Anita Ravi, MD, MPH, MSHP is a family physician engaged in clinical, research, and policy work focused on addressing gender-based violence and health. She is the founder and clinical director of the Institute for Family Health’s PurpLE Clinic (Purpose: Listen and Engage), a primary care clinic that serves people who have experienced sexual trauma, including sex trafficking. During Sexual Assault Awareness Month, we are collaborating on a three blog series on the intersection of sexual assault and reproductive healthcare.

Every Monday afternoon in the summer of 2015, I would ride the bus home from Rikers Island, quietly panicked.  I was in the midst of completing a series of interviews with women incarcerated on Rikers who had experienced sex trafficking.  As sex trafficking in the United States is being recognized as a significant but understudied medical and public health issue, and because some survivors experience repeated incarcerations due to trafficking-related circumstances, the interviews were designed to better understand the healthcare experiences of women who had experienced sex trafficking.   After each interview, as I turned the tape recorder off, my mind reactively turned on, with fragments of the day’s conversations replaying incessantly in my mind. Every bus ride home became a frenzied attempt to process and reconcile the advice that the women had shared, with my current understanding of how to practice medicine.

As a family medicine doctor who works with people who have experienced sexual violence, one interview in particular plays on loop in my mind.  “Lady M” (a pseudonym she chose) was one of the 26 women who had shared her perspectives on sex trafficking and healthcare. For 54 minutes, she navigated me through the pivotal experiences in her life that formed the advice she wanted to offer to healthcare providers.  As most of the women in the interviews did, unprompted, she started her story by describing experiences with childhood sexual abuse and incest, and the ways in which she tried coping with these abuses, including excelling academically. She talked about her experience with a trafficker, who serially raped her, and then began selling her to buyers. Later in life, she sold sex to pay for her substance use addiction.  When we transitioned to discussing her reproductive healthcare experiences, she shared  a story from her first pregnancy:

“I had four sonograms throughout…that pregnancy. Three of them stand out amongst them all.  One of them, she’s in the fetal position…but her hands were together like she was praying.  Her second sonogram she was on her hands and knees, almost…doggy style.  And her third one was the most interesting.  She’s laying on her side, but she’s like cocking her leg open.  It looks sexual to me… I was floored. Did this kid know anything about what I was doing?  And so, I’m like more trauma.  More trauma, because my mind, I’m like ‘oh, God.  Maybe her egg knew.’  Like I’m talking about naïve.  I’m thinking like her egg knew that I was prostituting.  But she’s showing me that, ‘mom, I know.’”

On the bus ride home that day, flashing through my mind were the numerous times that I had stood next to my patients, performing their prenatal ultrasounds. With each visit, I remember learning another item to add onto the trauma-informed care checklist that our attendings had so diligently taught us: notify patients in advance that the ultrasound probe will be inserted vaginally, apply lubrication generously, use appropriate, non-biased language when describing the images on the screen, and the list goes on– all with the intent of decreasing the risk for traumatization when providing medical care.  But I had no tools for Lady M’s scenario. I felt overwhelmed- hers was a reaction to a routine part of medical care that I had never considered, and it made me wonder how many others I was missing. How can we make sure that we anticipate all potential triggers for a trauma survivor when providing care?

The answer is: we can’t.  And that’s okay. Hearing about Lady M’s experience changed the way I approach trauma-informed care. Her reaction made me realize that while we can do everything in our power to learn and anticipate ways to provide sensitive care and expand our list of “Dos” and “Don’ts”, we must also acknowledge that because we cannot anticipate every potential trigger for a survivor, we must also simultaneously invest in building a patient-provider communication safety net.  The safety net, built on verbal and non-verbal signs of empathy and non-judgmental communication, is there to catch the moments in medicine when feelings such as fear, anxiety and shame may unexpectedly arise and invade the visit.  The safety net provides the reliable, tested and trusted foundation that patients can count on to disclose and discuss sensitive issues from the past or as they arise, if they desire to.

How do I know this to be true? Because, in the final moments of our interview together, after reflecting on her experiences, Lady M prepared the message she wanted to share with healthcare providers:

“Doc, if you’re out there, listen.  Like Lady M is asking you to be a little bit more patient with your patients… Doctors have a tendency to make people feel dumb when they walk into the room.  Take off that white coat. Allow the person to be themselves.  Don’t undermine who’s sitting in front of you. Become more personable with your patients, because nine times out of ten, you make them comfortable, they will be comfortable enough to express things that you might need to know…”