Breastfeeding
and the Sexual Abuse Survivor
Kathleen
Kendall-Tackett, PhD
from Breastfeeding
Abstracts, May 1998, Volume 17, Number 4, pp. 27-28.
One out of
five American women has been sexually abused as a child.l-2
Past sexual abuse can affect many aspects of a woman's current level
of functioning, including breastfeeding and parenting.3
Only one recent study has specifically considered breastfeeding among
sexual abuse survivors.4 The authors found
a higher intention to breastfeed among survivors than their non-abused
counterparts.
Even with
the dearth of directly relevant studies, there is a large body of research
on the long-term effects of sexual abuse. This literature can be helpful
in identifying some of the issues and concerns that adult survivors
face.
Long-term
effects of sexual abuse can be divided into seven domains of functioning.3,
5-6 Thus there is a range of possible symptoms that may
affect breastfeeding to varying degrees. Sexual abuse survivors may
experience any of these symptoms, or none at all.
Post-Traumatic
Stress Disorder (PTSD).
Mothers may experience sudden and intrusive flashbacks, hypervigilance,
and sleep disturbances. While most do not meet full diagnostic criteria
of PTSD, 50% of adult survivors have PTSD symptoms.3,7
Mothers may experience flashbacks of their abuse either during labor
and delivery or when they bring their babies to breast. Triggers for
these flashbacks may include squirting milk or skin-to-skin contact.
Other women may not experience flashbacks but may experience a vague
discomfort whenever they breastfeed.7
Cognitive
Distortions.
Mothers may overestimate danger to themselves or
their babies, and perceive themselves as weak or helpless. These perceptions
can lead to a state of "learned helplessness" that can influence
their emotional state and their ability to seek assistance when necessary.3, 5
When they encounter breastfeeding difficulties, they may assume that
there is nothing they can do that will help.
Emotional
Distress.
Emotional distress includes some of the most common
sequelae of sexual abuse: depression, anxiety, panic disorders, and
anger. Depression is an especially common symptom; adult survivors
have a four-times greater lifetime risk of depression than do their
non-abused counterparts.3, 7 This is a concern
because postpartum can be a time when many women are vulnerable to
depression. Mood disorders can have a negative effect on how mothers
interact with their babies.
Impaired
Sense of Self.
Mothers may manifest an impaired sense of self
by having difficulty separating their emotional states from the reactions
of others. They may have difficulties in self-protection, leading
to an increased risk of re-victimization.3
More typically, they may not be able to mobilize necessary social
support from among their network of friends and family at a time when
they really need it.7
Avoidance.
Some of the most serious long-term effects of sexual abuse fall into
the category of avoidance. Mothers may experience dissociation, which
includes alterations in body perception, emotional numbing, amnesia
for painful memories, and multiple personality disorder. Other types
of avoidant behavior are substance abuse, suicidal ideation and attempts,
and "tension-reducing activities" including indiscriminate
sexual behavior, bingeing and purging, and self-mutilation.
3-5
A mother may suddenly recover memories of abuse in the puerperium,
or she may have an eating disorder, or she may be a substance abuser.
All of these situations require intervention by a mental health provider.
Interpersonal
Difficulties.
Not surprisingly, adult survivors may also have
problems with interpersonal relationships. They may adopt an "avoidant"
style, characterized by low interdependency, self-disclosure, and
warmth. Or they may adopt an "intrusive" style, characterized
by extremely high needs for closeness, excessive self-disclosure,
and a demanding and controlling style. These styles can affect relationships
with friends, partners, and their children. Both styles are problematic
and generally result in loneliness.3, 6 For
the breastfeeding mother, these ineffective styles may blunt her ability
to read and respond appropriately to her baby's cues.
Physical
Health and Susceptibility to Illness.
This is the newest area
of study in sexual abuse. Findings from these studies indicate that
a relatively high percentage of sexual abuse survivors are at increased
risks for health problems,8 especially those
with a strong mind-body component such as irritable bowel syndrome
and fibromyalgia.5, 9-10 These can affect
the overall health and energy level of the mother, increasing her
vulnerability to breast infections, and compounding the stresses of
the postpartum period.
There are
some other symptoms that practitioners may encounter that should alert
them to the possibility of past sexual abuse. For example, some mothers
cannot tolerate the feel of the baby on the breast. They may indicate
that the baby is "biting," even when there is no evidence
of this. Others may make inappropriate jokes or comments about breastfeeding
and the needs of the baby (e.g., "like all men"). Still others
may appear to be ashamed of their breasts. Some of these comments may
be from nervousness or may be the result of living in a culture that
is ambivalent about breastfeeding, and have nothing to do with sexual
abuse. For others, these comments should at least raise the possibility
of sexual abuse in the mind of the practitioner.
There are
a number of positive steps that professionals can take to assist a sexual
abuse survivor with breastfeeding. It is important to keep in mind that
every mother is different. Approach each situation with an open mind.
What may be an issue or problem for one mother may not be for another.
Offer suggestions
that will make breastfeeding more comfortable. Try to find out which
situations make a mother uncomfortable. Some potential problem areas
include (but are not limited to) skin-to-skin contact, playful older
babies and nighttime breastfeeding. Help mothers work within their comfort
level, and find a solution that works for them. If a mother might be
a sexual abuse survivor, always ask permission before touching her.
This gives her the chance to control the amount of contact.
Make a referral.
If a mother mentions that she has been sexually abused, talk with her
about the importance of seeing a professional who can help (if she is
not already doing so). While breastfeeding professionals want to be
sympathetic and supportive, they must avoid becoming the main source
of emotional support for issues that are only tangentially related to
breastfeeding. For a mother experiencing serious difficulties, or difficulties
outside the realm of breastfeeding, referral is a must.
Educate care
providers about the normal course of breastfeeding, including breastfeeding
on demand, co-sleeping and late weaning. This is an area where professional
expertise in breastfeeding can make a significant difference. Many professionals
in the sexual abuse field feel that attachment-parenting practices,
such as co-sleeping and demand feeding, are a negative result of the
sexual abuse experience. Breastfeeding advocates can educate mental
health providers, either directly or via the mother, about the normality
of these practices, especially from a global perspective.11
Some survivors
cannot even consider breastfeeding, while others may find it healing.
Still others are somewhere in between. By approaching each mother with
gentleness and respect, we can help women who want to breastfeed have
a positive breastfeeding experience.
Kathleen
Kendall-Tackett is a Research Associate at the Family Research Laboratory,
University of New Hampshire in Durham, New Hampshire. She is the author
of Postpartum Depression: A Comprehensive Approach for Nurses and
is an active La Leche League Leader.
References
1. Finkelhor,
D. Current information on the scope and nature of child sexual abuse.
Future Child 4:31-53.
2. Gorey,
K. M. and D. R. Leslie. The prevalence of child sexual abuse: Integrative
review adjustment for potential response and measurement biases. Child
Abuse Neglect 1997; 21:391-98.
3. Briere,
J. N. and D. Elliot. Immediate and long-term impacts of child sexual
abuse. Future Child 4: 54-69.
4. Benedict,
M., L. Paine, and L. Paine. Long-term effects of child sexual abuse
on functioning in pregnancy and pregnancy outcome: Final report.
Washington DC: National Center on Child Abuse and Neglect, 1994.
5. Kendall-Tackett,
K. A and R. Marshall. Sexual victimization of children: Incest and
child sexual abuse. In Issues in Intimate Violence, ed. R.
K. Bergen, 47-63. Newbury Park, CA: Sage, 1998.
6. Becker-Lausen,
E. and S. Mallon-Kraft. Pandemic outcomes: The intimacy variable.
In Out of Darkness: Current Perspectives on Family Violence, ed.
G. K. Kantor and J. S. Jasinski, 49-57. Newbury Park, CA: Sage, 1997.
7. Kendall-Tackett,
K. A. Breastfeeding and the sexual abuse survivor. J Hum Lact
(in press).
8. Moeller,
T. P., G. A. Bachman, and J. R. Moeller. The combined effects of physical,
sexual, and emotional abuse during childhood: Long-term health consequences
for women. Child Abuse Neglect 1993; 17:623-40.
9. Drossman,
D., J. Leserman, G. Nachman et al. Sexual and physical abuse in women
with functional and organic gastrointestinal disorders. Ann Intern
Med 1990; 113: 828-33.
10. Boisset-Pioro,
M. H., J. M. Esdaile, M. A. Fitzcharles. Sexual and physical abuse
in women with fibromyalgia syndrome. Arth Rheum 1995; 38: 235-41.
11. Stuart-Macadam,
P and K. A. Dettwyler. Breastfeeding: Biocultural Perspectives.
New York: De Gruyter, 1995.
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