Sexual Abuse & Medicine: Working with Survivors

Sexual Abuse & Medicine: Working with Survivors

The Sherwin B. Nuland Summer Institute in Bioethics

Yale University

Ruth Retassie

The standard approach to medical care in the U.S. involves a presenting issue(s), the diagnosis of the issue, then treatment and follow-up of that same issue. Generally this model works well, but what about the underlying, harder-to-detect concerns of the patient? What about the problems that the patients don't even know may be contributing to their current state of ill-being? This essay introduces readers to sexual violence as it pertains to the medical field.

Sexual abuse is one key example of a trauma that can have life-long effects in a wide range of manifestations. Most survivors do not even realize this. A lot of survivors do not identify as survivors of sexual abuse, let alone as persons suffering from ailments that may have been caused by trauma. Many medical professionals do not screen for sexual abuse, and even less discuss abuse with their patients. Often there are delays in the time it takes for people to receive the help and services they need, if they receive any assistance at all.

To put it into perspective: if doctors screened every patient for abuse histories, more people would be getting offered therapy, legal services, support systems, and the chance to tell someone their stories. They can become empowered making a decision to act in response to their past. While this isn't preventive care, it might be early response care for some people. Prevention of the abuse entirely is the priority, but it requires a lot of systemic changes. Indeed, screening may be the first step towards that goal because it creates a space to talk about it.

So, what exactly is sexual violence? It is any sexual act done without the explicit consent of the recipient. Sexual abuse runs the gamut from harassment to rape. The term "sexual assault" is the legal umbrella term that encompasses the range of crimes. A common misconception is that it is an action out of extreme lust or passion; however, sexual violence is a demonstration of power (Minnesota, 2007).

A major obstacle to improved nationwide knowledge of and concern for sexual violence continues to be misinformation and false beliefs. The myths that get propagated and the victim-blaming in American culture is pervasive and damaging. Here are some facts researchers know about sexual violence. Most sexual assaults: 1) occur at home, 2) are committed by someone known, 3) occur during the day, 4) approximately 63% go unreported, 4) happen to any and all types of people. Sexual violence affects people of all orientations, genders, ages, religions, marital statuses, socioeconomic statuses, ethnicities and so on (Centers, 2010). With that being said, certain populations are more at risk, including prison inmates, transgender people, and homeless people (Minnesota, 2014).

The prevailing case is that medical professionals are not trained to discuss this topic within the scope of their practices; they also often remain unaware of the prevalence of sexual abuse. The National Intimate Partner & Sexual Violence Survey reported that one in five women and one in seventy-one men will be sexually assaulted in their lifetimes (Centers, 2010). In Connecticut the statistic is one in four women, and one in five state residents, as reported by Connecticut Sexual Assault Crisis Services in 2000. Male survivors make up 10% of the victims in Connecticut (Macro, 2000). The U.S. Department of Justice reported that an American is sexually assaulted every two minutes (2013).

When we look at the vulnerability of this population, it becomes clear that they tend to interact with medical professionals more on average than non-survivors and victims of other crimes. Survivors of sexual assault tend to need lots of gastrointestinal care, and they tend to avoid obstetric/gynecological care even though they often have great need for those services. Some common health concerns include: sexual dysfunction, chronic pelvic pain, eating disorders, personality disorders, PTSD and depression, as well as issues with pregnancy, childbirth and breastfeeding (Horvath-Cosper, 2014). The wellness of survivors varies greatly, but it can be useful to note that patients who have heavy medical histories may need some extra support. Indeed a lot of patients have bad experiences with medical professionals due to their lack of sensitivity.

The Pennsylvania Coalition Against Rape has developed a model to screen for sexual violence called the SAVE model. This model involves: 1) Screening all patients for sexual violence; 2) Asking direct, non-judgmental questions; 3) Validating the patients by believing them; 4) Evaluating, educating, and referring the patients when appropriate (Pennsylvania, 2007). This model is thorough and keeps in mind the medical professionals' scope of practice, i.e., there is no expectation for doctors to act as therapists. One of the best aspects of this screening model is that it trains people to be empathetic, objective, and active listeners. Below are each of these steps in closer detail.

Screening all patients begins to normalize the conversations about sexuality and, in particular, sexual abuse. Medical professionals can begin the screening process via patient intake forms. Forms are a great approach because the conversations can be modified based on how the patients respond. Many survivors want to talk to someone they trust about their experiences, but they do not want to begin the conversations themselves for numerous reasons. Some examples of why patients do not start the conversation is because of shame, increased arousal, avoidance of triggering stimuli, or they may not see its relevance to their current concerns (Pennsylvania, 2007).

Asking direct questions in a respectful way is a skill that takes practice. Most importantly, doctors should never blame the victim. Survivors may blame themselves, but it is not appropriate to blame them too. They might try to dismiss what happened to them but agreeing with such claims will not help. Asking questions while a patient is fully dressed can really help them feel safe and comfortable. Medical professionals must practice staying calm and unaffected by such news, because if they seem anxious and worried, the patients will feel so too. Survivors need not go into all of the details of their experiences, but a confirmation and a description of their concerns can be really helpful in determining what an appropriate treatment plan may be. There's no rush, they need not share any details during the first visit. Knowing they can reach out to their health care professionals about past traumas is valuable itself.

Validating the patient is an important step in the SAVE model. Doctors need to thank the patients for telling their stories, and they also need to tell patients they believe them and do not blame them for what happened. Telling someone about past trauma is a big step. Having the patients express their concerns and emotions at their own pace is priceless. Medical professionals can empower the patients by letting them make their own decisions.

The final step of the SAVE model is to evaluate the patient's situation. What are the current concerns? When was the incident? Does the patient have suicidal ideations? Once the time sensitive assessments have been made, it is time to educate the patient and provide options. Some education might pertain to legal definitions or biological explanations, but doctors should keep it brief and respectful--using their own terminology is important. Having pamphlets detailing local therapists and professionals experienced in working with survivors is very useful. Being able to distribute a couple of options in each type of referral maximizes the patients' opportunities to make their own decisions regarding their sexual abuse treatment.

There are numerous benefits to screening for sexual violence during medical exams. Medical appointments are entry points where professionals engage with a large percentage of the population. Survivors want to start healing, but often do not have the resources to do so. By screening for sexual violence, doctors are abiding by their duty of care as well as caring for the patients' needs (Jacob, 2014). Screening can act as an educational tool that also ultimately helps more people have access to the services and support they might need.

One concern for implementing screening is time constraints both in educating and training medical professionals, but also time limits on doctor visits. One way to anticipate appointment lengths might be through screening via intake forms. Depending on the way a patient responds can set the stage for each visit. Another way to manage various patients' concerns could be through integrative care, i.e., by having a licensed therapist on staff to further assist patients.

The final question is: what does it mean to be a great provider? One component is being a good listener, by taking the time to hear what patients say and by making them feel believed and feel safe to disclose information. Another skill is they need to be mindful of nonverbal signals. It's very easy for people to read body language and think the listener is disgusted, uninterested, or uncomfortable based on how they are positioned during the conversation. A skillful provider can connect the dots with the information gleaned from the patients. Reading between the lines may involve the mindfulness that any and every patient could be a survivor of sexual violence.

In conclusion, screening all medical patients for sexual violence seems like the next best step toward sexual violence prevention. This can begin to improve many folks' quality of life, and it will create a greater awareness of sexual violence in general. As front-line caregivers, doctors can screen more patients and get them direct care, which may reduce some patients' health care costs and concerns down the road. This can be valuable for physicians to incorporate into their practice as a means of addressing its prevalence. By at least asking patients, medical professionals create a space in which people will be given the opportunity to begin the healing process if and when they are ready.

Bibliography

Centers for Disease Control and Prevention. (2010). The national intimate partner & sexual violence survey. Retrieved from

Chartier, M.J. (2009). Health risk behaviors and mental health problems as mediators of the relationship between childhood abuse and adult health. American Journal of Public Health, 847-854.

Dickinson, L. M. (1999). Health-related quality of life and symptom profiles of female survivors of sexual abuse. Archives of Family Medicine, 35-43.

Dube, S.R. (2005). Long-term consequences of childhood sexual abuse by gender of victim. American Journal of Preventive Medicine, 430-438.

Hazzard, Ann. (1993). Trauma-related beliefs as mediators of sexual abuse impact in adult women survivors. Journal of Child Sexual Abuse.

Horvath-Cosper, D. (2014). OB/GYN care of the sexual assault patient. Sexual Assault Fundamentals Education conference.

Jacob, C. A. (2014). Empowering conversations: talking with survivors of sexual assault and child sexual abuse. Sexual Assault Fundamentals Education conference.

Macro International, Inc. (2000). Sexual assault in Connecticut. Retrieved from

Mcnutt, L. (2002). Partner violence intervention in the busy primary care environment. American Journal of Preventive Medicine, 84-91.

Minnesota Coalition Against Sexual Assault. (2007). Sexual violence in Minnesota: a resource manual for advocates. Sexual Harassment: A Matter of Power, 13-20.

Minnesota Coalition Against Sexual Assault. (2014). What is sexual violence? Retrieved from

Mol, S. S. (2002). Traumatic events in a general practice population: the patient's perspective. Family Practice, 390-396.

Pennsylvania Coalition Against Rape. (2007). Screening patients for sexual violence: an accredited curriculum for nurses in Pennsylvania. Retrieved from

Robohm, J.S. (1996). The gynecological care experience of adult survivors of childhood sexual abuse: a preliminary investigation. Women & Health, 59-75.

United States Department of Justice. (2013). Female victims of sexual violence. Bureau of Justice Statistics. Retrieved from

Weinreb, L. (2010). Screening for childhood trauma in adult primary care patients. The Primary Care Companion to the Journal of Clinical Psychiatry.

Widom, C.S. (2012). A prospective investigation of physical health outcomes in abused and neglected children: new findings from a 30-year follow-up. American Journal of Public Health, 1135-1144.

Zinzow, H.M. (2012). Receipt of post-rape medical care in a national sample of female victims. American Journal of Preventive Medicine, 183-187.