When a pelvic exam is traumatic

If you're a survivor of sexual assault or trauma, medical visits may heighten anxiety, particularly if you're concerned that a pelvic exam will be performed. As an obstetrician-gynecologist, I have had patients who experienced sexual assault confess that they have avoided or delayed seeking medical care due to their anxiety surrounding pelvic exams. Even for women without a history of sexual trauma, pelvic exams and a visit to the gynecologist may be embarrassing or painful; for women with a history of sexual trauma, it can be unbearable.

Statistics tell us that one of out of every three women has experienced sexual violence. The #MeToo movement empowered women to speak out about their experiences. Discussions engendered by the movement connected us to people rather than just to a number, subtly shifting how we as a society think about and process sexual violence. On social media, the hashtag #triggerwarning alerts viewers to potentially disturbing information. However, little discussion has focused on the intersection of trauma and health care.

What does research tell us?

Studies have found that survivors of sexual assault have higher rates of anxiety compared to the general population. They may also be affected by post-traumatic stress disorder (PTSD), which can make them feel as though they are being re-traumatized by a pelvic exam. While taking the initial step to proceed with a gynecologic visit or pelvic exam may feel insurmountable, there are ways that health care providers and patients can approach this visit to make it feel safe for survivors.

A study published in Obstetrics and Gynecology focused on survivors of sexual assault who were pregnant and analyzed what helped them throughout the pregnancy and during the time of delivery. These women wanted their health care providers to know about their history of sexual trauma. At the time of delivery, they wanted to know who would be present in the labor and delivery room. And they wanted to be able to control how much or how little of their bodies they exposed.

How can you talk to your doctor about trauma?

Communication is key to the physician-patient relationship, especially when a patient has a history of trauma. In my practice, I want my patients to feel empowered to inform me of their history, without ever feeling the need to delve into specifics or details. They can choose to establish rapport prior to undergoing a pelvic exam, even if that necessitates multiple visits. They can dictate the pace of the pelvic exam and tell me if they need a break or feel overwhelmed.

As the patient, it can feel difficult to ask this much, but as a women's health physician, one way in which I can address a woman's anxiety about a pelvic exam is by giving her control over the exam and over her body. I appreciate it when patients voice their concerns. I always tell my patients, particularly those with a history of sexual trauma, that they have control over their bodies and the exam, and that my office is a safe space for them.

Wondering what to say?

Maybe you're wondering what to say. People may start the conversation in different ways. Here are some ideas that may help:

• You might start by saying, "I feel anxious when I come to the doctor."
• You could say a few words about what worries you: being touched, needing to undress, having a pelvic exam.
• You can choose how much to explain. "I've experienced sexual assault. I'd rather not talk about the details, though."
• You can even keep it vague: "Pelvic exams are difficult for me because of my history."
• You can share any ideas you have about how to make you comfortable during a pelvic exam or any medical exam. Please also share anything that you've found helpful. "It might help if you explain steps before doing them. I hope you're willing to go slowly, stop for a break, or even stop the exam if I start feeling overwhelmed."

If you're a survivor of sexual violence, I encourage you to openly communicate with your health care providers. If you're a provider, listen carefully and do all you can to create a safe space that allows women to obtain the care that they need without compromise.

Resources

Boston Area Rape Crisis Center has a phone (800-841-8371) or web chat hotline and offers a range of resources to people in the greater Boston area.

The National Sexual Violence Resource Center has a list of groups that offer online support for sexual violence survivors.

RAINN offers information on recovering from sexual violence, a national hotline (800-656-4673), and access to local resources.

The Voices and Faces Project hosts writing workshops for people who have experienced gender-based violence called The Stories We Tell.