Suggestions for interacting during visits

    Be sensitive, patient, and sympathetic

    • Use empathetic questioning regarding abuse and integrate the patient's history of abuse with current health care. 34
    • Ask sensitive questions when the patient is fully dressed and sitting, a task-oriented question such as, "Is there anything about your past experiences that makes this exam particularly difficult for you?" with a follow-up question such as "What can I do to make it easier for you?" is appropriate. 6

    Share control

    • Include the patient in the treatment choices (i.e. a less invasive procedure, having a support person, or having a female practitioner) 2
    • Regard the patient as a partner in treatment 37

    Ensure privacy

    • Keep the patient covered as much as possible and keep doors closed
    • Only require the absolute minimum amount of clothing be removed. Even telling the patient it is okay for them to leave their socks on can help.

    Practice skillful communication

    • Pay attention to and respond to the patient’s body language.
    • Say something to the effect of, "If you feel uncomfortable with anything that I do, please let me know.” 37

    Explain before you do

    • It is best for providers to be sensitive to the patient’s needs and to tell the patient exactly what to expect during each step of the exam. 2

    Be mindful of possible stress reactions

    • Signs such as becoming stiff, cringing, pulling away, shaking, startling, or crying should not be ignored.
    • Address these signs in a respectful fashion. One way is to normalize the experience. The provider could say, “You seem a little anxious, it is very common for people to feel nervous in these kinds of situations. For some people this anxiety could be due to some physical or sexual abuse that happened in their past. Has this ever happened to you?” 2
    • The provider may also want to stop the exam, allow the patient to sit up and cover herself, and then ask whether she would be more comfortable talking about her discomfort with the exam and reschedule the exam for another day.18

    Respond appropriately if a patient is triggered or dissociates

    • Let the patient know where they are
    • Reassure them that they are in a safe place
    • Encourage them to take slow deep breaths
    • Ask them to look at you and keep you in focus
    • Ask them how they are feeling using a calm voice, but do not inundate them with questions
    • Avoid touching the patient
    • If the patient has disclosed past abuse, let them know that treatment can sometimes trigger flashbacks or emotional responses and that this is not uncommon.
    • If they experienced a strong emotional reaction, reassure them that it is okay to be angry, sad or afraid (or whatever they are feeling). 2

Asking about abuse and responding to disclosure

Potential benefits of disclosure

  • Understanding how a childhood trauma might affect survivors may be crucial to accurately diagnosing and treating somatic and psychosomatic complaints. 6
  • The patient might make a connection between current emotional and physical symptoms with past abuse and might realize that his or her own body is not shameful and start to be able to take better care of it and make healthier lifestyle choices. 47 46
  • A caring relationship with a non-abusive adult such as a primary care provider may facilitate healing and recovery. 48

When to ask about past abuse

  • It is recommended that all providers ask about a history of childhood sexual abuse on intake, but especially if: 76
  • If the patient has numerous painful chronic health symptoms (e.g., IBS, chronic pelvic pain, headaches and extreme obesity)
  • The patient has psychiatric symptoms like PTSD, panic attacks, depression, or dissociation
  • The patient has a hard time establishing trust and has feelings of helplessness, shame, or guilt
  • Or the patient has extreme difficulty with medical procedures 63
  • "The providers should have established rapport and trust with the patient, feel comfortable discussing the topic, can provide an environment where the patient feels safe, have sufficient time to begin to discuss issues of abuse, and have access to psychological referral resources for the patient." 63

How to ask about past abuse

  • Many want to discuss past abuse with their provider, but are never asked or have received a negative reaction in the past.
  • You can either ask directly or through a questionnaire. 33 34
  • If included on the initial patient history form it could read:
    • "Do you have any concerns about rape, sexual abuse, or unwanted sexual activity?"
    • “Did you ever have any unwanted sexual experiences as a child?" 62
  • You can also ask directly. Here are some suggestions:
    • Normalize the question by explaining that this is a routine question that you ask all your patients, recognizing that it may be important in their physical or mental health.
    • Asking very general, open-ended questions, such as "When you were growing up, did you have experiences of a sexual nature that were frightening or embarrassing or confusing to you?"
    • "As a child, did anyone touch you in any way that was frightening, embarrassing, or confusing?" 76
    • "Are there any experiences not yet discussed that have been particularly difficult or painful for you?"
    • “It is not uncommon for a person to have been emotionally, physically, or sexually victimized at some time in their life, and this can affect their health many years later. Has this ever happened to you?” 63
    • "Are there any incidents of physical or sexual abuse in your past?"
    • "Have there been any traumatic experience or major loss in your life?"
  • Remember that it may take a long time before a survivor tells a provider about their abuse, so there may be a lot of false negatives on initial inquiry.

What to say and do when a patient discloses

  • If a negative message is conveyed to the survivor at the time of disclosure, the survivor may re-experience the feelings associated with abuse such as betrayal, stigmatization, and powerlessness. 45
  • When disclosure is received and acted upon in a sensitive, therapeutic manner, the survivor is empowered and can enter into an effective therapeutic alliance. 45
  • Every survivor is different in terms of how much they remember about their sexual abuse, what effect it had, how they cope with it, and if or how far along they are in the healing process. 4
  • You could say something like, "I'm sorry this happened to you. Please know you are not alone and it is not your fault. Your experience must have been very frightening, and it would not be uncommon to feel angry, embarrassed, and fearful afterward.”
  • Ask survivors if they have ever told anyone else about their abuse
  • Find out about their support systems and if they are in any current danger 51
  • If the patient does have a history of sexual abuse, the provider could also ask about symptoms of depression, suicidality, self-mutilation, or PTSD. 64
  • Remember: As a healthcare provider you are a mandated reporter. Laws of reporting childhood sexual abuse vary by state, so be familiar with your state's laws.

What to do next: Recommending coping strategies, referrals, and patient resources

Recommend good coping strategies

  • Suggest to the patient to find a support system, reach out and connect with others, especially those who may have shared the stressful event
  • Talk about the traumatic experience with empathic listeners
  • Engage in exercise like jogging, aerobics, bicycling, or walking
  • Try relaxation exercise like yoga, stretching, and massage
  • Prayer and/or meditation; listening to relaxing guided imagery; progressive deep muscle relaxation are helpful for some
  • Take hot baths, cry, use humor, music or art
  • Eat a balanced diet and maintain a good sleep cycle
  • Journal about your experience, feelings and thoughts 49

Refer patients to good providers

  • Ask if there is someone they can talk to.
  • Find therapists or counselors that are survivor based and are comfortable with helping patients who have been sexually abused in the past. 55
  • Consider therapists or counselors with an alcohol or drug abuse/dependence specialty 73

Provide patients with resources and recommend support groups

  • Click here to go to the resource section for articles, patient education materials, additional website links, and support group ideas.

Click here to download a 5x8 card with a summary of the communication suggestions

"If You are Going to Help Me:

  1. Please be patient while I decide if I trust you.
  2. Let me tell you my story. The whole story. In my own way.
  3. Please accept that whatever I may have done, whatever I may do is the best I have to offer and seemed right at the time.
  4. I am not ‘a’ person. I am this person, unique and special.
  5. Don’t judge me as right or wrong, bad or good. I am what I am and that is all I have got.
  6. Don’t assume that your knowledge about me is more accurate than mine. You only know what I have told you. That’s only part of me.
  7. Don’t ever think that you know what I should do – you don’t. I may be confused, but I am still the expert about me.
  8. Don’t place me in a position of living up to your expectations. I have enough trouble with mine.
  9. Please hear my feelings, not just my words – accept all of them. If you can’t, how can I?
  10. Don’t save me. I can do it myself. I knew enough to ask for your help didn’t I?" - Anonymous 4