For patients with a history of sexual trauma, pelvic exams may trigger PTSD symptoms. The techniques of trauma-informed care can lead to an easier exam.

Studies show that trauma survivors want providers to ask about sexual trauma before the exam (that is, while the patient is clothed and seated). During the exam, patients prefer that the clinician listens, anticipates each step of the procedure, and affirms the patient’s control over the exam. For example, giving women the option of self-inserting the speculum has been shown to lower patients’ anxiety and pain.

Clinicians should use the following patient-centered techniques to lower patients’ anxiety:

• Establish rapport before the exam. In some cases, this means doing the exam at a separate visit.
• Invite the patient to suggest measures that will make her more comfortable with the exam.
• Allow a support person to accompany the patient during the exam.
• Allow the patient to choose a female examiner if she prefers this.
• Before starting, inform the patient that the exam will stop if she feels uncomfortable. Assure her that she has control over the pace.
• Tell the patient about each step of the exam right before it happens.
• Keep the patient’s body covered, exposing only the areas being examined.
• Encourage the patient to breathe abdominally in order to relax her pelvic floor muscles.
• Rest the unopened speculum against the patient’s vagina so that she can get used to the sensation before the speculum is inserted and opened.
• Use the smallest possible speculum.
• Use lubricant.
• Offer self-insertion of the speculum.
• Offer frog-leg positioning without stirrups. Call stirrups “foot rests.”

If the patient does not want to continue the exam, the clinician should stop, inquire about the patient’s needs, and proceed only when the patient is ready.

Sources

Sharkansky E. Sexual Trauma: Information for Women’s Medical Providers. National Center for PTSD. 2014.

Adult Manifestations of Childhood Sexual Abuse. American College of Obstetricians and Gynecologists website. Updated August 2011, Accessed February 2015.

Yannikerem E, Ozdemir M, Bingol H, Tatar A, Karadeniz G. Women’s attitudes and expectations regarding gynaecological examination. Midwifery. 2009;25:500–508.

Wright D, Fenwick J, Stephenson P, Monterosso L. Speculum ‘self-insertion’: a pilot study. Journal of Clinical Nursing. 2005; 14(9): 1098-2111.

Bates C, Carroll N, Potter J. The Challenging Pelvic Examination. Journal of General Internal Medicine.2011; 26(6): 651-657.

Barr W. Vaginal Speculum Examinations Without Stirrups. BMJ. 2006; 333(7560): 158-159.

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