April 2019

 

A Reflection on Sexual Assault in the Exam Room: from patient stories to provider lessons

My next patient, Sara, was new to the practice. She opened the visit with, “I have lots of issues.” She was in her mid-thirties, pleasant, and poised. I asked her if we could make a list of her issues and prioritize them since I needed to gather her entire medical history. She agreed without hesitation. The first item rolled off of her tongue, “I need medication for genital herpes. My grandfather gave it to me when I was a child. He abused me from age 3-12.” She quickly changed the subject without missing a beat and moved to her next request, saying, “I also have lots on cherry angiomas on my face that I would like removed.” She did not flinch. Her voice did not tremble. The trauma had become part of her story but it did not define her.

I wish I could say that sexual assault survivors are uncommon in my practice, but they are not. At least one or two patients I see a day have a history of sexual trauma. Many sexual assault survivors I see are burdened by depression, anxiety, PTSD, substance use, chronic pain, and multiple somatic complaints. It is hard for them to have intimate relationships. They cannot always hold a job. Many people of color have added minority stress and experience racism and discrimination in addition. Transgender and gender diverse patients also have an added layer of stigma due to transphobia.

Why am I sharing this? What does this mean for the medical community? Many survivors have also been re-victimized and memories of the trauma can be triggered by clinicians during an exam. The survivor above made it clear that her grandfather was the perpetrator, but on questioning about routine cancer screening she told me, “I was having my pap smear and the OBGYN ran out of the room crying because of all the scarring she saw.” The patient was reminded of her trauma but had to comfort the provider because of her reaction. Another young woman, a lesbian of color, presented with recurrent vaginitis and when asked about doing a pelvic exam, she froze and said, “I don’t want any more pelvic exams because the last one was a male OBGYN who put his fingers in me so hard. It caused me a lot of pain.” Lastly, a middle-aged trans masculine patient was due for a cervical cancer screening. He told me that he was prepared for the exam and we walked through it with his partner in the room. Only later did he tell me that this triggered his previous abuse and during the exam, he went into a dissociative state.

How do we as a medical community address the distress of sexual trauma? How can we make sure that we are not the perpetrators? In recent years, the term “trauma-informed care” has been used to describe the ways in which providers in varied settings (i.e. social service, education, health care, and corrections) can better serve people who have experienced traumatic life events. As a family physician with a focus in women’s and LGBT health, we have adopted the following tips. For more tips, refer to this paper on Trauma-Informed Care in Medicine.

1. Whenever examining any part of the patient, ask permission. For non-sensitive exams like listening to the heart, use implicit consent: “I’m going to listen to your heart now.” Wait for the response, then proceed. For more sensitive exams, always ask explicit consent. Allow the patient to know that they are in control throughout and nothing will happen that they do not want to happen. For example: “If I do something that makes you uncomfortable, let me know and I will stop.”
2. Use non-sexualized language in the exam room, ie: drape instead of sheet, foot rests instead of stirrups, examine or palpate instead of touch or feel.
3. For pelvic exams, make sure the bed is lifted at least 30 degrees so the patient is not flat on their back.

Recent research is insufficient to show that annual clinical screening pelvic or breast exams improve health outcomes. US Preventive Services Task Force gives routine pelvic exams in asymptomatic women grade I. The American Cancer Society does not support routine clinical breast exams as a method for cancer screening. We argue that both of these exams should be a discussion and to use shared decision making with the patient. This is a situation where the risks of anxiety may outweigh the benefits. Pelvic and breast exams may be particularly triggering for some patients. Why perform them routinely when there is no evidence if we may be doing more harm than good? This topic becomes even more sensitive for the transgender and gender diverse population where patients may be uncomfortable with their body. For routine physical exams, we should be asking about genital complaints and avoid routine exams unless the medical history indicates otherwise.

At the end of the visit with Sara, her eyes filled with tears, as she gave me a hug. “I want to give back. I didn’t want to be defined by my abuse. I’ve worked hard to overcome it. I want to share my story.” Sara went through five years of counseling to be able to process what happened. For the last ten years, she has been in a successful relationship. She has a full-time job and two children. Sara inspired me, and if she had not shared her story, I would have never known. With her permission, I share her story with you.

Unfortunately, Sara is one of that few survivors that I have cared for who is able to live her life to the fullest despite her trauma history. She has taught me to be more aware of trauma, listen to our patients, validate their experience, and respect their boundaries.

Chelsea Graham, DO

Family Physician and Rhode Island Network Member

 

New Resource: “Sam’s Medication Abortion”

The Reproductive Health Access Project (RHAP) is proud to provide accessible, evidence-based, and free educational materials on abortion, contraception, and early pregnancy loss for patients and clinicians. We strive to create materials that meet the needs of the entire RHAP community. With the many attacks on access to abortion services, we have been working hard to update our abortion materials and fill in any gaps we find. With this in mind, we are thrilled to present our latest resource to the RHAP community – a mini comic book, or zine, titled “Sam’s Medication Abortion.”

“Sam’s Medication Abortion” follows one person’s experience with using medication for an abortion. The content of the comic book takes our evidence-based resources and brings them to life through Sam’s story. As the reader, we follow Sam as they find out they are pregnant, consult with a friend, learn that medication is an option for abortion, take the pills, and deal with some of the symptoms and side effects of the medication.

Many people are unaware or misinformed about medication abortion (also known as the “abortion pill”). We hope that this zine will help inform people that medication is a safe and effective option for abortion and that readers will get a realistic look into what a medication abortion experience could be like. We hope the zine helps to educate readers on how medication abortion works and what someone can expect. We also hope that by telling Sam’s story, we are helping to normalize the experience of abortion and combat the reproductive stigma that is so pervasive.

We invite you to read through the zine, print it out, share it around, and post it on social media (and tag @RHAP1 so we can be part of the conversation). We’d love to hear your thoughts about our newest resource and how you plan to utilize “Sam’s Medication Abortion.” Send us your thoughts and reactions. Additionally, we would like to give a special THANK YOU to Kit Mills, the amazing artist who brought our vision to life!

 

Help Us Ramp Up Medication Abortion Training

Abortion care is under constant threat and access to abortion care training is limited in primary care medicine. So, we are taking action by increasing our efforts to train more clinicians in medication abortion. The good news is that we have primary care clinicians who are eager to add medication abortion to their practices. By training more clinicians to provide medication abortion, we are decreasing abortion stigma, improving abortion referrals, and laying the groundwork to expand access to abortion care!

RHAP’s medication abortion workshops train primary care clinicians – family physicians, internists, pediatricians, nurse practitioners, physician assistants, and certified nurse midwives – in the fundamentals of counseling and managing medication abortions using mifepristone (the “abortion pill”) while providing them with needed continuing education credits. Our workshops cover how to counsel patients, what tests to run, what to do if they don’t have access to ultrasound equipment, how to manage complications, and more. We are ramping up our medication abortion training through securing certification for continuing education credit, expanding our Network with more experienced clinicians wanting to provide abortion services, ready to train, and offering these medication abortion workshops free of charge.

RHAP is working to expand medication abortion training to reach more clinicians than ever. This April and May, we ask you to help us train 440 clinicians across the country in medication abortion via 22 workshops we will offer throughout the year. Your support will allow us to offer clinicians continuing education credit, tools, resources, and even start- up supplies. Your impact will be doubled thanks to a dollar-for-dollar match from a generous donor!

 

News from the Network: Connecting with Medical Students

During March, RHAP’s Network members gathered at the annual American Medical Student Association (AMSA) Conference in Washington, D.C., a national conference that brings together medical and pre-med students to network, attend workshops, explore new skills, and meet clinicians from various medical fields.

We were able to host a booth for the first time at this year’s conference. We had the opportunity to connect with students who are interested in practicing and passionate about reproductive health care. While RHAP’s programs generally focus on post-residency clinicians, we love chatting to folks new to the field about our work and our programs – everyone has to start somewhere!

The second day of AMSA was all hands on deck for our Papaya Workshop Sessions! RHAP Network members facilitated two back-to-back workshops for medical students. Attendees were able to learn more about patient-centered counseling, debunk clinical misconceptions of manual vacuum aspiration abortion, and receive in-depth support from our facilitators throughout the entire hands-on workshop. We look forward to attending next year!

The Reproductive Health Access Network is RHAP’s Community of over 2,700 primary care clinicians in 46 states who mobilize to expand access to abortion, contraception, and miscarriage care in their primary care settings. Network members engage in training, advocacy, and peer support both locally and nationally. The Network currently has 23 Clusters (aka chapters) in 22 states through which clinicians who engage in Network activities in their local communities. If you are a clinician and would like to be connected with your local Cluster, or would like to start one in your state, please email Laura Riker, RHAP’s National Organizer.