Imagine this patient is you: A podiatrist’s hand rests uncomfortably high on a patient’s thigh while he checks her body alignment in new orthotics. In a follow-up appointment, a dermatologist demands a returning patient remove her blouse in front of a handful of medical students to check for lesions before treating a face lesion. The patient reluctantly complies as her face blushes deep from the embarrassment. Or, imagine that a male patient beside you watches as a physiotherapist rolls the waistband of your shorts to your pubic bone in order to apply treatment. Now, imagine at some point—recently, or in your past—you experienced sexual assault.
WHILE PRIVACY IS AN ISSUE for many of us during examination and treatment by health care professionals, many are untrained to recognize the specific discomfort patients with sexual assault, rape, or childhood sexual abuse (CSA) history experience. In fact, many victims do not attend routine exams, making these patients vulnerable or prone to illness.
Statistics Canada reports that 51 percent of all Canadian women have experienced at least one incident of sexual or physical violence, and close to 60 percent of these women have survived more than one incident of violence, with only one out of six reporting the incident to police. For these individuals, annual visits to the doctor’s office for Pap smears and pelvic or breast examinations are difficult to endure. Some find visits to secondary healthcare practitioners such as dentists, chiropractors, and physiotherapists, difficult as well.
Health practitioners routinely fail to obtain information on a patient’s history of sexual or physical abuse while documenting their history. Getting this information in the beginning could help make examinations easier for these trauma survivors. It is typically absent on questionnaire forms for new patients, and rarely addressed during in-person consultation because the medical community is untrained and most do not know how to sensitively raise the subject. And many patients, prefer to visit a different doctor after a physical attack to ensure confidentiality and, understandably, never share this information with their family doctor.
It could be beneficial to patients for practitioners to be aware of a sexual assault history, the medical community is surprisingly untrained and ill-informed when it comes to caring for the needs of these patients. They simply do not know what to ask, or how to ask it. When the subject is raised with a gently posed question, or an explanation as to why it makes a difference in the patient’s treatment, helps the patient understand the benefits of disclosure. If the patient chooses to not to, offering the opportunity to do so later, at any time, makes it clear that her privacy is respected, and that the choice is hers.
Concerns of trust and safety are especially important to CSA survivors
An article by S. Tudiver, Ph.D., et al, published in A Friend Indeed, states concerns of trust and safety are especially important to CSA survivors, who fear losing control. It provides recommendations for menopausal patients, but is cautious when treating patients of all ages who have experienced sexual assault trauma recently, or at some time in their past. Giving the patient “control over whether they wish to disclose further details and/or offer practical suggestions to ease her care” is crucial, as is asking sensitive questions such as, “Is there anything about your past experience that makes this exam particularly difficult for you?” and “What can I do to make it easier for you?”
Training for doctors needs to be based on survivors’ needs and recommendations. Even small changes such as artwork, music, and cartoons can help women with CSA histories feel safe and comfortable. Other suggestions include:
- asking permission before touching
- careful and thorough explanation of procedures
- warning about pain
- encouraging questions
- confirming that the patient can stop the procedure at any time
The article states that there is “an urgent need for health care professionals to be educated about issues related to childhood sexual abuse, in ways appropriate to their practice.”
In a companion piece, Getting Through Medical Examinations A Resource for Women Survivors of Abuse and their Health Care Providers, also provided by the Canadian Women’s Hospital Network (CWHN), the writers offer specific ways for physicians and primary care nurses, dentists, sonographers, mammographers and breast-screening nurses to help survivors of abuse, including those listed above, and identify possible signs of past sexual abuse based on a patient’s perceived anxiety about and reaction to the procedure. The article highlights the importance of health care professionals educating themselves about the long-term effects of abuse in ways appropriate to their practice, but how many actually take the steps to do so?
The College of Physicians and Surgeons of Ontario (CPSO) does “recommend life-long learning for physicians,” however, “[They] do not set continuing professional development requirements—individual doctors are expected to stay current in their particular area of practice,” says Kathryn Clarke, senior communications specialist CPSO. Primary care providers such as family doctors are on their own when it comes to training and education. They are expected to continue training and development on their own, as are registered massage therapists, chiropractors, and physiotherapists.
Health care practitioners routinely avoid asking patients for their complete history, partly because they have not been trained to do so, but, also because of concerns over confidentiality laws. In a two-part series in the Canadian Medical Association Journal, human rights lawyer Marilou McPhedran discusses concerns about a 1996 Supreme Court decision to demand disclosure of medical records of patients who made allegations of sexual assault, sexual abuse or incest.
By having the confidentiality of patient records called into question, these patients, key witnesses in legal proceedings, who have reported the assault to the authorities and are in treatment to heal from physical, psychological and emotional trauma are subjected to re-victimization in a legal system at odds with the medical community bound by a Code of Ethics to honour confidentiality and in opposition to rights of the accused.
About this effect of this legal decision, McPhedran, who is also the newly appointed Principal of the Global College, University of Winnipeg quotes Kathleen Parfitt, a psychiatrist who practices in British Columbia: “I’m a doctor, but I’m also a citizen, and I question how I can help the government understand just how harmful these recent decisions are to the practice of medicine.” The requirement to reveal private medical records may explain hesitancy on behalf of medical professionals to collect this type of information, even if it enhances patient care.
“It’s a difficult question to ask,” asserts the office manager at a dental office. Although, she says, dentists and hygienists are sensitive to verbal discussions when treating patients who have stated a preference for a female dentist, practitioners in her office do not address the specialized needs of these patients.
If it is uncomfortable for health care providers to ask, imagine the difficulty for patients to raise the issue.
For many survivors, silence condones, as much as it displays, disapproval and judgment. Victims innately understand that what is unspoken is not worth discussing, and they may take it as a reflection of their self worth, creating further traumatization.
Lack of inquiry may even trigger secondary victimization—the “insensitive, victim-blaming treatment from community system personnel”—described by Rebecca Campbell and Patricia Yancy Martin, in The Role of Rape Crisis Centers Sourcebook on Violence Against Women. If secondary victimization can be defined as “negative treatment that mirrors and exacerbates the trauma” then we can think of the lack of acknowledgment and sensitivity that health care professionals who routinely ignore the need for when treating the health needs of female patients with a history of sexual assault, rape, or CSA, as a form of repeated victimization.
Lack of interest in a patient’s emotional and psychological care is harmful, and there are fewer situations in which a woman is exposed—literally and figuratively—than during childbirth when nurses and doctors, some of whom a patient never sees again during her hospital stay, conduct invasive examinations. A retired career labour and delivery Registered Nurse recalls some expectant mothers who refused examination. It was assumed, she says, that there had been, or was currently, some form of abuse, but patients were never pushed to disclose this. It was simply noted on the patient’s chart. And, despite being part of a committee of hospital peers that created a labour and delivery form they used to chart medical information, she says no one thought to include a sensitively-worded question designed to give the patient an opportunity to disclose her sexual assault, rape, or CSA history. Even if acknowledgment meant nursing staff could take extra measures to ensure comfort.
Even with an option to disclose, survivors are entitled to privacy and should not feel obligated, or believe that disclosure is requisite for medical care, which may be the case when included on a medical form. However, to meet survivors’ needs, health care professionals must be trained in how to best treat patients with sexual assault, rape, and childhood sexual assault histories.