Several points have been raised in the discussion of working with breastfeeding mothers who have experienced sexual abuse. Beth wrote that "women should be in charge of revealing that information." While Nancy wrote that "...the fact is that for some women (maybe not all), past attempts to reveal may have been met with resistance at best, punishment at worse. Therefore, they have learned that it's not safe to tell. Secrecy is a fertile breeding ground for shame, which then leads to more secrets..." and advocated asking directly about sexual abuse to make "it clear that she is interested and that there won't be recriminations to the client if she tells." Karen Gromada, in a forwarded post, stated that "Even if a client has not yet built a trusting therapeutic relationship with the LC or perhaps is not yet even aware of the history herself due to repressed memories, she now knows she may bring such issues up at a later time as this LC has shown she is comfortable talking about mental health issues that can have a profound effect on pregnancy, birth and breastfeeding." and that "Asking assessment questions about any possible abuse/other mental health history cannot take control of any revelation from the mother." My own thoughts on this issue are based on my work with women in the context of both breastfeeding and psychological counseling, my training in clinical psychology, my training and experience working in a women's shelter, and diverse readings on this and related topics... Women who have been sexually abused have had major violations of their trust, emotional and physical boundaries, physical and psychological integrity, the timing, nature, and experience of their sexual development, ... They have experienced a lack of safety at a profoundly fundamental level. The LC does not have the right or ability to determine for the mother that it is safe to reveal a history of sexual abuse. Only the mother can make this determination for herself. The creation of an environment of safety is critical to accurate assessment of sexual abuse. When LCs listen with empathy, reflecting their understanding of the information and feelings a mother expresses, offering suggestions and alternatives in a nonjudgmental manner, they do a great deal toward creating that environment of safety. In addition to this general way of interacting, LCs can directly state their willingness to talk about sexual issues by saying something along the lines of: "Breastfeeding has many aspects--from beliefs to feelings to techniques. Women often don't get the chance to learn how to breastfeed by watching other women. Even when they know how to breastfeed, they may not have the social support that they need to continue to breastfeed as long as they want. And the experiences that women have had with relationships, their bodies and their sexuality during childhood and adulthood impact breastfeeding. We can talk about any of these things and more--and I can help you find information and support for your own situation." Such a statement is direct, holistic, matter-of-fact, conveys to the mother that the LC does NOT consider anything taboo, conveys a critical message of respect for the mother's choice to have or not have the conversation, does not put the mother "on the spot," gives the mother as much time as she needs to assess safety and opens the door to a future conversation if the mother is not ready at the time. In contrast, "Were you sexually abused?" (as a standard assessment tool for sexual abuse) requires an exact answer to that exact question at that exact moment. She and the LC know that a "yes" or "no" is expected as an answer to that question. She and the LC know that a truthful answer is expected to that question. If the answer is "yes" and the mother is ready to reveal that information to the LC, the LC has accomplished the assessment of sexual abuse and can go on to referral to mental health care and to providing specialized breastfeeding help in the context of past sexual abuse. If the true answer is "yes" and the mother is cognizant of her sexual abuse but not ready to reveal that information to the LC (and so says "no"), the LC has NOT accomplished the assessment of sexual abuse AND has put the mother in a situation that may be experienced as very frightening. Such a mother, who may not have remotely been expecting such a question, must decide in the fraction of a second (lest she unintentionally reveal the truth by her body language, delayed answer, tone of voice, etc.) to tell the truth or to lie. She must evaluate in the fraction of a second the safety of revealing the information to the LC. And while the LC may believe that it is safe for the woman to reveal that information to her, the woman may not (and it is her belief that counts): she may need more information, more time, and/or more interaction with the LC before she can feel safe. If the true answer is "yes" and the mother is NOT cognizant of her sexual abuse, she will answer "no" and the LC has still not accomplished the assessment of sexual abuse. So the RISKS involved in assessing sexual abuse by asking directly "Were you sexually abused?" include (at least) 1) the failure of the assessment tool to get an accurate answer, 2) the violation of the woman's right to FULLY determine when and whether it is safe to talk about the topic (and ultimately reveal--or not-- a history of sexual abuse), and 3) the creation of an environment that does not feel safe to the woman. Some references for anyone wanting to learn more about this topic are below. These are the resources listed in the bibliography for the session "Breastfeeding and the Sexual Abuse Survivor" presented by Deirdre Knowles, MA at the LLL of Washington Area Conference on October 7th, 2000. Bass, E. and Davis, L. (1984) The Courage to Heal. New York: Harper Perennial. Banyard, V. (1997). The impact of childhood sexual abuse and family func tioning on four dimensions of women's later parenting. Child Abuse and Neglect, 21, 1095-1107. Digman, D. M. (1995). Understanding intimacy as experienced by breastfeeding women. Health Care for Women International, 16, 477-485. Gallop, R. McKeever, P., Toner, B., Lancee, W. and Lueck, M. (1995). Inquiring about childhood sexual abuse as part of the nursing history: opinions of abused and non-abused nurses. Archives of Psychiatric Nursing, 9:3, 146-151. Hall, J. (1997). Breastfeeding and sexuality. British Journal of Midwifery, 5:6, 350-354. Hastings, A.S. (1998). Treating Sexual Shame. New Jersey: Jason Aronson, Inc. Hastings, A. S. (1996). Body and Soul. New York, NY: Insight Books. Hastings, A. S. (1993). Discovering Sexuality that will Satisfy You Both. Tiburon, CA: The Printed Voice. Herman, J.L. (1994). Trauma and Recovery. New York: Guilford. Kendall-Tackett, K. (1998). Breastfeeding and the sexual abuse survivor. Journal of Human Lactation, 14:2, 125-130. Kendall-Tackett, K. (1997). Breastfeeding and the sexual abuse survivor, Leaven, 33:2, 27-29. Rhodes, N. and Hutchinson, S. (1994). Labor experiences of childhood sexual abuse survivors. Birth, 21: 4, 213-220. Robohm, J.S. and Buttenheim, M. (1996). The gynecological care experience of adult survivors of childhood sexual abuse: a preliminary investigation. Women and Health, 24:3, 59-75. Schnarch, D. (1997). Passionate Marriage. New York: Henry Holt and Co. Weiner, R. (1995). I am a survivor: childhood sexual abuse's effect on medical consultation. British Medical Journal, 311: 7007, 758. Williams, N. (1997). Maternal psychological issues in the experience of breastfeeding. Journal of Human Lactation, 13:1, 57-60. A reminder to all that I post to LACTNET not as a representative of La Leche League, rather, in my other roles. Cynthia Good Mojab, MS Clinical Psychology (Breastfeeding mother, advocate, independent [cross-cultural] researcher and author; LLL Leader and researcher in the LLLI Publications Department; and former psychotherapist currently busy nurturing her own little one.) Ammawell Email: [log in to unmask] Web site: http://ammawell.homepage.com *********************************************** The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(TM) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html