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Background: Rape is one of the most traumatizing violations a woman can be subjected to, and leads to extensive health problems, predominantly psychological ones. A large proportion of women develop a form of posttraumatic stress termed Rape Trauma Syndrome. A previous study by our research group has shown that women with a history of rape far more often had an operative delivery in their first birth and those who gave birth vaginally had second stages twice as long as women with no history of sexual assault. The aim of this study is to examine and illuminate how women previously subjected to rape experience giving birth for the first time and their advice on the kind of birth care they regard as good for women with a history of rape. Methods: A semi-structured interview with 10 women, who had been exposed to rape before their first childbirth. Data on the birth experience were analyzed by qualitative content analysis. Results: The main theme was “being back in the rape” with two categories: “reactivation of the rape during labor,” with subcategories “struggle,” “surrender,” and “escape” and “re-traumatization after birth,” with the subcategories “objectified,” “dirtied,” and “alienated body.” Conclusion: A rape trauma can be reactivated during the first childbirth regardless of mode of delivery. After birth, the women found themselves re-traumatized with the feeling of being dirtied, alienated, and reduced to just a body that another body is to come out of. Birth attendants should acknowledge that the common measures and procedures used during normal birth or cesarean section can contribute to a reactivation of the rape trauma. (BIRTH 40:3 September 2013)
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Giving Birth with Rape in One’s Past:
A Qualitative Study
Lotta Halvorsen, RN, RM, MHSc, Hilde Nerum, RN, RM, MHSc, Pa
˚l Øian, MD, PhD,
and Tore Sørlie, MD, PhD
ABSTRACT: Background: Rape is one of the most traumatizing violations a woman can be
subjected to, and leads to extensive health problems, predominantly psychological ones. A
large proportion of women develop a form of posttraumatic stress termed Rape Trauma
Syndrome. A previous study by our research group has shown that women with a history of
rape far more often had an operative delivery in their rst birth and those who gave birth
vaginally had second stages twice as long as women with no history of sexual assault. The
aim of this study is to examine and illuminate how women previously subjected to rape
experience giving birth for the rst time and their advice on the kind of birth care they
regard as good for women with a history of rape. Methods: A semi-structured interview with
10 women, who had been exposed to rape before their rst childbirth. Data on the birth
experience were analyzed by qualitative content analysis. Results: The main theme was
being back in the rapewith two categories: reactivation of the rape during labor,with
subcategories struggle,”“surrender,and escapeand re-traumatization after birth,
with the subcategories objectied,”“dirtied,and alienated body.Conclusion: A rape
trauma can be reactivated during the rst childbirth regardless of mode of delivery. After
birth, the women found themselves re-traumatized with the feeling of being dirtied, alienated,
and reduced to just a body that another body is to come out of. Birth attendants should
acknowledge that the common measures and procedures used during normal birth or
cesarean section can contribute to a reactivation of the rape trauma. (BIRTH 40:3
September 2013)
Key words: birth experiences, birth trauma, content analysis, rape, re-traumatization
Rape is one of the most traumatizing violations a
woman can be subjected to, with negative conse-
quences for her health and reproductive life (13). It is
well documented that a rape can lead to long-term reac-
tions, fear, anxiety, depression, fatigue, chronic pain,
sleep or eating disturbances, self-harm, substance
abuse, and suicidal thoughts or attempts (310). It is
the psychological injuries that dominate, and a large
proportion of women develop a form of posttraumatic
stress disorder in the aftermath, termed Rape Trauma
Syndrome, in which the rape is the stressor (11,12).
Sufferers of Rape Trauma Syndrome tend to have more
serious symptoms than individuals in which posttrau-
matic stress disorder is because of other stressors, and
the closer their assault is to the legal denition of rape
(forced, nonconsenting sexual activity) the stronger the
Lotta Halvorsen and Hilde Nerum are Doctoral students at the Uni-
versity of Tromsø, Norway, and midwives at the Department of
Obstetrics and Gynecology, University Hospital of North Norway,
Tromsø. They are equal rst authors of the following paper. Pål Øian
is a professor in the Department of Obstetrics and Gynecology, Uni-
versity Hospital of North Norway, Tromsø, and Institute of Clinical
Medicine, University of Tromsø, Norway. Tore Sørlie is a professor
in the Department of General Psychiatry, University Hospital of
North Norway, Tromsø, and Institute of Clinical Medicine, University
of Tromsø, Norway.
Address correspondence to Lotta Halvorsen, Department of Obstet-
rics and Gynecology University Hospital of North Norway, Postbox
100, Langnes, 9038 Tromsø, Norway.
Accepted July 9, 2013
©2013, Copyright the Authors
Journal compilation ©2013, Wiley Periodicals, Inc.
182 BIRTH 40:3 September 2013
symptoms of Rape Trauma Syndrome (3,13). Features
that seem more prominent in victims of rape are shame,
guilt, and suicidal ideation (2,6). The rape crisis is
assumed to strike a core in the woman that affects her
fundamental value as a woman and inuences her rela-
tionships with other people in the future (6,14).
Estimates indicate that 636 percent of all women
have been subjected to forced sexual activity or sexual
violence (1,5,79,15). Statistics from the United States
show that between 12 and 18 percent of women have
been subject to a rape in the course of their lifetimes
(9). Several studies indicate that the risk of being sub-
ject to sexual assault is highest in late adolescence
(6,15,16). In most studies of the association between
various forms of sexual assault and subsequent birth
outcomes, women with a history of sexual assault have
not been found to have higher incidence of medical
complications or operative delivery than women with-
out such histories (1719). A study carried out by our
research group has, however, shown that women who
were raped as adults were delivered by cesarean, for-
ceps, or vacuum extraction to a much greater degree,
and that those who gave birth vaginally had second
stages of labor twice as long compared with women
with no history of sexual assault (20). Studies have
shown that a large proportion of women requesting
cesarean for fear of birth have been subject to sexual
assault earlier in life, and have experienced their rst
birth as traumatic (21,22). During the many years of
our clinical practice as midwives, we have counseled
numerous women with a history of sexual assault and
rape, many of whom experienced the care they received
during labor as new assaults. The actual birth experi-
ence of women who have been subject to rape previ-
ously has been little researched or described in the
obstetric literature. The aim of this study is to examine
and illuminate the way a rst childbirth is experienced
by women previously subjected to rape, and advice on
the kind of birth care they regard as good for women
with a history of being raped.
Design and Population
To examine the womens experiences, a qualitative
semi-structured interview was used. This approach is
suitable for sensitive topics, and gives access to human
thoughts and experiences (23). The interviews were
carried out according to Kvales principles for the qual-
itative research interview (24). This process means that
the informants do not merely answer questions posed
by the researcher, but that through dialogue with the
interviewer they formulate their own experience and
perception of the world they live in. Data were ana-
lyzed qualitatively as described by Graneheim and
Lundman, a method for systematic identication of var-
iation in the text with regard to similarities and differ-
ences (25). Advice on good birth care for women with
a past history of rape is summarized and presented in a
schematic model.
The study population consists of women subjected to
rape after the legal age of consent (16 years) and
before giving birth to their rst child. The informants
were recruited from a cohort of 808 women who had
been referred for counseling for various psychosocial
problems to a mental health team at the antenatal clinic,
University Hospital of Northern Norway, in the period
from 2000 to 2007. Of the 808 women, 59 reported
having been raped as adults, whereof 50 were part of a
study showing primiparous labor outcome (21). All of
the women had been subjected to vaginal rape with
penetration. The information about the rape was regis-
tered as part of a systematic charting of their reproduc-
tive and mental health during counseling at the
antenatal clinic. The womens rape history was not
known to their caregivers during pregnancy and
remained unknown to the birth attendants during the
womensrst birth. A strategic sample was chosen
using the following criteria: the woman had to speak
Norwegian, not be pregnant, and not be suffering from
serious mental illness at the time of the interview. The
womens births represented different modes of delivery:
vaginal birth, vacuum extraction, and cesarean section.
Written requests to participate in the study were sent to
11 women, with information about the aim of the study
and what participation entailed. In the letter it was
emphasized that there would be an offer of professional
help if the interview itself caused problematic reactions.
Those who wished to participate posted their consent
directly to the researchers. No reminders were sent.
Ten women consented to participate, and these com-
prise the informants for this study. Their ages at the
time they were raped and at their rst childbirth and
the outcomes of those births are described in Table 1.
The interviews were carried out in the period 2009
to 2010 jointly by the two rst authors (LH, HN), who
both have extensive clinical experience discussing sen-
sitive themes with women. Eight of the interviews took
place in an undisturbed place at the hospital and two
took place in the homes of the informants. The inter-
views were audio recorded, and lasted on average two
hours each. An interview guide had been developed
with focus on the following themes: the rst birth
experience, interaction with birth attendants, what the
informants considered good birth care,and asking
the informants to describe their own mental and sexual
health at the time of the interview. The opening ques-
tion was Tell us about your rst childbirthin as
BIRTH 40:3 September 2013 183
much detail as you can recall.The subsequent the-
matic order was dependent on what the individual
woman brought up.
The interviewees were encouraged to tell freely about
their experiences related to the various themes. No direct
questions about the rape were included. Clarifying ques-
tions were posed as needed. Before ending, the interview
guide was checked to ensure that all of the themes had
been dealt with. After each interview, individual notes
were made that summed up the interviewersimmediate
reections on the content of the interview. The rst six
interviews were transcribed consecutively (by LH), and
the rest were transcribed by an external person without
any connection to the study. The interviews were
transcribed verbatim in dialect, as close to the oral form
as possible, with noting of laughter, crying, silence, or
other forms of nonverbal communication.
Data Analysis
Interviews consisting of 131,261 words were analyzed
by the two rst authors (LH, HN). Because this study
focuses on the rst birth experience, only those parts of
the text dealing with labor and the advice of the birth
attendants were used (98,467 words). To get a compre-
hensive picture of the experience as a whole, the inter-
views were listened to and the transcripts re-read
several times. Thereafter, the same two researchers
reected together on the main themes of the content.
The text was then divided into meaning units that were
coded, condensed, and thematized. The development of
the main theme was an ongoing process throughout the
entire analysis period. Presenting the material in a clear
way was emphasized, without changing the meaning of
the womens comments. Further analysis was discussed
by the other two coauthors (TS, PØ) to achieve a
greater common understanding of the abstracted mate-
rial in the text. The entire analysis was carried out
manually, without the use of electronic instruments of
Ethical Approval
The study was approved by the Regional Committee
for Medical and Health Professional Research Ethics
for Northern Norway (Reference 2009/1146-2).
Descriptions of the Study Population
The informants were aged 2138 years (Mean 26.2) at
the time of their rst childbirths (Table 1). Seven were
married or cohabiting with partners and three were
single. All resided in Northern Norway, and four had
Sami ethnic origin. All had completed secondary
school and four had university educations lasting more
than 4 years. Nine were in full-time employment; one
was temporarily disabled as a result of serious somatic
illness. At the time of the interview, eight had two chil-
dren, whereas two had one child each. They had been
raped when they were 1626 years old and the rst
childbirth occurred 616 years after the rape. Nine of
the women had experienced attack rapes by strangers,
two of them by multiple attackers; one woman had
been raped by her partner. In the case of four of the
women, the rape was their sexual debut. One rape had
been reported to police.
Being Back in the Rape
In the analysis, one main theme, two categories, and
six subcategories were identied. The main theme was
being back in the rape.The category reactivation of
the rape during laborhad the subcategories struggle,
surrender,and escape,whereas the category re-
traumatisation after birthhad the subcategories objec-
tied,”“dirtied,and alienated body.
Reactivation of the Rape
All of the informants described persistent strong memo-
ries of having been back in the rape during their rst
childbirth, independent of whether they gave birth
Table 1. Informantsage at time of rape, at time of rst
childbirth, type of onset of labor, and mode of birth
Age at
Age at
onset Mode of birth
1 22 38 Spontaneous Vacuum
2 18 22 Spontaneous Vacuum
3 17 29 Induced Spontaneous
4 16 26 Induced Spontaneous
5 26 29 Spontaneous Vacuum
6 16 25 Spontaneous Spontaneous
7 16 26 Induced Emergency
8 19 23 Induced Emergency
9 16 21 Spontaneous Spontaneous
10 16 23 Induced Emergency
184 BIRTH 40:3 September 2013
vaginally or by cesarean section. They described it as
switching back and forth between scary memories from
the rape and conditions during labor that reminded
them of the rape.
The informants described having carried on an intense
internal struggle during labor, in which the rapist and the
birth attendant switched roles as main actor. One of the
informants described her ght with the rapist this way:
I recall the birth as dark and ominous, a big black hole I was
afraid to fall into, because there he stood, the man who raped
me and he was grinning this awful grin. I know I fought not
to fall down the hole, because if that happened I would lose
my mind. It was vital to stay on the edge and not fall in. My
husband realized I was struggling in my own world, ghting
with someone outside the room. It cannot have been easy to
be him while I was battling another man in the midst of the
birth of our child. (3)
In the battle with the birth attendants, the women
were in conict with themselves and their own needs,
and the wards procedures and routines.
I was alone against them. All information was given with their
hands inside meI tried to tell myself Relax!Get a grip!
but it was no use. (10)
The birth attendantstouching of intimate parts of
their bodies was experienced as an invasive procedure,
and this intrusion was intensied when the attendants
without warning touched them without the women
understanding what the attendants were doing, and
why. The women tried actively to maintain control over
their bodies by protecting themselves with clothes or
bedding. They described the feeling of once more
being held captive, held forcibly in positions they
expressed strongly that they did not wish to be in. Pro-
cedures such as vaginal examinations to monitor pro-
gress in labor were tied to their experiences of the
violent vaginal penetration during the rape. The pain
experienced by the lower part of their bodies once
again became the main body part, which once again
was subject to events reminiscent of the rape.
I felt he was brutal, it was just kind of a whooshfelt he
just broke my legs apart, and right in and just go ahead and
check me. It was such a helpless situation to be lying there
in way likea bit of a violation really. Even though I tried
to tell myself, sort of sensibly that they do have to do this
and I guess they need to check that everything is OK.(4)
The alternating battle with the birth attendant and the
rapist was experienced over time as a useless one, in
which the women nally simply surrendered.
The women felt that their physical and emotional
reactions were either overlooked or overrun by the
birth attendants. Through the unintended unfortunate
interaction with the birth attendants, in which they tried
in vain to resist, the women gradually allowed them-
selves to be dominated and nally surrendered.
I did not want to be on my back with my legs up, but they
held my legs. Something happened to me around that, being
held in place. For me, it led to just giving up, they could do
whatever they wanted. It was kind ofall the way up to that
point, I was protesting. (9)
When they laid me on the operating table I felt as if I died.
My whole body disappeared. I felt nothing, I was gone, I had
no way to get away, I could not get away. (10)
When the woman gave up, the birth attendants inter-
preted the situation as an inability to give birth, and their
next move was an even more active intervention to deli-
ver her. The women perceived this interference as if they
were unable to master the task and that their bodies had
failed them. When they had surrendered, they saw no
other option than to mentally escape out of their bodies.
When they put in that vacuum cupit was the rst time I
really had thought about the rape in years. I was back in it,
being held down and not being able to move. In any case I
was completely naked. I felt a kind of shame too. Up to this
point I was kind of angry, in a way. But then it was a little
bit like when he(the rapist) it was kind of too late. Noth-
ing left to ght for. Afterwards I felt Id done such a terribly
bad job. (2)
Just lying there on your back and youre in the same position
when you again go into the same state as when you were raped,
plain and simple. Youre lying there and things happen down
there (points between her legs), the feeling of being held down.
It was really strangemy body held back and would not do it.
I wanted to give birth but my body would not do it. (1)
Both the birth and the rape were experienced by the
informants as unavoidable and uncontrollable situa-
tions. They let their captive bodies remain, and saw
themselves from outside, or from above.
I no longer knew I was giving birth. It was very unreal, but
so is a rape. I felt that in a way, I left my body, like when I
was raped. I did not know where I was, if I was above myself
looking down. But it felt very similar. (4)
I was stuck in the bed, they could do what they wanted with
me. They were saying something about them seeing that I am
in pain, but they will be quick.They pull away the duvet I
BIRTH 40:3 September 2013 185
am clinging to for dear life and they pull up my top. Lying in
bed, vulnerable, I leave the room; they can just do whatever
they have to. (10)
Looked down and saw myself from above, like a slaughtered
animal lying there that they could do whatever they wanted
to. Could not move a muscle, and real scared. I am lying there
stunned, and cannot get away. Cannot take in what is happen-
ing. I am good at leaving the crime scene. (7)
The informants described the way they experienced
being treated as a passive object instead of a partici-
pant. Their intention was to collaborate with the birth
attendant, something that gradually seemed as an
impossible task. They described birth attendants who
seemed stressed, and who they felt had no time or
inclination to work with them. They experienced their
own reactions as deviant and inappropriate, and per-
ceived that the attendants focused exclusively on the
babys birth, to which the women themselves com-
prised an obstacle.
Re-traumatization after birth
The informants had tried to deal with the rape as a
non-eventin their lives. The shame of having been
raped was so overwhelming that the trauma remained
unspoken and thereby unprocessed. In pregnancy they
had thought that the rape might inuence the birth, but
the thought had been shoved aside. After the birth, they
experienced that the same patterns of reaction and the
same defense strategies elicited by the rape, also had
been activated during labor.
What they had attempted to communicate to the birth
attendants had not been received; their body language
had been overlooked and not given considerationas
though they had not even been present. They felt reduced
to a birth machineand were ashamed that they had not
been able to prevent this process from happening.
That the midwife did not talk to me, did not address meand
that I was not allowed to be involved. I was just a kind of
robot machine bodythat was there to give birth to a baby
where nobody saw me.There is something very degrading
about being treated like a birth machine that is just something
to be repaired. You are not a machine that is going to give
birth to a kid, you are there as a person too. You are not just
a body that another body is going to come out of. So in a
way it is a bodythat gave birthbut it was not me. (2)
It was sort of the baby it was all about, not meat all. It was
so strange reallyas if I was not even thereI was not there.
I was justI was not even a patient, reallywas actually
nobody. There was just a baby who was going to come out of
me. (4)
The women recognized well the same unworthy feel-
ing of being useless, like some random object, and they
again assumed the blame for it having turned out that
The women described the way all forms of touch by
unfamiliar hands invaded and dirtied their bodies. Dirt-
iedin the sense that the feeling came as a consequence
of something they were subjected to from outside them-
selves, and that had stuck to their bodies. Immediately
after the birth or the cesarean section there arose an
acute and pressing need to wash themselves clean.
Recall that I felt dirty!I felt violated, and I really wanted to
brush my teeth. I felt I wanted to brush away something or
other. And this has something to do with me feeling really
dirtyand those old nightmares about the hands came back. (1)
It got so important to get on my feet again, after the cesarean
section. Everything had to be washed away, sweat, blood,
lth, bits of tape, and most important, hands. All the hands
that had been there, had to go. (10)
I felt I had to have a shower. Not so much the birth, because
I do not know if I was bloody, I have no ideaI am sure I
was, and sweaty too, but there was something else I had to
shower off. Felt I had to make myself clean in some way or
another. After that rape I have always been like thatfelt that
I had toall this stuff about cleanliness. (4)
The feeling of being dirtied persisted far into the
puerperium; they felt they had bodies they did not rec-
ognize as their own, and this feeling made it difcult
to carry out the natural tasks of mothering.
Alienated Body
The birth became a new assault in which the women
experienced being violated in a similar way to when
they were raped. They recognized the degradation of
having been objectied and reduced to a physical thing
that others had made use of. The feeling was not
directly tied to how the child was born, but to how the
interaction between the women and the birth attendants
had developed during the birth.
I felt just gross. They shoved me further and further away
from myself, just slammed on. They stood there all three with
their heads in me, down there. Was not that nobody saw me
or talked to me. I was just empty. I hate my body, thinking of
186 BIRTH 40:3 September 2013
myself as one thing, my body as something else, and we are
not working together. My body is just gross. (10)
Well, it feels like certain of your body parts are not yours no
more. It is just something someone takes all away from you.
You sit there or lie there, just like that, and just ARE like a
carcass or a beached whale in my case. I felt like I was just
laying there, stuck, and could not come back to my own self.
I feel Im still lying there, when I ought to be lying out to
sea, swimming. (9)
The rape trauma had invaded the entire birth experi-
ence so that instead of feeling like a proud new mother,
this woman remained re-traumatized.
Caring in labor for women with a past history of rape
Figure 1 shows advice on what kind of care in labor
the informants would have liked, and their advice to
birth attendants on the kind of care they regard as good
for women who have been raped previously. They were
very clear that the most important condition for the best
possible outcome is good interaction between the
woman and her attendants. It is important that the birth
attendants understand that routine procedures used dur-
ing labor or a cesarean section can contribute to a reac-
tivation of the rape trauma. They state that the woman
should have enough time and a calm atmosphere in
which to give birth to her baby, with as few interven-
tions or disturbances as possible that may remind her
of the rape. All of our informants reected on how giv-
ing birth vaginally and spontaneously without operative
intervention can give a feeling of self-efcacy and thus
contribute to moving forward in processing their attack.
Those informants who had given birth twice recounted
that the memory of the rape was most prominent
during their rst childbirth.
The ndings of this study show how our informants dur-
ing their rst childbirth were caught by their bodily
experiences and memories from the rape. This experi-
ence led to a chaotic mixture of the rape in the past and
their labor in the present, and was unrelated to whether
the woman gave birth spontaneously, was operatively
delivered by vacuum extraction, or was delivered by
cesarean section. In the literature this chaotic mixture is
described as the person behaving as though the trau-
matic situation poses a current threat, with a desire to
defend herself against the threat in the way she tried in
the original situation, without success (10). It has been
documented that unprocessed traumatic life events can
force themselves on the individual so they experience
that the event is occurring again (10,26,27). In the theo-
retical model in Fig. 1, the central expressions of how
the memories of the rape were triggered in the birth situ-
ation are shown. During labor, the informants noted that
several of the same reactions and defense strategies as
they experienced during the rape were elicited. After
birth this phenomenon made them feel as if they had
been raped again.
It has been described previously that childbirth can
reactivate memories of rape (2630). Rhodes and
Hutchinson have described four different extremes of
behavioral patterns during labor, which can be associ-
ated with posttraumatic stress reactions after sexual
abuse or assault: ghting, taking control, surrendering,
and retreating (29). The same patterns can be seen in
our informants when they describe that in the unin-
tended poor interaction with their attendants, they rst
tried to resist, but after a while allowed themselves to
be dominated and surrendered, and nally ended up
feeling that their bodies were alien to them. The infor-
mants described how the birth attendants doing as
they pleasedwith their bodies, externally and inter-
nally, without preparing them for this act, contributed
to their being drawn back in time to the rape in their
past. The informants described being very disturbed by
all of the interventions used during labor. The methods
used for pain relief did not help against what they
found painful, but rather enhanced the feeling of being
paralyzed and out of control. Burgess has described
that the immediate reactions that automatically arise
during a rape give a surreal feeling in which the body
no longer reacts or carries out the orders given by the
brain, and the woman becomes physically unable to
remove herself from the situation (11).
The predominant feeling the informants in various
ways communicated, and the feeling they were left with
after birth, was a deep shame. They were ashamed that
their body once again had been invaded and they had not
been able to prevent a new assault. They were ashamed
that they had not managed to communicate and cooper-
ate with their birth attendants. The shame of not measur-
ing up as a woman giving birth, nor as a mother, was a
burden they carried in silence as they went on with their
lives. The most prominent expression of deep shame is
silence, and the perception of ones own worthlessness
(31). Being raped is more than experiencing vaginal pen-
etration against ones will; it involves an injury to the
core of the self, a violation of ones human dignity, and
those who have been subjected to it frequently assume
the blame for what happened.
For our informants, the rape had been such an
extreme event that a reactivation during their rst child-
birth was inevitable. The informants in this study had
all been subjected to a violent vaginal penetration; for
nine of them, the rape had been part of an attack in
which they had feared for their lives. Other studies
BIRTH 40:3 September 2013 187
Memories of the rape
Brought to the fore during labor
Lying supine, forcibly restrained
Violent approach to the body/genitals
Painfully forced entry and vaginal penetration
Perpetrator takes over control of her body
Struggle, shouting, crying for help
Darkness, blood, semen, sweat, breath
Feels unclothed, despised
Helpless, degraded
Gives up, lets it happen, feels ashamed,
leaves her body, disappears
Conditions during labor
Reminding woman of the rape
Being placed supine, physically restrained
Legs forced apart, placed in stirrups
Invasive procedures, not being listened to or seen
Invasive vaginal examinations
Unfamiliar hands touching body, being overruled
Sight / smell of blood, amniotic fluid, feces, sweat
Dimmed lighting/being unclothed
Bodily integrity not ensured
Being tied to bed or operating table, giving up
Birth attendants control body, room, time
Being back in the rape
Alienated from body
After birth
Informant’s advice on good birth care for women with past history of rape
That birth attendant knows about the rape before labor, shows understanding for her reactions
Not talking about the rape during labor
Being included in treatment decisions, being addressed directly, with eye contact
Being encouraged and supported, helped to stay in the present during labor, “being brought back” to present task
Protection of bodily integrity, as little manipulation of the bod y as possible, fewest possible vaginal exams
Help to maintain an upright position, avoid being placed supine
Awareness that epidural can give same paralyzed feeling as during rape, and both nitrous oxide
and pethidine can give unpleasant fogginess and feeling out of control
Informing her in advance of any touching of her body by anyone, allowing time for her to cooperate freely
As few unfamiliar people as possible in the labor or op erating room
Allowing her enough time, especially in second stage
Creating a calm space and time for giving birth
Understanding her need to wash and freshen up immediately a fter birth
to talk throu
h labor with her birth attendants afterwards
During labor
Escape Surrender
Memories of
the rape LaborRape
Figure 1. Schematic model of reactivation of the rape during labor, re-traumatization after the birth, and the kind of
birth care the informants consider as good birth care for women who have a past history of rape.
188 BIRTH 40:3 September 2013
have shown that when rape is associated with mortal
fear, and when the attack is not reported, or for other
reasons remains hidden by silence, the psychological
problems are more serious in the aftermath (3,6,11).
Only one of our informants had reported the rape to
the police.
For most of the women the trauma had been sup-
pressed and unprocessed. Childbirth was for all of
them a new and shocking confrontation with their pre-
vious trauma. We believe that the degree to which
childbirth reactivates a rape trauma depends on, among
other things, the quality of the interaction with the
birth attendants. This belief, however, poses certain
requirements to charting previous trauma, working
through this trauma before the birth, and tailoring the
birth situation to the womans needs. Our informants
expressed how important it was to be seen, and to be
addressed directly. They wanted help to protect their
bodily integrity from the view and touch of those pres-
ent, and they needed sufcient time to prepare so they
could cooperate with necessary procedures such as
vaginal examinations. They wished to be encouraged
and supported to be present in their bodies during
labor, so that they did not surrender and escape men-
tally from the situation. This approach requires that the
birth attendant has knowledge of reactivation of
assault, and that the attendant is familiar with the con-
ditions during labor, which may remind the woman of
her assault. Birth attendants often lack knowledge
about the womans history, and the woman may not
think that the assault will have any signicance during
childbirth. One explanation for this lack may be that
the theme of assault, and of rape in particular, is laden
with shame and therefore surrounded by silence in
such a way that it is difcult to approach for the
woman and her helpers alike. The shame of having
been raped can be overwhelming for the woman, and
difcult for her helpers to identify. Health care person-
nel who provide antenatal care frequently feel they do
not have the necessary competence or preparation to
take in the womans history of assault, and this feeling
may be a factor in leaving the theme untouched upon
(32). When those caring for pregnant women for vari-
ous reasons do not give attention to the theme of sex-
ual assault, it can send a signal that burdensome life
experiences and psychological problems are not seen
as factors of signicance for birth. When working with
women who have had a traumatic birth experience,
one should ask oneself whether she has had other trau-
matic life experiences, which could potentially be reac-
tivated during the birth.
One can imagine the possibility that performing a
planned elective cesarean section might be a way to
avoid reactivating a rape trauma in labor. However,
our informants who were delivered by cesarean
reported similar reactions to those who gave birth vagi-
nally. They described among other things that being
touched by strangershands, placed in supine position,
anesthetized, and xed to an operating table reactivated
the rape trauma in the same way. They felt just as
objectied, dirtied, and alienated from their bodies as
those who gave birth vaginally. The informants also
reected on how a planned cesarean section would not
be able to prevent a reactivation as it necessarily
involves being touched by others as well as insertion
of intravenous and urinary catheters, washing of the
surgical eld, and being tied to necessary equipment.
It is also possible to view reactivation of a trauma as
an opportunity to connect with the traumatic event and
to begin processing it (33). Childbirth holds the poten-
tial to enter a dialogue with ones body, a dialogue
that can lead to growth in the longer term. Having a
new experience can give a feeling of self-efcacy,
which itself is important for the condence that one
can protect oneself in the future. All of the informants
reected on how a vaginal birth without operative
intervention would promote an experience of mastery,
and the informants in this study who had given birth
to subsequent children described the memory of the
rape being most intrusive during their rst childs
birth. This reection may be interpreted as performing
elective planned cesarean section to protect the woman
in the short term may hinder her opportunity for
growth in the long term. None of the women in this
study wanted a cesarean delivery.
Limitations and Strengths of the Study
Our informants were very clear about their main motive
to participate in the study. By sharing their experiences
they hoped to contribute to increased knowledge of
how rape can affect birth, so that both birthing women
and their attendants may benet from this sharing in
the future.
A limitation of this study is that all of the informants
were recruited from the cohort of women who were
referred for counseling for psychological problems by a
mental health team at a hospital antenatal clinic; these
informantsexperiences may not apply to all women
with a history of rape. Even though no direct questions
were asked about the rape, all of our informants spon-
taneously gave in-depth descriptions of the attack. The
close association between the memories of the rape and
the birth experience strengthens the supposition of an
internal association between the two.
The interviews, however, were performed 112 years
after the rst birth and for the women who had given
birth twice, even though they described their labor
experiences very clearly and separated the rst and sec-
BIRTH 40:3 September 2013 189
ond ones, the possibility of confusion cannot be ruled
Clinical Implications
This study presents the way women subjected to rape
experience their rst childbirth. We know little of how
the birth attendants experienced the interaction with the
women. More in-depth studies of the relationships
between birth attendants and women in labor, seen
from both sides, will increase the understanding of the
dimension of trauma in their interactions. Provided that
there exists a good relationship with the birth atten-
dants, childbirth can also carry the possibility of pro-
gress in working through a rape trauma.
A rape trauma may be reactivated during the rst child-
birth, independent of mode of birth. The birth for our
informants came as a shock, a confrontation with the
past trauma in which the woman was emotionally para-
lyzed and alienated from her body, feelings that per-
sisted for a long time after birth. Birth attendants
should acknowledge that common measures and proce-
dures used in labor and during cesarean section can
reactivate the rape trauma. Future research should focus
on how best to provide care in labor and birth to
women with a past history of rape.
The study was supported by the North Norway Regio-
nal Authority Clinical Research fund, Helse Nord RHF,
8038 Bodø, Norway. We wish to thank our informants
for their participation in this study. They based their
willingness to participate on their hope that sharing
their experiences could help improve care in the future
for other women with a history of being raped. We
thank Rachel Myr for her translation of this paper.
1. Campbell R, Wasco SM. Understanding rape and sexual assault:
20 years of progress and future directions. J Interpers Violence
2. Ellsberg M, Jansen HA, Heise L, et al. Intimate partner violence
and womens physical and mental health in the WHO multi-
country study on womens health and domestic violence: An
observational study. Lancet 2008;371(9619):11651172.
3. Faravelli C, Giugni A, Salvatori S, Ricca V. Psychopathology
after rape. Am J Psychiatry 2004;161(8):14831485.
4. Conoscenti LM, McNally RJ. Health complaints in acknowl-
edged and unacknowledged rape victims. J Anxiety Disord
5. Chen LP, Murad MH, Paras ML, et al. Sexual abuse and lifetime
diagnosis of psychiatric disorders: Systematic review and meta-
analysis. Mayo Clin Proc 2010;85(7):618629.
6. Dahl S. Rape A Hazard to Health. Oslo: Scandinavian Univer-
sity Press, 1993, 154 p.
7. Eberhard-Gran M, Schei B, Eskild A. Somatic symptoms and
diseases are more common in women exposed to violence. J Gen
Intern Med 2007;22(12):16681673.
8. Paras ML, Murad MH, Chen LP, et al. Sexual abuse and lifetime
diagnosis of somatic disorders: A systematic review and meta-
analysis. JAMA 2009;302(5):550561.
9. Zinzow HM, Resnick HS, McCauley JL, et al. Prevalence and
risk of psychiatric disorders as a function of variant rape histo-
ries: Results from a national survey of women. Soc Psychiatr
Epidemiol 2012;47:893902.
10. van der Kolk B. Posttraumatic stress disorder and the nature of
trauma. Dialogues in Clin Neurosci 2000;2(1):722.
11. Burgess AW. Rape trauma syndrome. Behav Sci Law 1983;
12. Frazier PA, Borgida E. Rape trauma syndrome. A Review of
Case Law and Psychological Research. Law Hum Behav 1992;
13. Frazier PA. Perceived control and distress following sexual
assault: A longitudinal test of a new model. J Pers Soc Psychol
14. Heimer G, Posse B. Våldsutsatte kvinnor - samh
allets ansvar
[Abused women a public responsibility]. Lund, Sweden: Stu-
dentlitteratur, 2003. 267 p. (in Swedish)
15. Johnson JK, Haider F, Ellis K, et al. The prevalence of domestic
violence in pregnant women. BJOG 2003;110(3):272275.
16. Noll JG, Shenk CE, Putnam KT. Childhood sexual abuse and
adolescent pregnancy: A meta-analytic update. J Ped Psychol
17. Van der Hulst LAM, Bonsel GJ, Eskes M, et al. Bad experi-
ence, good birthing: Dutch low-risk pregnant women with a his-
tory of sexual abuse. J Psychom Obstet Gynecol 2006;27(1):
18. Grimstad H, Schei B. Pregnancy and delivery for women with
a history of child sexual abuse. Child Abuse Negl 1999;23(1):
19. Benedict MI, Paine LL, Paine LA, et al. The association of
childhood sexual abuse with depressive symptoms during preg-
nancy, and selected pregnacy outcomes. Child Abuse Negl 1999;
20. Nerum H, Halvorsen L, Oian P, et al. Birth outcomes in primipa-
rous women who were raped as adults: A matched controlled
study. BJOG 2010;117(3):288294.
21. Lukasse M, Vangen S, Oian P, Schei B. Fear of childbirth,
womens preference for cesarean section and childhood abuse:
A longitudinal study. Acta Obstet Gynecol Scand 2011;90(1):
22. Nerum H, Halvorsen L, Sorlie T, Oian P. Maternal request for
cesarean section due to fear of birth: Can it be changed through
crisis-oriented counseling? Birth 2006;33(3):221228.
23. Malterud K. Qualitative research: Standards, challenges, and
guidelines. Lancet 2001;358(9280):483488.
24. Kvale S. Det kvalitative forskningsintervju [The qualitative res-
arch interview], 2007 ed. Oslo: Gyldendal Norsk Forlag A S,
2007. 231 p. (in Norweigan).
25. Graneheim UH, Lundman B. Qualitative content analysis in
nursing research: Concepts, procedures and measures to achieve
trustworthiness. Nurse Educ Today 2004;24(2):105112.
190 BIRTH 40:3 September 2013
26. Sperlich M, Seng JS. Survivor Moms. Womens Stories of Birth-
ing, Mothering and Healing after Sexual Abuse. Eugene, OR:
Motherbaby Press, 2008, 246 p.
27. Simkin P, Klaus P. When Survivors Give Birth. Understanding
and Healing the Effects of Early Sexual Abuse on the Childbear-
ing Women. Seattle, WA: Classic Day Publishing, 2004, 450 p.
28. Parratt J. The experience of childbirth for survivors of incest.
Midwifery 1994;10(1):2639.
29. Rhodes N, Hutchinson S. Labor experiences of childhood sexual
abuse survivors. Birth 1994;21(4):213220.
30. Thomson G, Downe S. Widening the trauma discourse: The link
between childbirth and experiences of abuse. J Psychosom Obstet
Gynecol 2008;29(4):268273.
31. Skarderud F. Skammens stemmer om taushet, veltalenhet og ra-
seri i behandlingsrommet [Voice of shamesilence, eloquence
and rage in the therapeutic relationship]. Tidsskr Nor Laegeforen
32. Jackson KB, Fraser D. A study exploring UK midwives knowl-
edge and attitudes toward caring for women who have been sex-
ually abused. Midwifery 2009;25:253263.
33. Nygaard KK. Ikke all empati er empatisk [Not all empahty is
empathetic]. Tidskr Nor Psykologforen 2011;48:566567. (in
BIRTH 40:3 September 2013 191
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Full-text available
The role of psychological trauma (eg, rape, physical assaults, torture, motor vehicle accidents) as an etiological factor in mental disorders, anticipated as early as the 19th century by Janet, Freud, and Breuer, and more specifically during World War I and II by Kardiner, was "rediscovered" some 20 years ago in the wake of the psychological traumas inflicted by the Vietnam war and the discussion "in the open " of sexual abuse and rape by the women's liberation movement, 1980 marked a major turning point, with the incorporation of the diagnostic construct of posttraumatic stress disorder (PTSD) into the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and the definition of its main diagnostic criteria (reexperiencing of the traumatic event, avoidance of stimuli associated with the trauma, and symptoms of increased arousal). Initially described as resulting from a onetime severe traumatic incident, PTSD has now been shown to be triggered by chronic multiple traumas as well. This "state-of-the-art" article discusses past and current understanding of the disorder, with particular emphasis on the recent explosive developments in neuroimaging and other fields of the neurosciences that have highlighted the complex interrelationships between the psychological, psychiatric, biological, and neuroanatomical components of the disorder, and opened up entirely new therapeutic perspectives on how to help the victims of trauma overcome their past.
Full-text available
Rape is an established risk factor for mental health disorders, such as posttraumatic stress disorder (PTSD), major depressive episodes (MDE), and substance use disorders. The majority of studies have not differentiated substance-involved rape or examined comorbid diagnoses among victims. Therefore, the aim of the present study was to estimate the prevalence of common trauma-related psychiatric disorders (and their comorbidity) in a national sample of women, with an emphasis on distinguishing between rape tactics. A secondary objective was to estimate the risk for psychiatric disorders among victims of variant rape tactics, in comparison to non-victims. A nationally representative population-based sample of 3,001 non-institutionalized, civilian, English or Spanish speaking women (aged 18-86 years) participated in a structured telephone interview assessing rape history and DSM-IV criteria for PTSD, MDE, alcohol abuse (AA), and drug abuse (DA). Descriptive statistics and multivariate logistic regression analyses were employed. Women with rape histories involving both substance facilitation and forcible tactics reported the highest current prevalence of PTSD (36%), MDE (36%), and AA (20%). Multivariate models demonstrated that this victim group was also at highest risk for psychiatric disorders, after controlling for demographics and childhood and multiple victimization history. Women with substance-facilitated rapes reported higher prevalence of substance abuse in comparison to women with forcible rape histories. Comorbidity between PTSD and other psychiatric disorders was higher among rape victims in comparison to non-rape victims. Researchers and clinicians should assess substance-facilitated rape tactics and attend to comorbidity among rape victims. Empirically supported treatments are needed to address the complex presentations observed among women with variant rape histories.
The relationship of rape trauma syndrome to the official diagnostic nomenclature of Post-Traumatic Stress Disorder in the DSM-III is extensively discussed. The theoretical and practical clinical issues involved in rape trauma are reviewed as well as the early court rulings on the admissibility of rape trauma syndrome in criminal and civil cases.
Reviews recent case law on the admissibility of rape trauma syndrome (RTS) evidence and psychological research relevant to concerns raised about its scientific reliability, helpfulness, and prejudicial impact. Results indicate that (1) specific concerns raised by the courts about the reliability of RTS evidence may not be warranted, (2) expert testimony on RTS could be helpful in educating jurors, and (3) expert testimony on RTS does appear to exert some influence on jury decision making in rape trials, but does not appear to unfairly prejudice the defendant. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
To examine the association between childhood abuse and fear of childbirth and the wish for cesarean section during second pregnancy. A longitudinal cohort study using data from the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. Fifty maternity units in Norway, 1999-2006. We included 4,876 women who participated in the MoBa study during their first and second pregnancy. Postal questionnaires at 18 and 30 weeks' gestation and 6 months postpartum linked to the Medical Birth Registry of Norway. Associations between childhood abuse and women's fear of childbirth and preference for cesarean section during second pregnancy were assessed using regression analyses, adjusting for confounding factors such as mode of delivery and birth experience of first pregnancy. Of 4,876 women, 1,023 (21%) reported some form of childhood abuse. Compared to women without a history of childhood abuse, childhood-abused women more frequently reported fear of childbirth (23% vs. 15%, p < 0.001) and the wish for cesarean section (6.4% vs. 4.0%, p < 0.002) during second pregnancy. The association between childhood abuse and fear of childbirth and preference for cesarean section remained significant after adjusting for mode of first delivery and experience of first birth (adjusted odds ratio [OR] 1.53, 95%CI 1.24-1.90 and 1.57, 1.09-2.27, respectively). Childhood abuse is associated with fear of childbirth and preference for cesarean section during second pregnancy. Mode of delivery and postpartum self-reported birth experience of the first pregnancy did not alter this association significantly.
To systematically assess the evidence for an association between sexual abuse and a lifetime diagnosis of psychiatric disorders. We performed a comprehensive search (from January 1980-December 2008, all age groups, any language, any population) of 9 databases: MEDLINE, EMBASE, CINAHL, Current Contents, PsycINFO, ACP Journal Club, CCTR, CDSR, and DARE. Controlled vocabulary supplemented with keywords was used to define the concept areas of sexual abuse and psychiatric disorders and was limited to epidemiological studies. Six independent reviewers extracted descriptive, quality, and outcome data from eligible longitudinal studies. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled across studies by using the random-effects model. The I(2) statistic was used to assess heterogeneity. The search yielded 37 eligible studies, 17 case-control and 20 cohort, with 3,162,318 participants. There was a statistically significant association between sexual abuse and a lifetime diagnosis of anxiety disorder (OR, 3.09; 95% CI, 2.43-3.94), depression (OR, 2.66; 95% CI, 2.14-3.30), eating disorders (OR, 2.72; 95% CI, 2.04-3.63), posttraumatic stress disorder (OR, 2.34; 95% CI, 1.59-3.43), sleep disorders (OR, 16.17; 95% CI, 2.06-126.76), and suicide attempts (OR, 4.14; 95% CI, 2.98-5.76). Associations persisted regardless of the victim's sex or the age at which abuse occurred. There was no statistically significant association between sexual abuse and a diagnosis of schizophrenia or somatoform disorders. No longitudinal studies that assessed bipolar disorder or obsessive-compulsive disorder were found. Associations between sexual abuse and depression, eating disorders, and posttraumatic stress disorder were strengthened by a history of rape. A history of sexual abuse is associated with an increased risk of a lifetime diagnosis of multiple psychiatric disorders.