Leila Hilal, MS4, Drexel University College of Medicine
As healthcare workers, we have a unique privilege in society; patients trust us at their most vulnerable moments and rely on us to help them reach their greatest potential in terms of their health. Patients who have experienced sexual assault are at an even more vulnerable position when it comes to routine gynecologic exams to for cervical cancer prevention. Trauma acts as a barrier to accessing healthcare. However, by providing patient-centered care with a trauma-informed approach, we can support our patients while providing the healthcare they need.
Within the past decade, there has been a large societal shift in the discussions around sexual assault and autonomy, best shown by the #MeToo movement. It is a clinician’s daily choice, and a necessary one at that, to be mindful of traumas that our patients carry, whether they choose to share them or not. In this blog, I’d like to review some of the ways to care for patients during a pelvic exam which can be a very stressful and triggering experience for survivors of sexual assault.
The basic framework of any clinical institution should recognize the 4 “R”s established by the Substance Abuse and Mental Health Services Administration (SAMHSA) as the foundation for trauma-informed care: Realize the impact of trauma and the potential for recovery, Recognize signs and symptoms of trauma, Respond by integrating knowledge about trauma into policies, and actively Resist Re-traumatization4.
Safety:
Ensuring that the patient and staff feel safe creates a calmer trusting environment.
1)
Have a chaperone in the room
2)
Offer a safety person to accompany
patient into the room
3)
Listen carefully to concerns or questions
4)
Allow for extra time – this prevents an
exam from being rushed
5)
Use the smallest speculum possible while
still optimizing viewing
6)
Use lubricant
7)
Offer shifting of clothing rather than
clothing removal
8) Avoid potentially triggering phrases such as “spread your legs” or “stirrups”, and instead choose phrases such as “allow your legs to fall open to the side” or “footholds”.
Trustworthiness and Transparency:
By being open and honest with your
patient, a rapport of trust can be established.
1)
Explain everything you will be doing in
advance, and while you are doing it1 – (but ask the patient if
they would like the explanation prior to giving it).
2)
Show the tools you will be using prior to
starting an exam – but ask first! This may or may not help the patient.
3)
Keep the patient covered, exposing only
areas necessary for examination.
Having resources to other trauma survivors
can promote healing, but this does not play a large part during a pelvic exam.
1)
Offer up trauma peer support materials at
the end of an exam
The aim of this principle is to
establish a partnership and lessen the power dynamic between the physician and
patient to decrease discomfort during the exam.
1)
Establish rapport before the exam
2)
Greet the patient while they are still
fully dressed and sitting upright
3)
Normalize any feelings of anxiety they
may have about pelvic exams
4)
Explain the importance of the exam and
its utility
5)
Check in regularly during the exam to
monitor the patient’s stress levels
6)
Offer up distractions during the exam
(e.g., talking or music)
7)
Offer self-insertion of speculum5
By supporting a patient to have
space to become a stronger self-advocate, the power dynamic lessens between
physician and patient thereby creating a calmer and safer environment.
1)
Give the patient as must control and
choice as possible
2)
Allow a female provider to perform the
exam if requested
3)
Ask the patient if they have suggestions
on how they would be more comfortable
4)
Before starting the exam, tell the
patient that the exam will stop if they feel uncomfortable - reinforce that
they are in control
5)
Ask permission before beginning the exam
6) Be willing and ready to reschedule the exam for a later time
Cultural, Historical and Gender Issues:
Recognize any move past any
stereotypes, biases or cultural barriers that may impede on a connection based
on trust
·
If you have experienced trauma, or find pelvic
exams nerve-wracking, consider letting your physician know when they schedule
your pap if you are comfortable. This
allows them to be aware in advance of how you are feeling and can be more
sensitive to your needs during the exam.
·
Know that it is a common experience for women to
feel nervous for their pelvic exams & pap smears – talk to friends or
family who have gotten it done, and how they reduce their anxiety.
·
If you have coping methods or grounding methods
that you use during anxiety-producing situations, ask your physician how you
may be able to incorporate these methods into the pelvic exam if you need
them.
·
If you would rather insert the speculum
yourself, ask your physician to do so and ask for proper technique.
·
If you are more comfortable with a certain
gender of provider, ask for this when scheduling your appointment.
·
If you would rather not get undressed for the
procedure, talk with your provider on how the exam may be performed while
staying dressed.
·
If talking/having a family member or friend
there/listening to music/watching a video makes you more comfortable during an
exam, ask the provider at the beginning of the office visit – they will be
willing to accommodate you.
·
If you do not want to be told what is happening
during a pelvic exam as it is going on, let your provider know so they don’t
introduce more anxiety for you.
·
Know that you can always say no to an exam or
stop an exam before or during the office visit.
·
Establish a word or signal that if said or done
will make your provider stop the exam until you are ready for them to continue.
·
If you have considerable anxiety during such
experiences, talk to your provider about any anxiolytic medications that may be
used to help you complete your screening with less discomfort.
· Check out this post by Dr. Glomski on other tips to help prepare for a pelvic exam: Mayo Clinic Health System - Preparing for your first pelvic exam2.
By recognizing trauma and approaching patients with care and
compassion, clinicians can support resilience and empower them to overcome
obstacles to their healthcare. By
normalizing trauma-informed care, sensitive clinical exams can become a less
anxiety-producing experience for patients knowing that they can trust their
provider and feel safe to obtain the care they need.
References
2.
Glomski,
Bridget, and Hannah Miller. “Preparing for Your First Pelvic Exam.” Mayo
Clinic Health System, 22 June 2021,
www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/preparing-for-your-first-pelvic-exam.
3.
Sharkansky E. Sexual Trauma: Information for
Women’s Medical Providers. National Center for PTSD. 2014.
4.
Substance Abuse and Mental Health Services
Administration . SAMHSA™s Concept of Trauma and Guidance for a Trauma-Informed
Approach. HHS Publication No. (SMA) 14-4884 . Rockville : SAMHSA ; 2014 .
5.
Wright
D, Fenwick J, Stephenson P, Monterosso L. Speculum ‘self-insertion’: a pilot
study. Journal of Clinical Nursing. 2005; 14(9): 1098-2111.
