An Adult Survivor of Child

Sexual Abuse and Her

Breastfeeding Experience:

A Case Study

Cheryl Tatano Beck, DNSc, CNM, FAAN

ABSTRACT
Purpose: To increase clinicians understanding of the impact
that child sexual abuse can have on womens breastfeeding
experiences.
Study Design and Methods: This was a holistic, single-case
study. Data were collected via the Internet. One mother sent her
story of her childhood sexual abuse and its impact on her
breastfeeding experiences by attachment to the researcher.
Yins pattern matching was used to develop the case description. A combination of linear-analytic and chronological
structures was used to write up this case study.
Results: This case study vividly and painfully describes the
impact of Marilyns childhood sexual abuse not only on her

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labor and delivery but also on how it permeated her breastfeeding

attempts. Breastfeeding triggered panic attacks, dissociation, and
flashbacks to the child sexual abuse.
Clinical Implications: When women seem to be struggling with
breastfeeding and sinking deeper into what could be depression or posttraumatic stress disorder due to childbirth, nurses
might need to help them by giving permission to stop breastfeeding if that is what they need to do for their own mental
health.
Key Words: Childhood sexual abuse; Breastfeeding; Case study;
Qualitative research.

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ne of the proposed targets of Healthy People 2010 is

to have 75% of women breastfeeding in the early postpartum period, 50% at 6 months, and 25% at 1 year
(US Department of Health & Human Services, 2000). On a
more global level, the World Health Organization (2002) recommends exclusive breastfeeding for 6 months. In our zeal
to achieve these goals, clinicians need to be cognizant that for
some women with a history of childhood sexual abuse,
breastfeeding may negatively affect their mental health. They
may struggle to continue to breastfeed under the weight of
societal pressure to provide their infants with the well-documented benefits of breast milk (Kendall-Tackett, 1998). Although there are varied extremes of the prevalence of child
sexual abuse, evidence is mounting that suggests that at least
20% of adult women in North America experienced child
sexual abuse (Finkelhor, 1994). In order to highlight some of
the breastfeeding struggles women experience who have been
sexually abused as a child, a case study is presented.

Review of the Literature

Limited research has been conducted on childhood sexual

abuse and breastfeeding. Five quantitative studies were located that examined the breastfeeding experience of sexual
abuse survivors. One
study did not find a
significant relationship between past or
current sexual abuse
and feeding choice
(Bullock, Libbus, &
Sable, 2001). In a sample of mainly African
American, low-income
women, a higher percentage of sexual abuse
survivors (54%) indicated their intention to
breastfeed as compared
to (41%) of nonabused
women (Benedict, Paine, & Paine, 1994).
Prentice, Lu, Lange, and Halfon (2002) compared the
breastfeeding initiation rates of women with and without
childhood sexual abuse. In this secondary analysis of a survey
of 1220 women, 66% initiated breastfeeding. Women with a
history of childhood sexual abuse were more than twice as
likely to initiate breastfeeding compared to women without
such histories. One month later, however, more women without childhood sexual abuse had continued to breastfeed as
opposed to mothers with such a history, although the difference did not reach significance. In investigating the effects of
incest on 43 survivors, Westerlund (1992) reported that 75%
of these women who breastfed shared that their experiences
were impacted by their incest. Thirty-three percent of these
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survivors were fearful that they would become sexually

aroused when breastfeeding. Another fear that 42% of these
women experienced was that they would not be able to nurse
because they felt inadequate or abnormal.
In a large survey of 118,579 women giving birth to live
infants, approximately 1 in 17 women (5.8%) reported intimate partner violence. Women who reported intimate
partner violence in the year before pregnancy, during pregnancy, or during both periods were significantly less likely
to breastfeed after this pregnancy (Silverman, Decker, Reed,
& Raj, 2006). Also when intimate partner violence occurred around the time of pregnancy, women who started
breastfeeding were more likely to stop breastfeeding within
the first 4 weeks postpartum.
In reviewing the literature, one qualitative description of
brief case studies was found. Klingelhafer (2007) was confused about why some women in her clinical practice with
sexual abuse histories could have consensual sexual relations but found breastfeeding offensive. One mother shared
that sex between consulting adults was all right; it was
breastfeeding that was not all right. She went on to explain
that in breastfeeding, she would be putting a part of her
body in her babys mouth and her baby cannot consent.

Evidence is mounting that suggests

that at least 20% of adult women in
North America have experienced child
sexual abuse, and nurses need
increased awareness and recognition
of the impact of child sexual abuse on
womens childbearing experiences.
Her baby would not have a choice. Another mother also
revealed that putting her breast in her babys mouth was
dirty and she could not stand it. Klingelhafer also reported
that on the other hand, some mothers shared that breastfeeding allowed them the opportunity to reclaim their bodies and their identities as women. Clinicians need to be vigilant in respecting each womans choice of feeding method,
because overly promoting breastfeeding can be detrimental
to some women with sexual abuse histories.
As this literature review highlights, knowledge regarding
child sexual abuse and breastfeeding is scant. Therefore, the
purpose of this qualitative case study was to increase our
understanding of the impact of childhood sexual abuse on
a mothers breastfeeding experience.
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Single-Case Designs

CONTEXT

Multiple-Case Designs
CONTEXT

CONTEXT

Case

Case

CONTEXT

CONTEXT

Case

Case

CONTEXT

CONTEXT

Case
Holistic
(Single-unit
of analysis)

CONTEXT
Embedded
(Multiple
units of
analysis)

Case

Case

Embedded

Embedded

Unit of
Analysis 1

Unit of
Analysis 1

Case

Embedded

Embedded

Unit of
Analysis 2

Unit of
Analysis 2

Embedded
Unit of
Analysis 1
CONTEXT

Embedded
Unit of
Analysis 2

Case

CONTEXT
Case

Embedded

Embedded

Unit of
Analysis 1

Unit of
Analysis 1
Embedded

Embedded

Unit of
Analysis 2

Unit of
Analysis 2

Figure 1. Basic types of designs for case studies. Reprinted with permission from Yin, R. K. (2003). Case
study research methods: Design and methods. Thousand Oaks, CA: Sage Publications, p. 40.
Case Study Design

It has been said that Singularities are the skeletons of phenomena (Petitot, as cited in Hamel, 1993, p.37). Case
study design is well suited when the purpose of the research
is to describe the holistic and meaningful aspects of real life
events. Essential to a case study is that the unit or phenomenon be clearly defined (Yin, 2003). The phenomenon under
study is also linked to real life and placed within a social
context. Case studies can be either single-case designs or
multiple-case designs. Either of these case study designs can
be further classified as holistic (single unit of analysis) or embedded (multiple units of analysis) (Figure 1) (Yin, 2003). In
a single case study, the boundaries of the case need to be
clear and social context is a critical aspect of the study. A
case study can use multiple sources of data, such as participant observation, interviews, and documents. Statistical generalization is not the outcome of case study designs.
Yin (2003) suggested five possible reasons for the choice
of a single case as a research design. First, the case represents a critical case for testing a theory. Second, the case
represents a unique or extreme case. Third, it is a typical or
March/April 2009

representative case. Fourth, it is a longitudinal case. Finally,

the case is a revelatory one. Yin described a revelatory case
as being used when a researcher is studying a phenomenon
that has not been accessible and on which little research has
been conducted. It is his last rationale that was the determining factor in the choice of a single-case design to illustrate the impact of childhood sexual abuse can have on a
womans breastfeeding experience. Case study has a distinct advantage when a how or why question is being
asked about a contemporary set of events, over which the
investigator has little or not control (Yin, 2003, p. 9).
Yins general characteristics of an exemplary case study
guided the choice of this holistic case study of an adult survivor of sexual child abuse and her breastfeeding experience. The case study was significant, complete, had sufficient evidence, and was described in an engaging manner.
Stake (1995) offered four characteristics of case study research: holistic, empirical, interpretive, and empathic. The
last characteristic is especially relevant to this case study of
a woman who was sexually abused as a child and its impact on her breastfeeding experience. The empathic aspect
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of case studies calls for maintaining the value and respect

for individuals. Its issues are emic issues, and its report provides vicarious experience.
According to Stake (1995, p. 8) the real business of a
case study is particularization not generalization. We take a
particular case and come to know it well, not primarily as
to how it is different from others but what it is, what it
does. There is emphasis on uniqueness. The choice of a
case study design is not to enhance the production of generalizations. Cases are of interest for their uniqueness and
commonality. Another way to classify a case study is as an
intrinsic case study whose purpose is first and foremost to
better understand this particular case (Stake, 2005). The
more intrinsic the interest of the investigator in the case, the
more the researcher will concentrate on the idiosyncrasy of
that case, namely its specific context, issues, and story.
In writing up a case study, the reader should be provided
with good raw material for their own generalizing
(Stake, 1995, p. 102). Emphasis on narrative description in
the final report is justified. Stake (2005) warned that a researchers knowledge of the case faces hazardous passage
from writing to reading. The writer seeks ways of safeguarding the trip (p. 455).
When the purpose of a case study is a descriptive one, an
analytic strategy, pattern matching, is used to develop the
case description. The search for meaning in a case study is often a search for patterns (Stake, 1995). Yin (2003) suggested
six types of structure for reporting case studies: linear-analytic, comparative, chronological, theory building, suspense,
and unsequenced. A linear-analytic structure is a standard approach for research reports starting with the research problem, literature review, methods, findings, and conclusions.
Chronological structure also can be used when the case study
covers events over time. A combination of linear-analytic and
chronological structures was used to write up this case study
of childhood sexual abuse and breastfeeding.
Case Study: Marilyn

In an earlier phenomenological study via the Internet that explored the impact of birth trauma on breastfeeding experiences (Beck & Watson, 2008), Marilyn shared her story. This
research was approved by the universitys Institutional Review Board. The participants were sent an information sheet
as an attachment that they read before agreeing to participate
in the study. Marilyn so vividly and powerfully described
how her child sexual abuse affected her breastfeeding that
the researcher decided, with Marilyns permission, to present
her experience as a revelatory case study.
Marilyn was sexually abused as a child, a witness to incest, and raped as an adult. When Marilyn was 30, she had
an unplanned pregnancy during which she developed preeclampsia. At 39 weeks gestation she was induced. Marilyn dearly wanted to have a natural childbirth, so before
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transition she did not ask for an analgesics. During transition, Marilyn became totally overwhelmed with pain that
she described as intolerable. She recalled that by the time
she was desperate enough to beg for an epidural, it was too
late. She was almost fully dilated. Overwhelmed, naked,
and in incomprehensible pain, Marilyn got down onto the
floor to rest her body over a bean bag. Her husband, mother, and sister were in the labor room with her. What Marilyn remembers about her transition was this:
A haze of hospital labor room, nakedness, vulnerability,
pain. Silence, stretching, breathing, pain, terror, and then
I found myself 7 years old again, and sitting outside my
parents house in the car of a family acquaintance, being
digitally raped. The flashback to the abuse that I had experienced 23 years ago was not new. I always knew it
had happened. What was different this time was that I
felt the emotional response to it. I had never felt that before. In the midst of transition of the birth of my first
baby, I finally felt it all in one shocking moment: the anguish, the shame, the horror, the violation, the massive
breach of trust, the grief, the betrayal, the confusion, the
despair and the dirtiness.
I felt like I had left my body. I know now that I had
dissociated. But all I knew then was that I wasnt there
with my body, my baby any more. Of course, my body
was still there. Noises from the room were muffled and
muted. Faraway voices of my mother and the midwife
remarked upon how composed I was. How good I was
being. How little noise I was making. But I wasnt there.
That was the beginning of my life for the next 5 years.
After a period of dissociation during which I was simply not present, my midwife sensed something strange was
going on, and she told me in a gentle but clear, firm voice
that I needed to get this baby out or she was going to
have to intervene. Somehow I managed to pull myself
back into the reality of the moment, and I birthed my baby girl, but that part I dont remember. All I do remember
is being handed my little baby on the floor in the middle
of a sea of bloody sheets and faces. I couldnt comprehend
the pain, the violence, or the brutality. Id been thrust into
a distraught experience that had been seared into my
memory by its trauma, and dragged back into the present,
into what looked like a war zone.
I dont even know whether in my mind the person
holding that baby and taking in the bloody sheets, shock
and pain was a 30-year-old woman, or a 7-year-old girl.
But now, upon reflection, Im pretty sure which one of
me was there in that moment. And maybe thats why
things went so bad. I think its important to note that to
an outsider, or to anyone present in the labor room, my
birth experience did not look traumatic at allbecause
the trauma physically took place 23 years before and only in my mind in the labor room.
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A mess is how Marilyn summed up her postpartum period. She went on to vividly describe:
Flashbacks of the abuse, the effects of the pre-eclampsia, feelings of disgust, distress, and anxiety made breastfeeding difficult and impossible. I discharged myself
from the hospital about 24 hours after birth because I
was in a room with two other mothers and two other
screaming babies and I was anxious and distressed and
had no privacy. I returned to my parents house where I
felt exposed and humiliated. I was trying to establish
breastfeeding under the watch of my father, who I had

one side of her body through her body and out the other side
and she would not feel a thing. Marilyn could not connect
with her baby, her husband, life, anything. After her husband
returned to work, if someone came to the door during the
day, she would hide inside, terrified, until they went away. At
that time she did not think that she actually wanted to live
anymore. She felt worthless and had no energy or ability to
concentrate. Marilyn was extremely anxious and too scared
to drive her car for about a year after she gave birth to her
daughter. She experienced panic attacks. Many things triggered her to dissociate frequently. As Marilyn shared, she
spent much of the first 5 months
of her new motherhood floating
somewhere above my head in a
My breastfeeding trauma had also compounded
dizzy, foggy spiral.
and I felt guilty, like a dismal, horrific, disgusting
My breastfeeding trauma had
also compounded and I felt
failure. Breastfeeding was being pushed very hard
guiltylike a dismal, horrific, disgusting failure. Breastfeeding was
to new mothers and it felt like I was going to be
being pushed very hard to new
judged and condemned if I gave up breastfeeding.
mothers and it felt like I was going to be judged and condemned
if I gave up breastfeeding. I was
comp feeding my daughter because I didnt have enough
spent my life from age 10 fearing, having witnessed him
milk, and that made it harder to feel good about myself.
molest my older sister and terrified it was my turn.
All the breastfeeding advocates told me that comp feedMarilyns milk never came in. She wasnt sure if it were
ing was a sure way to ensure failure of breastfeeding bedue to the pre-eclampsia or the trauma of her childbirth excause she would get used to the bottle. My mother-in-law,
perience. She waited for days for that feeling of fullness in
who had easily breastfed 3 babies, sagely suggested that I
her breasts but it never came. Under these circumstances
didnt have to keep breastfeeding if it wasnt working for
Marilyn persevered with breastfeeding but her daughter was
me. But apart from her, everyone told me to keep going
not getting enough milk and she became severely jaundiced.
with breastfeeding, no matter what.
Her daughter was rehospitalized for this jaundice. While her
Of course, I couldnt tell anyone what was really going
baby was hospitalized, Marilyn stayed at her parents house,
on in my head when I tried to breastfeed. When I placed my
which was much closer to the hospital than her own home.
baby to the breast, I experienced panic attacks, spaced out
Marilyn did not feel safe at her parents house. She did her
and dissociated. It triggered flashbacks of the abuse and a
best to express whatever breast milk she could to send to the
sick feeling in my stomach. I hated the physical feeling of
hospital for her daughter. During this time Marilyn felt she
breastfeeding. I hated having to offer my body to my child,
was still in shock from her dissociative episode.
who felt like a stranger. Whenever I put her to the breast, I
Her failure to breastfeed properly and the accompanying
wanted to scream and vomit at the same time. My body repressure to keep breastfeeding was compounded by feelings
coiled at the thought of placing my baby to my breast. The
of shame and inadequacy. After a few weeks of constant visithought of breastfeeding made my skin crawl. The very act
tors and feeling unsafe in her parents home, Marilyn and her
of breastfeeding, which was sustaining my baby, was forcing
husband returned to their own home. Although grateful for
me to relive the abuse. I resented her for needing to breastthe safety and privacy of her own house, Marilyn was totally
feed. I tried to write about my birth experience, to make
exhausted by that time and could not connect with her baby
sense of what I was going through, but I couldnt even begin
at all. She remembered feeling like someone could come and
to think about it without becoming overwhelmed with
take her daughter away and she would not care. Her husfloods of tears, panic, and despair. I didnt even understand
band did most of the night-walking of the baby. Marilyn just
what had happened, so I didnt talk about it at all.
wanted to sleep and disconnect from the world.
I did actually experience some relief when I exMarilyn shared that most of what she remembered was
pressed, rather than breastfeeding directly; however, my
a dreadful feeling of numbness. She experienced no joy, no
supply was so poor that for an hours effort expressing,
anger, no depressionshe was just dead inside. She recalled
Id only have about 10 mm of milk to give my daughter.
thinking that someone could come in and run a sword from
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Then Id be told that expressing didnt work for some

women, and I should just concentrate on breastfeeding.
Eventually I realized if I continued breastfeeding, with
all its flashbacks, panic attacks, and anxiety, I would totally
lose my mind. I was already feeling like I was further from
a healthy psychological reality than I had ever experienced
and I was exhausted from the struggle I was having. I hated that I was struggling against my daughter and resenting
her for the panic attacks, despair, and dissociation. So I
gave up breastfeeding and put her on the bottle totally. At
the moment I gave myself permission to give up on breast-

publication. Marilyn gave her permission and sent an additional piece of her story to the researcher. Marilyn shared that she
had been too ashamed to write this in her first story. She felt
strongly, however, that what she was about to share was fundamental to her recovery and her decision to give up breastfeeding and would enable her to concentrate on her baby.
Through my adult life, I had occasionally used marijuana.
It was occasional and light use, because I didnt ever like the
feeling of being out of control. I was never a pot head. I
cant remember how I came upon the idea of using it when
I was suffering postpartum depression, but I did. A couple
of weeks before I gave up breastfeeding, I began to use marijuana
Adult survivors of child sexual
at very low doses, in corked form. I
guess I was self-medicating. But
abuse may need to hear they
what I did discover was that at
very low doses, it actually subhave permission to stop
stantially relieved my anxiety and
took the edge off the sadness in my
breastfeeding if their mental
life. Id never been good at articuhealth is suffering.
lating my needs, because they had
always been suppressed in favor of
someone elses (usually my dads)
and I certainly couldnt identify my needs while I was defeeding, things started to look up. I slowly started to feel a
pressed, agoraphobic and dissociating.
sense of connection with my baby, and with my life, and I
When I used marijuana, I gained a few hours of
even began to feel a bit like my old self again.
When her daughter was 18 months old, Marilyn started
blessed relief, and I actually began to enjoy my baby. I
counseling for all the traumas she had experienced. She was
was able to laugh, see my babys gorgeousness, and gain a
diagnosed with posttraumatic stress disorder (PTSD), depressense of perspective, something I had totally lost. I began
to see that this is what motherhood was supposed to be
sion, and anxiety. She began to process her sexual assaults, inabout, not endless suffering. While that perspective disapcest, and abuse and began to understand what happened to
peared as the high wore off, and I never took to using it
her during the birth of her daughter. Marilyn became pregconstantly, I took the memory of that feeling with me and
nant again and described the birth of her second child as beused it to make decisions about what was working in my
ing much better than her first delivery. She gave herself perlife and what wasnt. It was what helped me make the demission with her second daughter to breastfeed if she really
cision to stop breastfeeding, and I never looked back.
wanted to and acknowledged that bottle feeding was totally
I dont use marijuana now, and Im not sharing this
okay. Marilyn successfully breastfed her second baby for 3
anecdote with you to advocate the use of marijuana in
months before acknowledging that the baby needed more
postpartally [sic] depressed women. I just hope it can help
than her milk supply could give. Marilyn decided to put her
illuminate how at least temporarily alleviating anxiety in
on the bottle completely rather than struggle with comp
women in my situation can act as a catalyst for positive
feeding and breastfeeding. By deciding to make things easy for
change, especially when psychological counseling is not an
herself and give herself permission to do whatever worked for
option for whatever reason, or when they cant identify
her, Marilyn ended up kind of liking breastfeeding. At least
that they are depressed, have PTSD or whatever.
this time she did not experience the anxiety, flashbacks, and
A few moments of relief from the despair, of seeing my
panic attacks she had the first time. Six years after the birth of
situation as not utterly hopeless was all I needed to act conher first baby was the first time Marilyn was able to write
structively and with a sense of autonomy (even if it was
about her experience with PTSD without experiencing panic
counter to all the advice I was being given) to give me back a
attacks, anxiety, and despair. It has taken all these years for
sense that my life could be self-directedand happyagain.
her to be able to integrate her experiences, to have enough understanding of what happened, and to put it all together.
Discussion
About 4 months after Marilyn first sent her story, the reBreastfeeding may be a trigger for pre-existing childhood sexual
searcher e-mailed her to obtain her permission to write about
abuse survivors defensive emotions that can result in women
her experiences as a case study that would be submitted for
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March/April 2009

deciding not to initiate breastfeeding or in women stopping

breastfeeding shortly after they start. Perinatal anticipatory guidance for breastfeeding needs to be incorporated into nursing
care of survivors of childhood sexual abuse. Roussillon (1998)
stressed preparing survivors for the possible sensual or sexual
feelings they may experience during breastfeeding, the possible
vaginal or uterine contractions while breastfeeding, and the potential for flashback to their incest while breastfeeding. Roussillon called for research to be conducted on the experiences of
survivors of childhood sexual abuse in regards to breastfeeding.
Nighttime breastfeeding may be difficult for some women,
especially if their sexual abuse occurred at night. Other survivors of sexual abuse are able to comfortably breastfeed their
newborns but encounter difficulty with older infants who play
with their breasts while breastfeeding. Women may be too uncomfortable to permit breastfeeding to continue (KendallTackett, 1998). Many women do get some sensual pleasure
from breastfeeding; however, women who have been sexually
abused may be concerned about whether these feelings are appropriate. Nurses need to help mothers learn what is normal
within their own bodies. Women can be reassured that there
are some pleasurable aspects of breastfeeding.
Bowman (2007) alerted nurses to be sensitive to possible
sexual abuse histories among adolescent mothers. Adolescents may be reluctant to breastfeed for fear it can trigger
anxiety and discomfort with this intimacy with their infants. Nurses need to encourage adolescent mothers to
choose the feeding method that is best for them.
Three concepts can be generalized to the care of women
who are survivors of child sexual abuse to help create an
empowering and safe patient-provider relationship: egalitarian work, exploring meaning, and framing and boundaries
(Seng & Hassinger, 1998). Egalitarian work focuses on
helping the less powerful survivor to have an increased level
of equality regarding her knowledge and ability to be autonomous. In exploring meaning with survivors of child
sexual abuse, work is done to help them understand how
their symptoms, distress, and abuse history fit together.
Seng and Hassinger explained that framing is the set of
constraints, such as safety, that surrounds the clinician and
child abuse survivor, whereas the boundaries are the limits
between them. Awareness and recognition of the impact of
child sexual abuse and adult rape on womens childbearing
experiences need to increase. For example, when women
have their initial prenatal interview, they can be told that
clinicians are available who have expertise in helping
women who have suffered through sexual abuse. After delivery, clinicians cannot rely on just outward signs of physical trauma or wait for women to recognize the signs and
symptoms of their own emotional trauma.
When women seem to be struggling with breastfeeding and
sinking deeper into depression or PTSD due to childbirth, they
may need to hear that they have permission to give up breastMarch/April 2009

feeding if that is what they need to do for their mental health.

Caring and compassion on the part of clinicians are critical in
providing a safe environment for women to trust enough to
share why they may be having difficulties with breastfeeding.
It seems fitting to close with these words from Marilyn:
I am eternally grateful that you have made it possible for
me to tell my story. Part of why I shared my story with you
was in the hope that it might help inform the way child
sexual abuse is considered, understood, and addressed by
healthcare providers. It would do my heart good if you felt
my experience was helpful in achieving that goal.
Acknowledgment
It is with tremendous gratitude that the author would like to
thank this courageous mother for sharing such a painful and
private story so healthcare providers can learn about the
detrimental impact that childhood sexual abuse can have on
breastfeeding.

Cheryl Tatano Beck is a Distinguished Professor, University

of Connecticut, School of Nursing, Storrs, CT. She can be
reached via e-mail at cheryl.beck@uconn.edu
The author has disclosed that she has no financial relationships related to this article.
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