How do I make this topic open to discussion?

Relationship of trust

Research shows that not all professionals include asking about sexual abuse in pregnant women or mothers in their standard questions, even when they suspect it (1). They are not sufficiently aware that this can be the case or fear that they may be unable to provide adequate support. On this page you can read about how to start the dialogue. Under ‘What are possible interventions’ you can read about the continuation.

"I am a psychologist, and asking if a pregnancy is planned is one of my default questions. If the answer is no, it provides an entrance into asking about how the child was conceived. Another standard question may be whether they are suffering from trauma. When you ask such questions by default during intake, it lowers the threshold for elaborating on possible sexual violence, both for you, as a professional, as well as for your client. However, sexual violence does not always come to light, not even from those standard questions. It is therefore good to be very aware of any signs of sexual violence and to ask the right questions. Good collaboration with the gynaecologist and nurse is essential, as they may also be able to detect signs. It is important to create an atmosphere of trust at all times, so that the mother feels safe to talk about sexual violence."

A traumatic experience can have a major impact on the mother-child relationship. Professionals therefore agree that it is important to discuss any sexual violence. Creating safety and trust is a prerequisite for a good discussion on this topic. People suffering from trauma may find it hard to trust other people. Building a good relationship of trust takes time. What helps to build a relationship of trust is: providing clear information, being transparent about the purpose of the help or treatment and explaining why you ask certain questions. And you should display an interested and non-judgmental attitude. Take your time and allow the mother to tell her story at her own pace. Silence can also help create a safe atmosphere.

Sample questions

There are several ways to ask about possible abuse or about a pregnancy or child as a result of sexual violence. It is helpful to agree in advance with the mother that she may indicate when questions are too difficult for her or if she doesn't want to talk about a topic.

During the conversation, indicate that you can see how she reacts and what your thoughts are. This way of ‘thinking out loud’ makes you more transparent for the mother and increases her trust.

Sample questions

Direct ways of asking questions
‘I know from experience that patients with the symptoms you describe have often experienced a traumatic event, such as physical or sexual abuse. Is this perhaps the case?’

Follow-up question
'Is it possible that this has led to your pregnancy?'

A general way of asking questions
‘Because we know that many women experience physical or sexual abuse and that this can cause all kinds of physical and mental problems, we now routinely ask about sexual abuse and domestic violence. Have you been affected by this at all?’

Follow-up question
‘We also know that this may sometimes result in pregnancy. Was this the case with you?’

Indirect way of asking
‘Since these complaints tend to occur in the event of relationship problems, do you mind if I ask you a few questions about your relationship?’

Follow-up questions
‘Are you experiencing tensions in your relationship?’
‘If you have a difference of opinion, are you able to discuss this calmly?’
‘If not, what happens?’
‘Do you feel safe in your relationship?’
‘Did you want to become pregnant?’

Way of asking questions to people with mental disabilities
‘Did someone touch you when you didn't want them to? Is this when you got pregnant?’ (Or: did a baby come into your belly afterwards?)

Source: Sample questions are based on source 2.

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Video: A mother asks for help for her child. How do you keep asking questions to find out about any sexual violence and how the child was conceived?

Relevance of the question

Questions about sexual violence are relevant if you suspect that this has led to pregnancy or the birth of the child. Consider why this question is relevant and explain this to the mother. How much you keep asking about the subject depends on the context and aim of the conversation. In a context where the focus is on parenthood and the parent-child relationship, sexual violence itself, the event itself, need not be discussed in detail, if it has already been mentioned.

The aim of this question is to assess the risks for mother and child and the mother's desire to receive help with parenting. Does the mother have any symptoms due to traumatic experiences? How often, how severe? What is the impact of this on parenthood/pregnancy? If you get the impression that the mother has many problems as a result of the sexual violence, it is important to discuss with her that support is available and to motivate her to ask for help. This will also benefit her child and the relationship between her and her child.

Asking further questions

After discussing sexual violence, it is important to ask what it means for this mother that her child was born as a result of this rape. What are the consequences for the mother's life, how does she see

parenthood and how does she see herself as a mother? How in-depth this conversation is depends greatly on the reason you are in contact with this mother. Starting a treatment for the mother or for the parent-child relationship requires other information than for support during childbirth or maternity care.

Assess what information is relevant to the support your organisation provides to mother and child.

Asking further question

Asking about pregnancy and childbirth
‘Was the pregnancy wanted?’ (If not; follow up with questions about sexual violence, see above)

‘How was your pregnancy?’

‘Did you experience any stress during pregnancy? If so, what caused it, and when?’

‘Were there any people who supported you during your pregnancy? In what way?’

‘How did the delivery go? How did you feel when you gave birth?’

‘What made you choose to keep the baby?’

Asking about the mother-child relationship
‘Are you happy with the gender of the child, or would you have preferred something else? Can you explain why you feel that way? How do you see your child now? Do you have specific concerns?’

'How do you see yourself as a mother?'
'At what moments do you find it difficult being a mother? At what moments do you have selfconfidence as a mother?’

‘How do you look at the future? Both for you and for your child as well as for both of you together.’

Asking about the father
‘Are people who are important to you involved?'
'Is there a partner involved?'
'Is this your child's biological father?'
'How is your relationship with the child's father?'
'Who knows about sexual abuse?'

When relevant:
‘What is the relationship between the father and the child?’

Asking about social support
‘Does anyone know who your child's father is/ how you became pregnant?'

If no one knows, 'What is it like for you to live with this secret?'
‘Do you ever feel excluded by what you have been through, or are you afraid that this might happen?’
‘Who in your surroundings is supporting you?'
'Do you currently have a partner? Does he or she know about your history and the way your child was conceived?'
'What is the relationship between your partner and your child?'
'Are you lacking any support? If so, what do you need?’

Excerise

Mapping the social support network

When it comes to questions about the social support network, it can be very helpful to work with a drawing or with dolls, if necessary blocks, to illustrate the support network. Often it becomes easier to talk about a subject if the words can be accompanied by actions.

After the conversation

It is important the conversation is concluded calmly. You can do this by offering support in the event of overwhelming emotional reactions and reflecting together on the conversation. Take sufficient time for this. Especially when a lot of the mother's emotions have come to the surface. Recognition of what someone has experienced and how they feel about it can be supportive.

Questions could be: ‘How was this conversation for you? How did you feel about my questions? How are you feeling now? Often, these questions bring back memories and associated emotions. Before you go home, shall we see what you can do to relax and get back to the order of the day?’ Think of a relaxation exercise or breathing exercise. ‘What would you prefer to do now? Is there anyone you can contact?’

Subsequently, schedule a follow-up appointment to discuss the situation more in depth or to give advice for further support.

“I am a psychotherapist and clinical psychologist. Some of my clients got pregnant after sexual assault. Asking about sexual assault is a matter of simply doing it. It is difficult to ask about painful topics like this, but it is necessary to provide adequate support for the mother and child. It is also important to be honest about any obstacles you may have when asking about sexual violence, both to yourself and to colleagues. Look for a way to deal with these obstacles, for example by talking to fellow colleagues or by taking a training course. The secrecy surrounding sexual abuse must be broken and this requires professionals to be aware of the impact of sexual violence on both the mother and the child."

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Video: A mother saying very little. A mother speaks hesitantly, reluctantly, and very little. How do you continue probing to find out about any sexual violence and how the child was conceived?

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