was undertaken to categorize the major health risks associated with pregnancy. The results were a surprise to researchers.

But not to women's advocates.

And who are these killers? Foreign terrorists? Domestic terrorists? Mad slashers from teenage horror movies? A stranger hiding in the bushes?

No.

The killers are most often fathers of the child; the boyfriend or husband of the victim; the guy next door. Women's advocates know that the main reason men abuse women is control. And in pregnancy, many men feel that they have totally lost control over the body of their wives or girlfriends and lost control over the course of their own lives. Sadly, in many of these cases the families of the murdered women didn't even know there was a problem in the marriage, because of the shame that abused women feel. Domestic abuse remains a big secret because of this shame, and all too often situations escalate until murder occurs.

Most women stay with their batterers because they hope things will improve. Unfortunately, the situation almost always gets worse. The violence becomes more frequent, and the level of force increases over time. The only way to break the cycle of violence is to get away.

In Why Do Women Return? I highlighted the obstacles that battered women face when they try to escape before they are killed. In this article, I'll give you ideas on how to overcome those obstacles.

The majority of reasons that battered women return to their batteres are due to basic economic necessities:

Until society helps meet these needs, battered women will find it very difficult to escape their abusers.

If you need to escape an abusive situation, your best resource is your local Women's Shelter. That name and phone number will be listed in the front of your local phone book, or you can find it at the link just mentioned. You can also call Information or the police to find a shelter or crisis center in your area.

Each state has different resources and different laws, so talking to an expert at the shelter or crisis center is the best way to find help available in your area. These resources are there to help you, so don't hesitate to ask for help.

Ask if there are women's shelters in your area, or if transitional housing is available. Even if you don't intend to leave when you talk to these experts, just learn about the help available to you and come up with a plan for the future.

Ask the advocates about the shelters. Are they nearby? Are they full? If you have a teenage son, are there provisions to help him too? Talk over the details of your situation and explore your options. If your medical insurance is in your batterer's name, what are the alternatives in your state? Are there educational grants for battered women? What about internship or jobs programs? Are there government child care centers or job training programs?

Murder and Pregnancy

If the shelters are full or there aren't any available, think about alternatives. You will need a safe place to stay so you can get back on your feet. The length of stay will depend on your emotional and financial needs. If your parents or a sibling would welcome you into their home, in many ways that is better than a shelter. You will be back among people who love you; you will be back in a ready-made support system. But remember that you will probably still need the services of the crisis center for support groups, help with court systems and restraining orders, and other forms of emotional and physical healing.

Often, the batterer has worked very hard to isolate his victim. He has insulted her friends, driven off her family, and made life unpleasant for anyone who can give her support. If you are in that type of situation, don't despair. It may feel like you have no friends, but that is not the case. The friends and family members he has driven off still love you. Even if you defended him or told them to mind their own business, they know this situation is his fault. They still think about you. They wish there was something they could do. If you called them, they would be relieved and delighted to help you. It's difficult to reach out for help. The shame you may feel can be overwhelming. But your friends and family would much rather have you safe and alive.

It's very difficult to leave an abuser. But there are people and organizations out there that can help you. Start with a phone call to a hotline. Talk about your options. Your call can be totally anonymous. Learn about the powerful friends you have in law enforcement, the courts, the medical system. Like any tool, you have to know what the system can do for you. Discuss your situation with an expert at a crisis center. They will be happy to work with you to develop a safety plan.

And if you are a friend or family member of a woman whose husband has tried to isolate her, take the first step yourself and call her. Ask if she is safe. Remind her that you care about her and only want the best for her. This simple action may save a life.

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Politics Of Rape And Contraception

CBS Evening News - LOS ANGELES, June 9, 2005

http://www.cbsnews.com/stories/2005/06/09/eveningnews/main700791.shtml

Lori Robinson is a survivor.

"When I got to my front doorstep I saw the barrel of a gun pointing at my head," she says. "I was rushed up to my apartment, blindfolded and gagged with duct-tape and tied down on my bed, and I was raped by two strangers."

She feared disease, emotional collapse but not pregnancy, because the hospital in Washington D.C. offered her emergency contraception.

Being told about the emergency contraception, she says, "in that time of total devastation, it was a relief."

But, as CBS News Correspondent Bill Whitaker reports, it wasn't a right, because these days emergency contraception is embroiled in the bitter politics of abortion.

Now, there's some confusion over just what emergency contraception is. It is not RU-486 - the pill which can cause an abortion early in a pregnancy. Emergency contraception is also known as the morning-after pill. Taken soon after a rape, it can actually prevent a pregnancy.

In Colorado, a measure that would have required hospitals to offer emergency contraception to rape victims was vetoed by the governor.

He was strongly supported by the Catholic Church, which calls it tantamount to abortion.

"If ovulation has occurred, there's a potential for new life in that woman, so then the church's responsibility is to protect both the woman and the new baby," says Alia Keys, coordinator of the Office of Marriage and Family for the Archdiocese of Denver.

The federal government is siding squarely with religious conservatives. Dr. Michael Weaver helped draft national guidelines for rape victims, which strongly recommended offering the morning-after pill.

But when the Justice Department released the final version, all mention of emergency contraception had been removed.

"If indeed this prevents an unwanted pregnancy then that subsequently prevents abortions down the line," says Weaver of St. Luke's Hospital in Kansas City.

Some 25,000 women become pregnant from rape each year. To this rape survivor, there is no debate.

"How dare someone tell me what's best," says Robinson.

But for many hospitals and physicians it's a moral issue.

"I think that it's not their decision to make," says Robinson.

Right now, that depends where a rape occurs.

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Sexual Trajectories of Abused and Neglected Youths

Brown J, Cohen P, Chen H, Smailes E, Johnson JG.

J Dev Behav Pediatr 2004 Apr; 25(2):77-82.

ABSTRACT.: The study objective was to examine whether childhood abuse or neglect is associated with the age of onset of puberty and sexual and romantic behavior. A cohort of children (the Children in the Community study) was randomly selected and studied prospectively from childhood to adulthood. A sample of 816 youths were interviewed in their homes at a mean age of 14, 16, and 22 years in 1983, from 1985 to 1986, and from 1991 to 1994. The outcome measures included age of menarche, signs of male puberty, first being in love, dating, sexual intercourse, and pregnancy reported by youths. Child abuse and neglect were measured by official records and youth reports. A history of two or more incidents of sexual abuse was significantly associated with early puberty and early pregnancy after gender, class, race, paternal absence, and mother's age at the birth of the study child were controlled statistically. Public education regarding risk for premature sexual behavior among youths who have experienced sexual abuse is warranted. Efforts to prevent teenage pregnancy should include monitoring and educating sexually abused children as they enter puberty.

From: Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York; Columbia University School of Medicine, New York State Psychiatric Institute, New York.

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Sexual Trauma and Pregnancy: A Conceptual Framework

Carie S. Rodgers, Ph.D.; Ariel J. Lang, Ph.D.; Elizabeth W. Twamley, Ph.D.; Murray B. Stein, M.D.

J Womens Health 12(10):961-970, 2003.

http://www.medscape.com/viewarticle/466545?mpid=24920

Abstract and Introduction

Abstract

In this paper, we propose that a history of sexual traumatization is associated with pregnancy complications and poor pregnancy-related outcomes. We further hypothesize that this relationship is mediated by the sequelae of trauma (psychopathology, health problems, and increased negative health behaviors). We review the literature linking sexual trauma with psychopathology, health, and health behavior and then outline the impact of these variables on pregnancy. Based on this review, we draw conclusions about the potential impact of sexual trauma on pregnancy outcomes. We suggest future directions for this area of research and discuss the clinical implications of this association, including the development of prenatal intervention and prevention programs.Introduction

Although estimates of sexual trauma vary considerably, epidemiological evidence suggests that it is a major societal problem. Lifetime estimates in women range from 7% to 17% for sexual assault, 3%-15% for rape,[1] and as high as 30%-50% for sexual harassment.[2] A history of sexual trauma (including sexual molestation, sexual assault or rape in either childhood or adulthood, and sexual harassment) is associated with (1) increased rates of psychopathology, (2) more frequent health problems, and (3) negative health behavior (i.e., behavior with a known negative impact on health outcomes).

Given the high prevalence of sexual trauma, it is likely that a substantial proportion of pregnant women have been victims of sexual trauma at some point in their lives. Further, sexual traumatization is associated with a number of behaviors that are known to negatively affect maternal health and the health of the fetus. In spite of this, very little research has examined the impact of psychiatric and physical health consequences of sexual trauma on pregnancy. Therefore, it is important to examine the nature of the relationship between exposure to sexual trauma and pregnancy outcomes. Our primary purpose in this paper is to generate hypotheses about the association between maternal history of sexual trauma and pregnancy outcome.

We first present literature linking sexual trauma to psychopathology, health problems, and negative health behaviors. It is our intent to provide an overview of these topics and present a few specific examples of the literature on these topics. We chose to include only quantitative studies in this paper, and studies that employed case studies or very few participants were excluded. Most of the studies cited were published after 1995, and all were indexed either in PsycInfo or MEDLINE databases. Many authors have examined these issues more completely than we do here, and the reader is referred to comprehensive reviews of these topics where appropriate.

Next, we outline the impact of psychopathology, health problems, and negative health behaviors on pregnancy and thereby hypothesize about the associations of maternal sexual trauma experience with pregnancy outcomes. We present a conceptual framework relating sexual trauma and pregnancy outcome mediated by increased psychopathology, poor health behaviors, and health problems. Finally, we discuss the implications of the proposed framework for prenatal care and pregnancy outcomes.

Sexual Trauma and Psychopathology

Female sexual trauma survivors are at high risk for multiple psychological problems. Many thorough review papers have been published in the last decade examining both the short-term and long-term psychiatric sequelae of sexual trauma.[3-5] It is our intent to highlight some of the more prevalent disorders that follow sexual trauma.

Posttraumatic stress disorder (PTSD) frequently is associated with exposure to sexual trauma. Norris[6] found that sexual assault was associated with a higher rate of current PTSD than other types of criminal victimization, natural or man-made disasters, or accidents. In our own work using a self-report measure of PTSD-related symptoms, we found that 47% of female military veterans with adult sexual assault or rape histories scored in the range associated with diagnosable PTSD, compared with 16% of the women without such a history.[7] In a nationally representative sample of the United States, Molnar et al.[8] reported that women who reported childhood sexual abuse were eight times more likely to be diagnosed with PTSD than women with no history of childhood sexual abuse. Not only are PTSD symptoms distressing and impairing, but also they increase the risk of additional psychopathology.[9-12]

Other anxiety symptoms appear to be prevalent in sexually traumatized women as well.[13,14] Falsetti and Resnick[11] found that 69% of participants seeking treatment for sexual trauma-related symptoms reported having panic attacks. Interestingly, Leskin and Sheikh[15] found higher rates of both adult and childhood sexual assault in a community sample of panic disorder patients without comorbid PTSD than in a community sample of PTSD patients. Stein et al.[16] compared a clinical sample of women with anxiety disorders (panic disorder, social phobia, and obsessive-compulsive disorder) with an age-matched and gender-matched community sample and found that women with anxiety disorders were significantly more likely to report childhood sexual abuse histories. Similarly, patients seeking psychiatric care who meet criteria for multiple anxiety disorders have increased rates of childhood abuse over patients with only one anxiety disorder.[17]

Depression frequently occurs soon after exposure to a traumatic event and is often present for months after the event.[18] Hankin et al.[19] found that outpatient female military veterans who reported being sexually assaulted as adults were three times more likely to screen positive for depression than were those who did not report such a history. Similarly, in a nationally representative sample of the United States, Molnar et al.[8] found that women who reported childhood sexual abuse but reported no other lifetime traumas were 3.8 times more likely to meet criteria for a major depressive disorder (MDD). Sexual abuse during childhood has been linked to chronic or recurrent episodes of major depression in both community and clinical samples,[20, 21] and suicide attempts in depressed adults.[22] In a systematic review of the literature on childhood sexual abuse and adult depression, Weiss et al.[23] found that women who were sexually abused in childhood were more likely to develop depression in adulthood. This pattern was consistent across studies and appears to be stronger for women than for men.

Sexual trauma also appears to be associated with personality disorder and dissociative symptoms. In studies of inpatients, Zanarini et al.[24] found sexual trauma to be a risk factor for dissociation. In addition, women with a diagnosis of borderline personality disorder were more likely to have experienced rape in adulthood than were axis II controls.[25] Yen et al.[26] examined the prevalence rates of sexual trauma in a community sample of participants diagnosed with personality disorders or MDD. They report a stronger correlation between the diagnosis of borderline personality disorder and physically forced/unwanted sexual contact, rape, and witnessing sexual abuse in either childhood or adulthood than in participants with other disorders.

Although research investigating sexual trauma and psychopathology consistently points to a relationship between these variables, many of the studies in this area are limited by confounders that are difficult to control for outside of randomized experimental designs. Most of this literature relies on retrospective self-report rather than more objective measures of both trauma and psychopathology (i.e., police reports, diagnoses based on structured clinical interviews), leaving unexamined the possibility of either overreporting or underreporting of variables. In addition, variables such as socioeconomic status, race, and other forms of trauma are difficult to control for but likely overlap significantly with sexual trauma.

Two recent studies have addressed some of these confounding variables in the relationship between childhood sexual abuse and psychopathology by examining samples of twins. Dinwiddie et al.[14] and Kendler et al.[27] examined the prevalence of psychiatric disorders among community samples of twins who were discordant for childhood sexual abuse, thus controlling for possible confound such as family environment or genetic vulnerability. Kendler et al.[27] found that women with childhood sexual abuse are at greater risk for developing psychopathology later in life and that this pattern was stable in comparing an exposed twin in a twin pair discordant for childhood sexual abuse with a nonexposed sibling. Similarly, Dinwiddie et al.[14] found nonsignificant trends for increased rates of psychopathology in abused twins when compared with nonabused co-twins.

Sexual Trauma and Health

Sexual trauma can have a direct impact on a woman's health. During a traumatic event, a woman may be injured or exposed to a sexually transmitted disease (STD). Both childhood sexual abuse and forced rape have been associated with reported STD-related symptoms and diagnosis as well as more episodes of different STDs.[28-30] Sexual trauma may also indirectly increase the likelihood of injury. For example, past work has shown that a sexual trauma history is associated with injury as a result of involvement in abusive relationships. In one study, college students who had been raped were more likely to have been in a physical fight with a boyfriend or spouse than women who had not been raped.[31] Cohen et al.[32] found that childhood sexual abuse was strongly associated with later domestic violence. When compared with women who have not been sexually abused, women with a history of sexual abuse report that their intimate relationships involve more incidents of severe forms of violence, such as hitting, kicking, and beating.[33] This increased severity of intimate partner abuse has the potential to lead to more serious injury (during pregnancy and at other times).

In community samples as well as samples of medical patients, female victims of rape or sexual assault in adulthood perceive their physical health as poorer and report more somatic symptoms and pain than do nontraumatized women.[34-36] In addition, women who report histories of either adult or childhood sexual assault/molestation or rape report higher rates of chronic illnesses, most commonly gastrointestinal and gynecological, but also including respiratory disorders (e.g., asthma, emphysema, and bronchitis), peptic ulcer disease, heart problems, hypertension, arthritis, and diabetes.[34,36-38] Gynecological complaints associated with sexual trauma include dysmenorrhea, excessive menstrual bleeding, sexual dysfunction,[39] abnormal Pap smears, pain in the lower abdomen other than during menstruation,[7] burning sensation in sexual organs, and pain during intercourse.[37] Golding et al.[40] interviewed women seeking treatment for severe premenstrual syndrome (PMS) and found that at least one attempted or completed sexual abuse event was reported by 95% of the sample and that 81% of these women reported being raped.

Given their higher rates of reported symptoms and illness, it is not surprising that traumatized women show higher rates of physical disability[37] and increased use of medical facilities.[41,42] Although the reasons for the association between sexual trauma and health problems are not well understood, differences in current symptomatology do not appear to be attributable to higher rates of past illness or family history of illness among traumatized women.[34]

Sexual Trauma and Negative Health Behaviors

There is growing evidence that female victims of sexual assault engage in more negative health behaviors than women without sexual trauma histories. One such type of behavior is substance use. Several studies have shown that traumatized women are more likely to smoke, begin smoking earlier, and smoke more heavily than nontraumatized women.[7,31,35,43,44] Increased risk of alcohol use disorders among traumatized women also has been demonstrated.[10,45] Traumatized women have been shown to drink more heavily than women without a trauma history,[31,35] are more likely to screen positive on an alcohol abuse/dependence measure,[7] more frequently engage in risky behaviors in conjunction with drinking, such as driving,[31] and report feeling the need to decrease alcohol use.[43] Traumatization also has been associated with problematic illicit drug use.[43] These studies included clinical as well as community samples and included women with histories of sexual assault and rape during childhood or adulthood or both.

Another negative health behavior that has been associated with trauma is failure to maintain heal