My next patient, Sara, was new to the practice. She opened the visit with, “I have lots of issues.” She was in her mid-thirties, pleasant, and poised. I asked her if we could make a list of her issues and prioritize them since I needed to gather her entire medical history. She agreed without hesitation. The first item rolled off of her tongue, “I need medication for genital herpes. My grandfather gave it to me when I was a child. He abused me from age 3-12.” She quickly changed the subject without missing a beat and moved to her next complaint, “I also have lots on cherry angiomas on my face that I would like removed.” She did not flinch. Her voice did not tremble. The trauma had become part of her story but it did not define her.
I wish I could say that sexual assault survivors are uncommon in my practice, but they are not. At least one or two patients I see a day have a history of sexual trauma. Many sexual assault survivors I see are burdened by depression, anxiety, PTSD, substance use, chronic pain, and multiple somatic complaints. It is hard for them to have intimate relationships. They cannot always hold a job. Many people of color have added minority stress and experience racism and discrimination in addition. Transgender and gender diverse patients also have an added layer of stigma due to transphobia.
Why am I sharing this? What does this mean for the medical community? Many survivors have also been re-victimized and memories of the trauma can be triggered by clinicians during an exam. The survivor above made it clear that her grandfather was the perpetrator, but on questioning about routine cancer screening she told me, “I was having my pap smear and the OBGYN ran out of the room crying because of all the scarring she saw.” The patient was reminded of her trauma, but had to comfort the provider because of her reaction. Another young woman, a lesbian of color, presented with recurrent vaginitis and when asked about doing a pelvic exam, she froze and said, “I don’t want any more pelvic exams because the last one was a male OBGYN who put his fingers in me so hard. It caused me a lot of pain.” Lastly, a middle-aged trans masculine patient was due for cervical cancer screening. He told me that he was prepared for the exam and we walked through it with his partner in the room. Only later did he tell me that this triggered his previous abuse and during the exam he went into a dissociative state.
How do we as a medical community address the distress of sexual trauma? How can we make sure that we are not the perpetrators? In recent years, the term “trauma-informed care” has been used to describe the ways in which providers in varied settings (i.e. social service, education, health care, and corrections) can better serve people who have experienced traumatic life events. As a family physician with a focus in women’s and LGBT health, we have adopted the following tips. For more tips, refer to this paper on Trauma Informed Care in Medicine.
- Whenever examining any part of the patient, ask permission. For non-sensitive exams like listening to the heart, use implicit consent, “I’m going to listen to your heart now.” Wait for the response, then proceed. For more sensitive exams, always ask explicit consent. Allow the patient to know that they are in control throughout and nothing will happen that they do not want to happen. For example, “If I do something that makes you uncomfortable, let me know and I will stop.”
- Use non-sexualized language in the exam room, ie: drape instead of sheet, foot rests instead of stirrups, examine or palpate instead of touch or feel.
- For pelvic exams, make sure the bed is lifted at least 30 degrees so the patient is not flat on their back.
Recent research is insufficient to show that annual clinical screening pelvic or breast exams improve health outcomes. US Preventive Services Task Force gives routine pelvic exams in asymptomatic women grade I. The American Cancer Society does not support routine clinical breast exams as a method for cancer screening. We argue that both of these exams should be a discussion and to use shared decision making with the patient. This is a situation where the risks of anxiety may outweigh the benefits. Pelvic and breast exams may be particularly triggering for some patients. Why perform them routinely when there is no evidence if we may be doing more harm than good? This topic becomes even more sensitive for the transgender and gender diverse population where patients may be uncomfortable with their body. For routine physical exams, we should be asking about genital complaints and avoid routine exams unless the medical history indicates otherwise.
At the end of the visit with Sara, her eyes filled with tears, as she gave me a hug. “I want to give back. I didn’t want to be defined by my abuse. I’ve worked hard to overcome it. I want to share my story.” Sara went through five years of counseling to be able to process what happened. For the last 10 years, she has been in a successful relationship. She has a full-time job and two children. Sara inspired me and if she had not shared her story, I would have never known. With her permission, I share her story with you.
Unfortunately, Sara is one of that few survivors that I have cared for who is able to live her life to the fullest despite her trauma history. She has taught me to be more aware of trauma, listen to our patients, validate their experience, and respect their boundaries.
Chelsea Graham, DO
Family Physician and Rhode Island Network Member