When a hospital midwife or obstetrician meets a woman in labor for the first time, even a detailed medical file about her health and pregnancy is not necessarily enough. If she had been a child victim of sexual (or other types of) abuse, the demons she has borne through her life are likely to come bursting out. World-famous physical therapist, childbirth educator, doula (labor supporter) and author Penny Simkin was in Israel to share her experiences with over 300 Israeli professionals. She was the sole lecturer at the annual childbirth education lecture organized by Great Shape/YMCA, which specializes in prenatal and postnatal health and fitness, in cooperation with the Israel Childbirth Education Center. Simkin, who lives in Seattle with her husband, Peter, has four grown children and eight grandchildren ranging in age from six to 23. Her other "offspring" are a variety of books, including The Labor Progress Handbook ( regarded by childbirth professionals as the authoritative textbook), Pregnancy, Childbirth and the Newborn: The Complete Guide and The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All other Labor Companions. She also coauthored with psychotherapist Phyllis Kraus the book When Survivors Give Birth, which focused on women who went through child abuse and presents a counseling approach. Simkin, a soft-spoken but energetic woman who estimates that since 1968 she has prepared over 10,000 women and their partners for childbirth, spent much of the day-long session talking about such survivors. Simkin was introduced to the enthusiastic audience (that included Jewish and some Arab and black women, and a lone unidentified man) by Rachelle Oseran, codirector of Great Shape and herself a certified Lamaze childbirth educator, doula and fitness trainer. Oseran said the subject of abuse survivors and delivery had been seriously neglected before Simkin and Kraus delved into it. In the US, said Simkin, women are required to bring to the delivery room not only their medical files but also a form testifying to their emotional and psychological past. However, a history of sexual abuse as a child is often left out, so midwives and doctors can easily be unaware of it. She asked the audience by a show of hands whether they receive such forms from patients, and no one had. Thus hospital staffers must always think of the possibility that the woman about to give birth is a survivor of abuse, just as any woman or child with signs of physical trauma should be regarded as a possible victim of abuse, whose case must be delicately handled. Simkin defined childhood sexual abuse as having occurred between a child or youth under 18 and an adult or someone close in age whom the child perceives as more powerful. "This is not the legal definition in the US, but it is mine. The child always perceives the abuser as being more powerful than her or him. The perpetrators usually are familiar to the child and can be their parents, stepparents, siblings, other relatives, 'respected' elders, neighbors, schoolmates, teachers or religious figures or - least frequently - strangers." She went on that the abuse could be sexual, physical, psychological (such as accusations, such as a father telling his daughter that she was dressing "like a whore") or verbal. "In the US, the prevalence of childhood sexual abuse is 25 percent to 40% of all girls and 20% to 25% of all boys up to the age of 18. The speaker presented a drawing that had been produced by a young pregnant woman; it showed the ideal of a joyous person with images of fetuses in various stages of development surrounding her like a necklace. But when she went to give birth, things did not go well, and she had to have a cesarean section, tied to tubes and sensors. Although she was "in love with her baby" afterward, the image she drew of a pregnant woman after delivery showed her leg attached to a ball and chain, wires, flames, harshness and ugliness. Simkin noted that as a small child, her patient had been held down and molested by her own father, who tickled her during this act, causing her to laugh and later cry. "Fortunately, she received help from a trauma therapist and ended up a childbirth education expert and a doula who gave birth to two more children." The abuse victim "is confused, frightened or hurt. She realizes something is wrong and may feel she herself is to blame. She is not sure how or whether to stop it. The perpetrator may tell the child that if she reveals what happens, her mother or her pet cat will die. The feelings are worse when the abuser is someone she loves, or depends upon for food and shelter." So what can the victim do to cope with this horror? Simkin said the victim may go into denial, saying even rape was "no big deal. I'm over it now." It is quite common, she noted, that women who use this technique "later become prostitutes." But it is also common that they lose their memory of the experience(s) by repressing their memory through dissociation, and they can do so even when the abusive act is occurring. Simkin noted that the vast majority of prostitutes have a history of child sexual abuse. "They learned bad lessons about their bodies. Many are also substance abusers to diminish their awareness. Many also have eating disorders such as morbid obesity, anorexia and bulimia, as well as a fear of medical and dental procedures (especially if oral sex was forced on them). "The abuse victim often blacks out mentally during the act of abuse, as if she has left her body so she can tell herself the act 'isn't happening.' One woman described it to me as 'just going into the light bulb hanging from the ceiling until it ends. This dissociation really removes her conscious memory, but the memory nevertheless remains some place in her body," Simkin explained. "There are body memories even when there is no conscious memory. This leads to physical reactions of extreme tension, pain or panic to events or stimuli that resemble the abuse." This somatization involves the conversion of mental or psychological pain into bodily symptoms, Simkin said. "The pain is expressed even if the victim can't recall the abuse." Doctors know now that many chronic medical conditions that don't respond to conventional treatment result from somatization of traumatic events in the past. Among these conditions are asthma, infertility, gastrointestinal problems, migraine, chronic pelvic pain, pain on intercourse, extreme constipation, musculoskeletal-like fibromyalgia and temporalmandibular (jawbone) problems. All of these could have come from sexual abuse." Simkin was clear in stating that many cases of these chronic illness have nothing to do with abuse, but the possibility should be considered, especially if patients have thick medical files and, with their physicians, feel hopeless. In the delivery room, if the midwife or obstetrician notices strange behavior, they should ask about a past of sexual abuse. " You can't just ask a yes-or-no question. You should rather say: ' Many women have had unpleasant sexual experiences of being touched or forced into sex or physically abused. Have you ever experienced anything like that?'" If she "admits" it and "you're in a real rush during the delivery, at least look right at her and say: 'I'm very sorry' or ' No one deserves to be treated that way!' That can bond you during delivery; she knows you are on her side," Simkin advised the childbirth professionals in the audience. If she is only at the beginning of delivery, the professional should tell a victim: 'Let me know how I can help you feel more comfortable." As many victims hate vaginal exams, Simkin continued, "delivery room staffers should "think very hard about whether they really need to do them, as sometimes patients feel that such an exam is like rape." If a woman can't tolerate invasive procedures such as blood draws, catheters and internal exams but they have to be done, "take it slowly. She might want to talk you through it. One woman I remember counted slowly to 100 or spoke to her partner or friend all the time," Simkin said. Victims have complained that during birth they felt they were being "ripped apart," said Simkin. "At one of my classes, I showed a film of the baby's head coming out. I always thought it was beautiful. But one woman who was a victim ran out of the room, went into a wall and cracked her head open. I never showed that image again." Abuse victims who are pregnant typically become "control freaks" when they come to the hospital, as they feel their lives were so long out of control. "They want to avoid pain and control the event to protect themselves. So they may arrive with a written "birth plan" that rigidly sets down what they want when they go into labor. Midwives welcome flexible birth plans, but when it becomes extreme, they usually resent it. A patient who was an abuse victim may prefer to have a woman obstetrician and insist on epidural anesthesia to minimize pain. But some may give no indication of a history of sexual abuse; nevertheless, suddenly they refuse to be touched or even disrobe. Some even faint or experience a seizure, Simkin related. And if they urinate or defecate during delivery, they may be so ashamed because they had to clean up their beds after a rape that they insist of cleaning up their own excretions instead of the midwife doing it. "This behavior is very odd and makes you mad. But they don't like being criticized. If you understand her background, you see her in a very different light." the Seattle expert insists. "Certainly, sex abuse and birth - which is a very sexual experience - don't mix very well." Although most pregnant women go for childbirth education courses at least once, in the US it is only a minority of around 35 percent. Simkin said that when she started her career, seven in 10 women went for such training. "Today, they are often ignorant of what happens and it's hard for them to assert themselves. Caregivers use professional jargon, such as "pit" for pitocin (a drug that induces labor). The initials and foreign words make some women feel vulnerable and dependent, "so try to avoid their use around the patient. And don't use phrases like: 'Surrender to your contractions.'" Once the baby is born, the abuse victim may be petrified of holding it or breastfeeding. "I am a baby myself," said one. "How am I going to take care of another baby?" While lactation is important for the baby, if doing it is traumatic because of its sexual connotation, Simkin advised to let them decide what they prefer. There are "lots of ways to have a baby," concludes the world-famous childbirth educator and doula. There should be choices. I always ask for a few introductory paragraphs abut themselves and experiences. Every woman who gives birth is special, not only those who had been abused as children." Simkin conducted research in which he interviewed ordinary women soon after they gave birth and then followed them up two decades later to see if the original memories had persisted. "In nearly every case, their recollections were very accurate. I asked them to rate their satisfaction, and those who had been treated and talked to nicely by the doctors and nurses almost all had very good memories and high satisfaction." Thus delivery room staffers should train themselves to treat their patients with the utmost respect and sensitivity, even if they've had a hectic day, because the resultant feelings will persevere long after the babies have grown up.