ABSTRACT
OBJECTIVE To explore the effects of childhood sexual abuse (CSA) on women’s breastfeeding and infant feeding decisions and experiences.
DESIGN Qualitative, participatory study using semistructured in-depth interviews.
SETTING Tamara’s House, a healing centre for women who were sexually abused in childhood, located in Saskatoon, Sask.
PARTICIPANTS Six mothers who were sexually abused in childhood.
METHODS In-depth interviews were conducted and transcribed verbatim. Thematic analysis was iterative and participatory. The emerging themes that resulted from initial analysis by the researchers were presented at a meeting held jointly with academics, survivors, and professionals in the field to achieve consensus. Throughout the process, findings were considered in relation to related literature on breasts, breastfeeding, and CSA.
MAIN FINDINGS History of CSA complicated the women’s infant feeding decisions and experiences. For 2 women, birthing and breastfeeding facilitated healing from the effects of the abuse. Shame, touch, breasts, dissociation, medical care, and healing emerged as analytic themes.
CONCLUSION A history of CSA can affect a woman’s experience of breastfeeding, including acting as a trigger for remembering or reexperiencing the abuse. Women who were sexually abused as children need to experience a sense of safety, acceptance, sensitivity, and understanding. Physicians need to be aware of the effects of CSA on infant feeding and women’s health, and might need to be trained in a sensitive-practice approach to working with patients who were sexually abused as children.
While comparable and reliable estimates of the true incidence of child abuse and maltreatment in Canada are difficult to determine,1 it is believed that the incidence of sexual abuse of girls is high, ranging from 1 in 3 to 1 in 5 girls having been sexually abused in childhood.2–4
The health of women who experienced childhood sexual abuse (CSA) is compromised.2,5–11 There is an association between CSA and various medical conditions, such as chronic pelvic pain, gastrointestinal disorders, irritable bowel syndrome, and recurrent headaches.8,11–18 Women who were sexually abused as children have more family physician visits, hospitalizations, and surgeries,3 and often experience shame, fear, guilt, isolation, flashbacks, dissociation, suicidal thoughts, addictions, eating disorders, powerlessness, hypervigilance to danger, and erosion of trust.10,19–21
Health care visits can trigger painful memories of childhood abuse,22,23 and many women who experienced CSA avoid seeing doctors because they experience health care visits as intrusive, violating, and uncomfortable, and because they have difficulty trusting health care providers.24 Kendall-Tackett20,21,25 and Klingelhafer26 have identified potential issues that highlight the need to consider breastfeeding in relation to the experiences of women who were sexually abused as children. The purpose of this study was to explore the effects of CSA on women’s breastfeeding and infant feeding decisions and experiences.
METHODS
This qualitative, participatory study used in-depth interviews to explore the infant feeding experiences and decisions of 6 mothers who had been sexually abused as children. The study was approved through the participating agency’s Board of Directors Research Ethics Review Committee.
Recruitment
Research participants were recruited through Tamara’s House, a healing centre for women who were sexually abused in childhood. Tamara’s House is located in Saskatoon, Sask. An invitation to participate in the research project was extended to the staff and volunteers of the agency. One research participant volunteered in another province, and the same interview protocol was followed as at the Saskatoon site. The research assistant who did the interviews had no position or authority within the agency. Informed consent was obtained, and all identifying information was eliminated from the transcripts to help ensure confidentiality. No information that could identify research participants was made available to agency personnel. Research participants were required to have professional support available to them in order to be included in the study.
Data collection
Research participants participated in 2 semistructured, audiotaped interviews; each interview lasted 1.5 to 2 hours. Research assistants transcribed the interviews.
Data analysis
Themes were determined and documented as they emerged in the transcripts and were summarized once saturation was reached. A meeting was held jointly with researchers, academics, survivors, and professionals in the field to present preliminary findings and to ensure robustness of the themes. The findings were reviewed throughout the process in light of the literature, to check for inconsistencies and to further ensure accuracy of findings. Through this process, consensus on the themes was achieved.
FINDINGS
Each of the women interviewed believed before delivery that breastfeeding was the best choice for her baby’s health and development and wanted to breastfeed, and all the research participants had problems breastfeeding. Two of the women believed that despite the difficulties they experienced, they had successful breastfeeding experiences. The themes that emerged were shame, touch, breasts, dissociation, medical care, and healing.
Shame
Each woman gave examples of how she felt ashamed of her body and how this sense of shame affected her comfort with breastfeeding. One woman, who had dreamed of breastfeeding, said, “It always amazed me as to how beautiful of an experience [breastfeeding] could be, and yet for me it was such a trauma. I was so ashamed of my body.” Her sense of shame over her body interfered with her ability to breastfeed, which then affected her self-esteem; in her words, “Here I am, a failure again.”
When the women discussed the experience of shame, they also referred to touch. Some of the women experienced a combination of shame about their bodies, embarrassment about their bodies being seen publicly, and discomfort with touching their breasts, all complicated by the shame of not being able to provide milk for their babies. When talking about her discomfort and sense of shame over her body, one woman stated simply that “that was the end of my experience with breastfeeding.”
Touch
There were 3 kinds of touch that were difficult for the women in this study: self-touch, infant touch, and medical touch. Regarding touching their own bodies, the women were uncomfortable—“because of the negative body image I was never comfortable with touching my body at different places”—making it difficult to be comfortable with the logistics of breastfeeding. In terms of infant touch, one woman, who was only able with great difficulty to breastfeed for the first 6 weeks of her son’s life, explained that “at 6 weeks he went on the bottle … and it was a loss for me. I was touched-out, and I’d had all the physical contact that I could possibly take in those 6 weeks.”
Having her body touched in the medical setting, where touch is inherently a part of the daily routine, posed difficulties for each of the research participants. For some the birthing experience was linked to the breastfeeding experience, particularly concerning touch. If the women were touched without warning or invitation during the birthing or the breastfeeding process, they experienced the touch as a violation, particularly if the body part that was touched was part of the abuse experience.
With my first pregnancy I didn’t know that was going to happen. I didn’t know all of these hands would be down there while I was delivering—in the vaginal area. Because that’s how I was molested when I was 5. So I was very traumatized thinking about the delivery. Not about the pain, but about the other person touching.
Some of the experiences of medical touch were experienced as abuse. One woman described having her nipple touched when she was not prepared as “invasive, to say the least.” Another research participant explained: “I didn’t expect some of the intrusive touching in the hospital. That was really traumatizing for me, just the treatment in the hospital. The nudity, all that kind of stuff. I hadn’t anticipated that.” This woman explained that if she had been mentally prepared for what she was likely to experience, it might not have been as traumatizing for her.
Breasts
The experience of breastfeeding was connected with the relationships women had with their breasts. Breasts were seen as the cause of abuse by some of the research participants.
If I hadn’t had large breasts, then none of this [sexual abuse] would have happened. That’s what I thought. If I hadn’t developed so young, if I hadn’t started menstruating, if I wasn’t already a woman, none of this would have happened.
Another woman explained, “Breasts were not a good experience. My father has always made fun of women’s breasts.” She carried the effect of the years of comments on her breasts with her into her experience of breastfeeding. The women made statements about their breasts being “an inconvenience. I sweat under them. If they were gone, I wouldn’t miss them.”
Not all of the women had negative experiences with breasts and the breastfeeding experience. One woman experienced her body in a new way:
My body changed; and you know they say women with little breasts get huge? Well they did! I had enough milk to feed the whole hospital, they said. And it was just hilarious! And everything was so new, and it was, but in a wondrous way, not in a rejection way, like I have always rejected my body. But in a wondrous way! You know how it’s almost like seeing things for the first time? It was so strange.
This woman experienced a shift in the way she viewed her breasts, from inviting unwelcome attention from men to being a healthy part of her body that could feed an entire hospital.
Dissociation
Dissociation is one way that children cope with sexual abuse. Some of the women in this research project discussed the effects dissociation had on their breastfeeding experience.
I think a part of my experience was that I didn’t really have a body. I was a head with legs. Or with feet. I was just kind of a walking turtle … I ignored everything in between .… I remember the breastfeeding. I remember the frustration. But I can’t say I remember any feeling from it—physical sensation. I didn’t register any body sensation anyway. I was just—the breasts were functional for that time.
This woman managed to breastfeed only because she was able to dissociate, but she paid the price of dissociating by not feeling anything physically or emotionally. She observed other women experiencing joy while breastfeeding, but she did not experience any emotion; she became clinically depressed and stopped breastfeeding.
Medical care
The experiences the women had with medical professionals varied. One woman said of her experience, “There was no nurturing or bedside manner for a new mom. There was no one that would sit with me and spend the time. It’s like they take for granted that you know all this.” She was unable to breastfeed any of her 3 children.
Another woman explained, “I got such bad mastitis, they recommended that I just stop. Unfortunately I took their advice.” She wished she had received support for dealing with the mastitis. A third woman got help from the La Leche League, a breastfeeding support group, for the difficulty she was having breastfeeding; she believed that because of this support she was able to continue breastfeeding, and her positive breastfeeding experience facilitated an overall experience of healing from the effects of the sexual abuse.
Childhood sexual abuse is an abuse of a position of trust and responsibility over a child, and as a result, for someone who was sexually abused in childhood to challenge someone they see as an authority, such as a doctor, can be very difficult.
I wasn’t in a space where I could have [expressed disagreement] to a physician. Because of course they knew more than me. They knew it! It was an authority, a power over things; I couldn’t have done that then.
As it was for other research participants, to simply question—never mind confront—her doctor, an authority figure, was unthinkable for this woman. Another woman echoed this:
If the physician isn’t helpful, then you’re screwed. I had no support from my physician. And very little in the hospital. I had no idea what I was doing, and that actually really made me quite angry. Because the assumption was that the bottle was the best thing for him, and it isn’t!
One research participant explained that women who have experienced CSA have learned not to trust their own instincts:
[T]hey won’t be able to question the medical professionals who are giving them conflicting or inaccurate advice. They won’t be able to just go with whatever their natural instinct is with regard to caring [for] and feeding the baby and part of that [is] in the labour and delivery.
One of the research participants suggested having information available in the doctor’s office. “When I was young and poor, the doctor’s office is where I saw a lot of information and was able to read the helpful information.” The doctor’s office was the one place where she was able to get information on breastfeeding when she needed it.
Research participants wished that their doctors knew to ask about a possible history of sexual abuse, and to respond sensitively to women who were sexually abused:
When health care people consider a history of violence in a person’s life, then they have to consider that the mind is going to have an effect on the body. And when they treat somebody, or they consult with somebody, they have to get that history and know it, and be sensitive.
Healing
Two women believed that their birthing and breastfeeding experiences made it possible for them to heal more substantially from the effects of CSA: “This is what my body was designed for! That’s what those parts were for.” Even though the women continued to experience memories and flashbacks of the sexual abuse, they experienced the process of birthing and nourishing their children as transformative, and their lives have been profoundly affected as a result.
DISCUSSION
As described by Kendall-Tackett and Klingelhafer, we found that the infant feeding decisions made by the women in this study were affected by their history of CSA. The findings of this research develop the analysis further by considering, and providing examples of, how the sexual abuse affected the women’s bodies, their capacity to challenge authority, and their ability to trust their instincts. The women experienced a sense of shame in a way that affected their comfort with and ability to breastfeed. The sexual abuse affected the way the women reacted to touch, including touching their own bodies to breastfeed and having their bodies touched by the infants, by the doctors, and by other medical staff.
The experience of breastfeeding and the infant feeding decisions the women made were in part connected to the relationship women had with their breasts, a relationship that was affected by the abuse. Two of the women also experienced dissociation that negatively affected breastfeeding success.
A doctor is someone who is seen by these women as an authority, and is someone who can influence a woman who was sexually abused in childhood. Because of the position of authority inherent in the physician role, there is a responsibility for the physician to respond sensitively to the needs of the patient, who is in a position of vulnerability. Women who have been sexually abused as children need to experience a sense of safety, acceptance, sensitivity, and understanding.3,22
Two of the research participants experienced profound healing from the effects of CSA through breastfeeding. Sensitivity from health professionals could facilitate a successful breastfeeding experience for other women who experienced CSA. This sensitivity can be achieved by following the guidelines recommended in the research on sensitive practice.3,10,23–25,27,28
The women who participated in this research project believed that education about and awareness of CSA for health professionals was important. They wanted doctors to understand that any female patient might have been sexually abused in childhood, and that sensitivity on the part of the physician could affect the patient’s health.
Limitations
A limitation to this study is that all of the research participants were associated with a healing centre for women who were sexually abused in childhood, and therefore had an understanding of the effects of CSA. Conclusions might be limited to the context of the research participants. Additionally, the level of training in sensitive practice on the part of the women’s respective physicians was not determined and might have affected the women’s experiences. Future research should include the infant feeding experiences of a more diverse group of women who experienced CSA, and should investigate the effects of sensitive-practice training for physicians on the birthing and infant feeding experiences of women who were sexually abused.
Conclusion
The breastfeeding experience can be a time of enhanced vulnerability and possible retraumatization for women who were sexually abused in childhood. While birthing and breastfeeding can be a time of increased physical and emotional vulnerability for women, who are dependent on medical caregivers for their well-being, it could also be a time of profound healing. Whether the experience is traumatizing or healing might well depend on the skills and sensitivity of the health professionals providing care.
Acknowledgments
This research was completed in partnership with the National Network on Environments and Women’s Health, which is financed through a contribution agreement with the Bureau of Women’s Health and Gender Analysis of Health Canada. Tamara’s House Services for Sexual Abuse Survivors Inc provided the release to write this article. We especially thank the women who participated in this study.
Notes
EDITOR’S KEY POINTS
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Women who were sexually abused as children have more family physician visits, hospitalizations, and surgeries, and often experience shame, fear, guilt, isolation, flashbacks, dissociation, suicidal thoughts, addictions, eating disorders, powerlessness, hypervigilance to danger, and erosion of trust.
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This study explores the effects of childhood sexual abuse on women’s breastfeeding and infant feeding decisions and experiences.
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While the birthing and breastfeeding experience can be a time of increased physical and emotional vulnerability for women, who are dependent on medical caregivers for their well-being, it might also be a time of profound healing.
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Doctors are seen by these women as authorities, and they can influence women who were sexually abused in childhood. Physicians have a responsibility to respond sensitively to the needs of such patients, who are in a position of vulnerability.
POINTS DE REPÈRE DU RÉDACTEUR
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Les femmes victimes de sévices sexuels dans l’enfance ont plus de visites chez des médecins de famille, d’hospitalisations et de chirurgies, éprouvent souvent des sentiments de honte, de peur, de culpabilité, de solitude et d’impuissance, et présentent des épisodes de reviviscence, de dissociation, d’idéation suicidaire, de toxicomanie, de troubles du comportement alimentaire, d’hypervigilance et de perte de confiance.
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Cette étude voulait vérifier les effets des sévices sexuels subis dans l’enfance sur l’allaitement maternel, la décision d’allaiter et l’expérience qu’ont ces femmes de l’allaitement.
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Même si la période de l’accouchement et de l’allaitement peut occasionner une augmentation de l’activité physique et de la vulnérabilité émotionnelle chez ces femmes, puisque leur bien-être dépend alors du personnel soignant, cela pourrait aussi être une période de profonde guérison.
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Pour ces patientes, le médecin fait autorité et il peut les influencer. Il a donc l’obligation de répondre avec sensibilité aux besoins de ces patientes particulièrement vulnérables.
Footnotes
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This article has been peer reviewed.
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Cet article a fait l’objet d’une révision par des pairs.
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Contributors
Dr Van Esterik and Dr Wood conceived and designed the study and contributed to data analysis and manuscript preparation. Dr Van Esterik supervised the development of the bibliographies and examined the literature on breasts, breastfeeding, and child sexual abuse, and Dr Wood supervised the recruitment, interviews, and transcriptions.
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Competing interests
None declared
- Copyright© the College of Family Physicians of Canada
