Our feature article in September’s International Doula was about supporting sexual abuse survivors, and we had a lot of great feedback from readers about how this will help them in their doula work. If you don’t know how to approach this topic with your clients or if you currently ask clients about sexual abuse history, reading Selena Shelley’s article will probably change how you handle this with future clients. — Susan Troy, Editor, International Doula

Trauma to Triumph
Why You Shouldn’t Ask: Tools for Working with Pregnant Childhood Sexual Abuse Survivors
By Selena Shelley, MA, CD, LCCE, CHBE

There’s a question often circulating around the doula community that goes something like, “Should I ask my client if she is a childhood sexual abuse survivor?” It is often followed by, “Won’t it help me provide better care if I know?” If you are a doula who has asked yourself these questions, I commend you; it shows that you want to provide thoughtful and excellent care to your clients. I hope this article will help you do exactly that by convincing you NOT to ask your clients about a history of childhood sexual abuse.

Until a couple of years ago, I was convinced the answer to both of those questions was “yes.” I was so convinced that I tried arguing my point with Penny Simkin, PT. Yes, the Penny Simkin, co-author of When Survivors Give Birth and all-around birth guru. Penny Simkin and her When Survivors Give Birth coauthor, Phyllis Klaus, MFT, are two of the most experienced birth counselors and practitioners around. And I, a seasoned doula and psychotherapist of 10 years and one of their From Trauma to Triumph:When Survivors Give Birth certifying trainers, thought I knew better. But once I was able to put my ego aside and listen to what Penny Simkin and Phyllis Klaus have learned over the past four decades, it made a lot of sense to me — doulas just shouldn’t ask.

In general, the potential benefit of confirming that your client is (or is not) a survivor does not outweigh the immense potential risks. There are four main reasons why.

1. She may react poorly to being asked.
Let us first acknowledge that if a woman hasn’t disclosed a history of abuse to you, there is probably a reason why. Maybe it is a conscious reason, such as her partner doesn’t know and she doesn’t want that person to know. Maybe it is an unconscious reason, such as one of her childhood coping mechanisms was to block out what was happening to her, and she doesn’t remember enough to tell you anything. Or maybe she simply hopes that her pregnancy and birth won’t be marred by her history, so she doesn’t want to bring it up. Any of these or a multitude of other reasons are incredibly valid explanations for why a woman might choose not to disclose a history of abuse to you. And if she hasn’t disclosed, putting her on the spot by asking such a personal question could lead her to feel ashamed, defensive, or withdrawn.
• “I didn’t come for counseling about that. She’s not my therapist, she’s my doula.”
• “How can she tell? Is it written all over me?”
• “I don’t want to go there. It’s none of her business.”
• “Why would she ask me a question like that?”

I expect you agree that putting a client in the position where she might respond with any of these thoughts or questions is unhelpful and potentially damaging to your role as her doula. This, therefore, seems like reason enough to refrain from asking about her sexual abuse history. And yet, there’s more.

2. You should instead “hear the music behind the words.”
For anyone who has taken a When Survivors Give Birth training with Penny Simkin and Phyllis Klaus, you know that this is one of Phyllis Klaus’ favorite sayings. Hearing the music behind the words means that we don’t need a disclosure in order to be truly sensitive and helpful. Let’s start with basic probability — as many as one in three women is a childhood sexual abuse survivor (1). Given such a dishearteningly high statistic, you should be prepared for the possibility that your client is a survivor. And then you should use that possibility to provide the best care possible to every one of your clients, regardless of whether she has a confirmed history of abuse.

Beyond that, you need to educate yourself about the possible signs or triggers that might indicate a woman has a history of childhood sexual abuse. This will allow you to hear the music behind the words and improve your care of every client, without putting the onus on her to confirm or deny your suspicions. To learn more about common signs and resultant maternity triggers for a trauma survivor, read When Survivors Give Birth, by Penny Simkin and Phyllis Klaus and/ or attend a training session on working with childhood sexual abuse survivors. For a current list of trainings, go to www.whensurvivorsgivebirth.net.

3. What if she says no?
You can imagine how this scenario might go. You strongly suspect your client has a history of childhood sexual abuse based on what you learned to look for in your reading and training. You let your ego get in the way and ask her if she is a survivor, and she denies it. You have now not only risked her reacting poorly about being asked, as mentioned above, but also potentially caused discord in your doula client relationship.

You might start to question your own skills and judgment (i.e., “How could I have gotten this wrong?”) or begin to second-guess whether she is being honest with you. The minute we start questioning a client’s decision to disclose or not, we shatter a part of our relationship. It is her right to keep that information private, if she chooses.

In addition, some survivor clients do not consciously choose to keep anything
from us. As a way to keep their world a little safer, some children who are being abused have an amazing ability to repress memories of the experience. And sometimes those memories get buried so deep that a woman may not actually remember that she was abused, or may not remember some of the details. In this case, when your client says “no,” she is being as honest as she can.

In either case — whether she knows she’s a survivor and chooses not to disclose, or she is a survivor but doesn’t consciously remember the abuse — you haven’t gained any value from asking.

Rather than put her on the spot, ask yourself the classic question that Penny Simkin and Phyllis Klaus train professionals to ask: “Would everything that I see, hear and feel with this client seem more natural or understandable and make more sense if she were, in fact, a childhood sexual abuse survivor?” And then, if your answer is yes, you simply get to hold additional space for her experience and for any triggers that may arise before, during or after her birth.

Hopefully, if you’ve taken a training on working with survivors, or at least read When Survivors Give Birth, you’ll have good tools for how to serve her more effectively and compassionately, under the premise that all women deserve better care, especially if they have a trauma history.

4. Trust issues
The final reason not to ask a client about a history of childhood sexual abuse is an amalgamation of all the other reasons: You risk breaking trust. Many childhood sexual abuse survivors have difficulty establishing trusting relationships, especially if their perpetrator was someone they or their family trusted. This is more common than you might think. According to the U.S. Department of Justice (2):
• 93% of juvenile sexual assault victims know their attacker.
• 34% of attackers were family members.

If we reluctantly accept that more than one-third of sexually abused children are abused by a family member, sometimes a family member they are being raised by and are dependent on for their basic needs, we can certainly understand why that child (and eventually that adolescent or adult) would have difficulty trusting people who are supposed to be trustworthy. And yes, that includes their doula.

Trust yourself. Trust your client. If and when she is comfortable and ready, and if and when it feels necessary and helpful, she will disclose her history to you. At that point, the disclosure actually has the ability to build trust, rather than strip it away. I should add that including the question on an intake form may prevent the client from feeling singled out, and may or may not improve the odds that you won’t second-guess yourself, but it is still not extremely helpful; at the time she is filling out intake paperwork, your client probably does not yet trust you. She probably hired you because she felt a connection with you at your interview, but it takes time to build trust, and that is often more true for a survivor. So, if you ask an incredibly personal question on an intake form, such as, “Do you have a history of abuse/trauma that you would like to discuss before your birth?” the chances are high she will answer no because she does not yet trust you enough to disclose that information.

In this article, I will not delve into what to do if you do include that question on your intake form and your client answers yes. But the general rule is you must follow up on such a brave and honest response. Do not allow your own discomfort, lack of time, or anything else keep you from reaching out to your client. Not addressing a trauma disclosure could potentially rewound your client and is, frankly, quite unprofessional.

Rather than including the question on your intake form, wait until you have a stronger, more trusting relationship with your client and then open the door for a disclosure of anything, ranging from her fear of pooping in labor to a history of childhood sexual abuse, by asking something like, “As we approach your birth, is there anything else that would be helpful for me to know about you, your history, your wishes or your fears so that I can be more supportive and helpful to you?” (For postpartum doulas this might sound like, “Now that we’ve been working together for a few weeks, is there any information or feedback that would help me better serve you and your family?”) I can almost guarantee that waiting for trust to organically grow in your doula-client relationship will not only increase the overall trust but make your job so much easier and more enjoyable.

My hope is that this information and reasoning resonated with you, and that you will now (re)consider whether to ask your clients if they have a history of childhood sexual abuse. As you continue to build a relationship with your client, allow the trust to build, as well. If she is a survivor, allow her to be the one in control, allow her to find her voice if and when it feels right, and ultimately allow her to have a repatterning experience that begins with you.

About the Author: Selena Shelley has more than 15 years of experience as a social worker, psychotherapist, birth doula and trauma consultant working with pregnant childhood sexual abuse survivors. As a certified From Trauma to Triumph trainer, she helps professionals learn how to work more easily and effectively with survivors during this transformative time in their lives. She loves serving clients and training other professionals, and also strives to find her own work/ life balance as a wife and mother to two beautiful children. You can learn more about Selena at her website selenashelley.com/internationaldoula.

References :
1. Briere, J., Eliot, D.M. Prevalence and Psychological Sequence of Self-Reported Childhood Physical and Sexual Abuse in General Population: Child Abuse and Neglect, 2003, 27 10.

2. Bureau of Justice Statistics, Sexual Assault of Young Children as Reported to Law Enforcement: Victim, Incident, and Offender Characteristics, http://www.bjs.gov/content/pub/pdf/saycrle.pdf (January 2015)