By Alisha Olsthoorn, 3rd year ObGyn Resident, University of Toronto
Sexual assault. We know it’s common. According to surveys, one in three women will experience some form of sexual assault in their lifetime. A staggering 80 percent of women with disabilities will be sexually abused in their lifetime. In a Canadian study of transgender and non-binary youth aged 19-25, 1 in 4 reported having been physically forced to have sex. This means that on any given day, I’m likely to see a patient who is a survivor of sexual assault.
As a resident in obstetrics and gynecology, my patients include any individual with gynecologic organs (vulva, vagina, cervix, uterus, fallopian tubes, and ovaries), regardless of their gender identity. This could include women, transgender, non-binary, or genderqueer individuals. Based on a number of studies, we know that being a survivor of sexual assault is associated with increased rates of gynecologic issues and reduced rates of cervical cancer screening.
A reported 94 percent of women who are sexually assaulted experience (PTSD) symptoms during the two weeks following the assault, and 30 percent will continue to experience PTSD symptoms nine months after the assault. We know that PTSD is associated with distress and discomfort during gynecologic exams. At its most severe, these sensitive exams can trigger flashbacks and re-traumatize individuals who suffer from PTSD. These examinations involve the use of a speculum device to look at the cervix, taking swabs for screening for sexually transmitted infections (STIs) or other infections, Pap tests for cervical cancer screening, and a bimanual examination that allows the doctor to feel the uterus and ovaries. This could also include cervical exams for pregnant individuals in labour when a doctor is checking how they are progressing.
As providers, how can we do better? The responsibility is on the physician to be a provider of trauma-informed care. We’re making moves in the right direction. In 2017, the Canadian Federation of Medical Students adopted a policy paper that recognized the need for adapting medical school curricula to provide medical students with the tools to provide trauma-informed care during gynecologic examinations by focusing on the needs of the individual patient.
If you’re a survivor of sexual assault, you have your own individual experience of gynecologic care. Maybe gynecologic examinations cause a lot of anxiety and maybe you’ve had experiences with providers who were not attuned to your distress and the experience was unnecessarily painful or triggering. Maybe you’ve found a provider you trust who you’ve disclosed your history to and they are able to perform these exams in a way that makes you feel comfortable and in control of the situation. Or maybe you avoid it entirely and you’ve been putting off your long overdue Pap test or STI screening. In fact, maybe the last time you had an exam was during a cervix check in labour. At a time when you’re anticipating the delivery of your child, you’re also having examinations done that can cause significant distress.
First off, I want to say that the way you feel during these exams or the difficulty you have proceeding with the exams, is not your fault. And as I said earlier, the responsibility is on the physician to create a safe space for you. But you and your physician can also be a team that works together to make these experiences better and improve your gynecologic care.
These are by no means things you have to do or should do, but things that you can do. It is important to note that you definitely do not need to disclose your history of sexual assault to your physician, however doing so may allow them to be more attuned to this during your care and can open a line of communication. If disclosing this information risks causing you more distress or re-traumatization, you do not need to do it if you do not want to. Even if you don’t disclose, you can explain to your physician that you find gynecologic exams challenging. Addressing your concerns can help your physician individualize your care and work toward developing strategies leading up to and during the examinations that allow you to feel comfortable, safe, and in control. These conversations are best had before the exam has begun and the communication should continue throughout.
Some practical things you and your physician can strategize includes making sure you have someone you trust in the room with you for support. You may prefer that they talk you through the steps of the exam before you even get undressed. During the exam, allowing you to dictate the speed of the exam and having them continue to explain every step as it progresses allows some people to feel a greater sense of control and comfort. You can also ask at any time that an exam pause or stop completely. There may be other strategies that you feel would work for you. In times of distress, some people may find a specific grounding or sensory experience helpful to manage these symptoms. Your physician also likely has strategies they use with other patients so ideally, you’d feel comfortable talking about these things with a physician you trust.
In case you’ve never felt that you had the permission to request these things from your physician – you do. If you feel like your provider would not be open to having this discussion, then there are likely gaps in their knowledge of providing trauma-informed care and they may not be the right provider for you. I acknowledge that depending on where you live, access to a different family doctor or gynecologist may be challenging. Hopefully we are moving in the direction of having all physicians across the country trained in providing you with care that allows you to feel safe, heard, comfortable, and in control. It’s what you deserve.