The past few years have witnessed unprecedented disclosures of sexual assault, spanning public figures from business, politics, pop culture, and the media. The #MeToo movement has sparked tremendous interest, involving people openly sharing their sexual trauma experiences privately in health care settings and in public venues such as social media.
Physicians should be prepared for patient disclosures of sexual trauma to occur in the exam room and be ready to respond in an empowering and compassionate manner. This article focuses on effective communication methods for addressing sexual trauma with patients who have experienced sexual assault in adulthood. The recommendations apply both to the immediate aftermath of the trauma and to working with survivors in the subsequent days, months, and years after the assault. The medical and legal issues around working with survivors of sexual assault are beyond the scope of this article, but excellent resources are available (see “Resources”).
Physicians need to be prepared for patients to disclose a history of sexual assault and respond to patients in an empowering, compassionate manner.
How physicians respond to disclosure of sexual assault matters. You can be most helpful by providing emotional support, offering resources, and reassuring patients the assault wasn't their fault.
Avoid using physical touch to comfort, as it's impossible to know how survivors will experience touch. Use your words, tone of voice, and body language to convey support.
DEFINING THE IMPACT ON SURVIVOR HEALTH
According to the Centers for Disease Control and Prevention, the lifetime prevalence of contact sexual violence (defined as rape, being made to penetrate someone else, sexual coercion, or unwanted sexual contact) is 36 percent for women and 17 percent for men.1 Among female survivors, nearly half of their perpetrators are current or former intimate partners.1 Furthermore, more than half of women report being re-victimized sexually.2
Sexual assault has a clear impact on survivors' physical and mental health. Women and men who have experienced sexual assault have a higher risk of health conditions such as asthma, irritable bowel syndrome, headaches, chronic pain, poor sleep, and overall poor physical health.1 Mental health problems are also more common among sexual assault survivors, including post-traumatic stress disorder (PTSD), depression, anxiety, substance abuse, excessive feelings of shame and guilt, sexual problems, and others.1,3
RESPONDING TO DISCLOSURES OF SEXUAL ASSAULT
How physicians respond to disclosure matters. Research has found that negative social reactions to sexual assault disclosure (e.g., blaming the victim, treating the victim differently, attempting to control the victim's actions, or focusing on one's own feelings rather than the victim's) are related to depression, substance abuse, and more severe PTSD symptoms among survivors.4–6 On the other hand, positive social reactions (e.g., providing emotional support, offering resources, and explaining that it wasn't the victim's fault) are related to survivors having a greater perceived control over recovery, which is related to fewer PTSD symptoms. Ullman suggests, “If we can teach people how to respond more positively to survivors' disclosures, then we can indirectly increase women's perceived control over recovery and adaptive social coping, and in turn potentially reduce PTSD symptoms.”4
The following suggestions may help you to respond effectively when patients share information about their sexual assault history:
1. Sit down. Move away from the computer, and make eye contact with the patient.
2. Listen nonjudgmentally. As with disclosures of other sensitive topics, your most important task when patients disclose a sexual assault history is to listen without judgment, express support, and avoid retraumatizing the survivor.
3. Choose words that support and empower. Using a gentle, receptive, and kind tone of voice may also help survivors feel comfortable talking about this difficult subject. Although the specific words you use when responding will likely vary depending on the patient's situation, your relationship, the recency of the trauma, and the patient's emotional state, the overriding sentiment should be one of empathy, empowerment, respect for patient autonomy, and reduction of self-blame (especially if the survivor knows the perpetrator). (See “Messages to convey after a survivor discloses sexual assault.”)
MESSAGES TO CONVEY AFTER A SURVIVOR DISCLOSES SEXUAL ASSAULT
Thank you for telling me.
It took a lot of courage to share this with me.
I'm sorry this happened. This must be really tough for you.
It's not your fault. You didn't do anything to deserve this.
You are not alone.
I care about you. I am here to listen or help in any way I can.
I wonder if there's anyone you'd feel comfortable talking to about this.
You decide what you think is best for you.
Adapted from RAINN. Tips for talking with survivors of sexual assault. 2018. https://www.rainn.org/articles/tips-talking-survivors-sexual-assault. Accessed May 9, 2019.
Some well-intentioned providers make comments that survivors find judgmental, hurtful, and unsupportive. Sexual trauma can involve feelings of grave personal violation, loss of control, fear, and humiliation, so routine instructions and questions may feel disrespectful and threatening. Avoid trying to investigate the assault; the legal team can manage the detective work. Statements to avoid include the following:
You should be over this by now.
Why don't you remember everything that happened?
You really need to report this to the police. (Note: It's OK to explore whether the patient has or wants to report it to the police, but empower survivors to make their own decisions.)
You really need counseling.
Why did you or didn't you (invite him over so late after you'd been drinking, fight back, call the police, etc.)?
Physicians should also use anatomical names of body parts when talking about the assault or subsequent health issues. Use of phrases such as “down there” may give the patient the message that the doctor is uncomfortable talking about sexual organs and may impede open communication.
4. Avoid using touch to comfort. Some empathic providers may feel the urge to offer reassurance to a distressed survivor through touch (e.g., a pat on the back or knee) or even by initiating a hug. However, by definition, sexual assault involves someone exerting control by violating someone else's physical space and boundaries. Even if the physical expression of support is intended to be nurturing, it is impossible to know how the survivor will experience it. Therefore, use words, tone of voice, and body language to convey support rather than physical touch.
5. Be prepared to offer resources and follow-up. Learn about your local community resources, and be prepared to offer referrals. Most large cities have organizations focused on helping survivors of sexual violence that offer 24/7 crisis phone lines and counseling. At the national level, RAINN (Rape, Abuse & Incest National Network) offers a 24/7 website live chat and phone hotline (see “Resources”) and can also connect people with support services in their areas. Clinics and hospitals may also consider placing brochures and posters in their waiting rooms for local or national anti-sexual-assault organizations. Also, adding a note to the patient's history can help remind you of the need to provide sensitive treatment during future visits to your office.
For physicians: Legal and clinical considerations
Cuevas KM, Balbo J, Duval K, Beverly EA. Neurobiology of sexual assault and osteopathic considerations for trauma-informed care and practice. J Am Osteopath Assoc. 2018;118(2):e2–e10.
Luce H, Schrager S, Gilchrist V. Sexual assault of women. Am Fam Physician. 2010;81(4):489–495.
World Health Organization. Guidelines for medico-legal care for victims of sexual violence. 2003. https://www.who.int/violence_injury_prevention/publications/violence/med_leg_guidelines/en/. Accessed May 4, 2019.
For patients: National resources
RAINN Hotline: 800-656-HOPE (4673)
SUPPORTING SURVIVORS DURING PHYSICAL EXAMS
Physical exams can be triggering for people who have experienced sexual assault. Any procedures that involve touch or inserting an object into the patient's body — including pelvic exams, colonoscopies, endoscopies, and oral procedures — may elicit a reaction. The power differential between the patient and physician or the process of removing clothing, being touched, or having one's sexual organs examined may also trigger reminders and feelings from the trauma. In response, the patient may feel overwhelmed, anxious, and scared. The patient may suddenly be flooded with distressing memories of the trauma, and may even dissociate and feel detached from the present situation.
Notably, sexual assault survivors usually don't tell the doctor that the exam was upsetting or triggering. However, due to previous negative experiences or fear of an intrusive exam, they may avoid doctors, minimize or deny symptoms, or refuse invasive tests. Without knowing the patient's trauma history, the physician may be baffled and frustrated, and may even label the patient as “noncompliant.”
Although it may be impossible for you to prevent all forms of distress for sexual assault survivors during physical exams, there are steps you can take to help the patient feel more in control, present in the here and now, and less emotionally flooded. (See “Recommendations for physical exams with survivors of sexual assault.”)
RECOMMENDATIONS FOR MANAGING PHYSICAL EXAMS WITH SURVIVORS OF SEXUAL ASSAULT
Before the exam
Allow extra time so you're not rushed.
Before the patient disrobes, explain everything you plan to do (as well as the reasons for doing so).
Consider questions such as:
“What part of this procedure is hardest or scariest for you?”
“What could I do to be of support to you during the exam?”
“How could you let me know if you need to take a break or stop? I want you to feel in control and safe here.”
Have resources and referrals available.
During the exam
Ask explicitly for the permission to touch.
Speak in a calm, matter-of-fact voice and avoid sudden movements.
Explain everything you're doing.
Talk about nonmedical, nonthreatening topics.
Check in regularly throughout the exam about how the patient is feeling and provide reassurance.
Offer a drink of water, an extra gown, or a warm or cold washcloth.
Offer to take a break or move with the patient into a different room to provide a change of environment, or reschedule the exam if needed.
Adapted from Sharkansky E. Sexual trauma: information for women's medical providers. Washington, DC: National Center for PTSD; 2018. https://www.ptsd.va.gov/professional/treat/type/sexual_trauma_women.asp. Accessed May 9, 2019.
SCREENING FOR A HISTORY OF SEXUAL ASSAULT
Although physicians rarely raise the topic of sexual assault with their patients, many survivors believe that discussing sexual assault with their physicians can help them recover, and they are much more likely to disclose sexual assault if they are asked about it.7 During an office visit, a physician's verbal and non-verbal communication skills can either help or hinder the elicitation of a disclosure.7 You can facilitate disclosures by establishing an open, supportive attitude, demeanor, and office environment.7 Consider incorporating questions about sexual assault history in templates or patient surveys for new patient appointments, annual visits, or first obstetric visits. If you already screen for intimate partner violence, consider broadening the screening questions to also include questions about sexual assault. We recommend addressing sexual assault history before performing an invasive exam, while the patient is fully dressed and when you and the patient are both seated.
To elicit sexual trauma history, some well-intentioned providers may ask broad questions such as, “Have you experienced any traumatic events?” However, patients who have experienced multiple traumas throughout their lifetimes may not know where to start or what you want to know. Therefore, a more direct approach may work best. We recommend the following phrasing: “I'm going to ask a few questions that will help me provide the best care for you. Many of my patients have experienced sexual violence. Has anything like that ever been done to you?” Or, in follow-up to a screening instrument completed before the visit, you might say, “Many of my patients have experienced sexual violence, and I noticed you marked ‘yes’ on the screening questions. Is there anything I can do to help make the exam more comfortable or easier for you?”
This wording offers several advantages: First, it offers some context. It can be helpful for patients to know why you are asking about something so private — some patients may not see the connection between a history of sexual assault and their current well-being. Second, it reminds patients that they are not alone and gives them permission to disclose if they feel comfortable and ready. Having the physician open the discussion may also enable survivors to disclose at a subsequent appointment if and when they feel safe to do so. Third, this approach avoids the “Did sexual assault happen to you?” phrasing that is commonly employed. Sexual violence never “ just happens.” Someone made a conscious choice to sexually assault the survivor. Small word choices can make a huge difference when talking with survivors.
Sexual assault is common and has a significant impact on survivors' health and well-being. As a family physician, you are uniquely positioned to support survivors with continuity of care and a holistic approach to patient care. We hope these recommendations assist you in responding to disclosures of sexual assault in an empowering, compassionate manner.