Hello, I’m a pediatrician who has been practicing for many years. I have taught many breastfeeding classes and enthusiastically promote the practice in our small city. At prenatal visits I often will briefly check a mom-to-be’s breast to make sure that we know what we’ll encounter postpartum (e.g., inverted nipples). There’s no touching involved, and the check just takes a few seconds. But I recently had a pregnant woman complain that it was inappropriate. This was the first time in over twenty-five years of practice anyone has complained. I later found out that she was sexually abused as a youngster. What are your thoughts on these screenings? I have spoken to several lactation consultants who think what I do is entirely appropriate. Thank you. – Old Doc
Dear Old Doc,
We think it’s really terrific that you’re a pediatrician with knowledge about breastfeeding. As we have complained in this column, before, many women turn to their doctors for advice and support about breastfeeding and don’t get it, or maybe even get outdated or incorrect information. It sounds like your experience and knowledge have been helpful to many of your patients. It also sounds like this particular patient was a little freaked out.
The transition to motherhood can bring up all kinds of issues when it comes to body and sex. If this is true for a person with a healthy sexual history, imagine how much more intense or even traumatic it can get for someone who’s been abused. Pregnancy, birth and breastfeeding can all trigger complicated feelings for survivors: Aside from a general feeling of loss of control, the sensations of having and feeding a baby can bring up terrible memories or associations. Women who were abused as children might feel especially afraid or upset by the idea of “loosening up” or “surrendering” during labor, feel invaded by needles or aggressively restrained by monitors. Breastfeeding may make a woman feel that her body has been taken over, or “owned” by someone else. Night feeding and public feeding can be especially hard for a woman who feels very protective of her boundaries.
Since a woman’s sexual history can have an impact on birth and childcare, OBs and midwives are trained to screen for abuse.
The Nurse-Midwifery Handbook: A Practical Guide to Prenatal and Postpartum Care by Linda Wheeler outlines the protocol for abuse screening. It’s very sensitively written with lots of information for how to talk to patients and direct them to appropriate support when necessary. You might want to check out the book, but that brings us to the next question: Does an inquiry into sexual abuse fall under your jurisdiction or the prenatal caregiver’s? We’re not entirely sure of your arrangement with patients, so we can’t make that call. Our hunch is that you’re simply being a really thoughtful pediatrician by meeting with pregnant women ahead of the birth to discuss breastfeeding – an important aspect of infant care. If that’s the case, and you’re not directly involved in prenatal care, it would be inappropriate for you to delve into a full Q&A about sexual history.
Still, if you’re discussing breastfeeding with a mother-to-be and feel that an examination of her breasts would be helpful, you need to be very clear about your role and the purpose of what you’re doing. We can imagine a patient being a little taken aback by the somewhat unusual scenario of having a doctor – who isn’t even ostensibly treating her – ask to see her breasts. While such a request makes sense to someone with breastfeeding expertise, it might not to a first time mom. Primiparas are at the very beginning of a long learning curve about what it’s like to consider their breasts in a non-sexual context. Some women are very comfortable with this; others – even those without a history of abuse – need more time and space to adjust. So, if you’re concerned about future patients who might have similar issues, here are a few thoughts to consider:
– Ask before you look or touch. The big issue here is boundaries; by asking first, you are immediately respecting them. Kathleen Kendall-Tackett, in her article, “Breastfeeding and the Sexual Abuse Survivor” writes, “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.”
– Then as you move forward – if you have gotten permission – continue to respect the woman’s boundaries by explaining precisely why you need to do what you are going to do. And narrate as you go: “I am going to do this; I am going to that; I will look for this; all done; great.”
– If the woman is not comfortable being examined, it’s probably best to leave it at that. Let her know you’ll be there for her as a resource for breastfeeding and perhaps give her some literature or avenues for support.
If sexual abuse ever directly comes up in a meeting with a patient, you could use of the questions Linda Wheeler offers midwives: “‘Is any of this unfinished for you?’ [This] can help you decide whether a referral for counseling should be suggested.” You may also want to look into support services in your area so you’re able to refer patients who could use some help.
The job of a good caregiver encompasses not only acting appropriately but also acting sensitively to the patient’s needs and responses. Your concern about this incident suggests that you’re interested in doing both, and we commend you on that.
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