By: Lydia Furman, MD, Assistant Editor
In
a recently released study in Pediatrics,
Dr. Rouhani et al. (doi: 10.1542/peds.2014-3373) presented us with a must read article about the burdens and experiences of
women who are raising children conceived through sexual violence in the
Democratic Republic of Congo (DRC) (ref here).
My first thought on reading this incredible article was that one does
not need to go to the Democratic Republic of Congo (DRC) to meet women who are
raising children conceived through sexual violence. Their conclusions are
logical and intuitive, yet ground breaking, and I believe I can apply their
“lessons” in my own practice. These authors interviewed over 700 women who are
raising a child conceived through sexual assault. They used a specific method
of locating hard-to-reach populations, called respondent driven sampling, in
which ten initial identified women each recruited three other women, who then
recruited three other women, and so on until the full population was
identified.
Please
read the article to immerse yourself in the study, because likely you will find
other parts of the work more meaningful than what captured me. What impressed
me most was the extraordinary resilience of the women and of the maternal-child
relationship. Over one third of women
reported that their community stigmatized their child, and over one third
reported that their community stigmatized them personally. “Perceived
acceptance of the child” by spouse, community and family seemed surprisingly low
to me, given that the entire community was exposed to known, ongoing and
multiple sexual assaults. Yet, despite all of this, 80.5% of women had
“positive regard” (questions drawn from the Parental Stress Scale) for their child
and 73.0% had “high attunement” (defined as “…awareness of, sensitivity to, and
responsiveness to the child’s needs…”). So in the face of incomprehensible
stress and challenge, including seeing their assailant and recalling the
assault when looking at their child, the great majority of women are raising
their children with engagement and kindness, as best one can understand. The
authors’ multivariate analysis examines this question quantitatively and expands
understanding further.
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While
the upheaval in The DRC is notorious for the horror of widespread sexual
violence, utilized as a weapon of war, the problems that women must face in
raising a child who is the product of a rape respect no geographic boundaries. An
issue that clinicians practicing in the US may have to recognize among women
raising a child conceived through sexual violence is the complex racism of skin
tone, which rears its ugly head when mother and child have obviously different
skin colors or eye colors, prompting family or non-family members to ask about
paternity. In the United States (US) it may be more possible for women to avoid
stigma by non-acknowledgement of the sexual violence (e.g. by asking for
non-inclusion of the information in the child’s medical record), but this does
not permit future providers to treat the mother optimally (since she may have
depression, anxiety, or other sequelae that are then not recognized), and this
also makes support of any discussion she may want or need to have about
conceiving in the setting of sexual violence almost
impossible.
While
Dr. Rouhani and colleagues studied a population in whom approximately 40% of
women experienced sexual violence, it is sobering to realize that the Centers
for Disease Control and Prevention (CDC) reports that “nearly one in five
(18.3%) of women (in the US) … reported experiencing rape at some time in their
lives” (http://www.cdc.gov/ViolencePrevention/pdf/SV-DataSheet-a.pdf ). While a
continent and world away for some, this is a reality we cannot ignore. Ultimately
prevention is the best cure, but in the meantime, removing stigma is
critical. Work is underway to support
de-stigmatization of sexual violence in the DRC, for example through the
Harvard Humanitarian Initiative (http://hhi.harvard.edu/sites/default/files/publications/women-in-war-stigmatization.pdf), and a brief
search reveals relatively limited initiatives in the US, most primarily focused
on domestic violence (for example, Triumph, a network for survivors
of domestic violence, http://www.seethetriumph.org/). We have work to
do, and the superb research of Dr. Rouhani and colleagues in the DRC is a
wakeup call to all of us.
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