In the United States, approximately 1 in 5 women have experienced rape or attempted rape some time in their lives. Sexual assault can impact every aspect of a person’s life, from their relationships to their physical and emotional well-being.

For individuals who are survivors of sexual assault, routine doctor’s visits can bring with them added layers of stress, particularly pelvic exams and pap smears.

These can be especially uncomfortable for sexual assault survivors because they require physicians to examine the sites where their sexual trauma occurred, which can be a triggering experience.

To help those who’ve experienced sexual violence and those closest to them navigate routine medical checkups, Healthline has collaborated with The National Sexual Violence Resource Center to create this guide.

There are many different types of healthcare providers people will encounter throughout the medical landscape. These are the some of the more common ones:

  • Primary care provider (PCP): Doctors that practice
    general medicine.
  • Specialists: Doctors that practice
    medicine in the context of specialized organs or organ systems.
  • Gynecologists: Medical professionals that are
    specialists who focus on female reproductive health.
  • Midwives: Healthcare providers that specialize
    in assisting a woman through pregnancy.
  • Nurses: Though there’s no set answer to describe
    what a nurse does, the responsibilities of these healthcare providers range from
    making acute treatment decisions to providing inoculations in schools.
  • Nurse practitioners: These nurses both diagnose
    and treat health conditions, while placing an added emphasis on disease
    prevention and health management.

There is, unfortunately, no standardized way to find a trauma-informed care physician. This is a healthcare provider who understands the impact of trauma and considers how this shapes all aspects of life for their patients in the short term and long term.

While most physicians have received some form of training related to screening for sexual violence, the extent to which the physicians are knowledgeable and accommodating is wildly variable. This is an issue with modern healthcare that needs imminent attention.

Currently, the best way to find a trauma-informed care provider is by word-of-mouth referrals.

Moreover, there are a number of organizations that cater to helping people who have experienced sexual assault and have healthcare providers or researchers on their board.

You can find a list of national rape crisis centers, who can act as a resource for referrals, here.

It’s your choice to communicate to your healthcare provider about your experience with sexual violence, whatever details you deem are necessary, before, during, and after appointments.

“An individual should communicate their sexual trauma with their physician when they are ready,” explains Dr. Angela Jones.

“This can be verbal or written communication — whatever makes the patient feel most safe and comfortable,” she adds.

understand your rights You have the right to:

  • Request
    the gender of your provider if you’re going to a general medical clinic or the
    emergency room.
  • Have another person that
    you trust in the room with you at all times.
  • Ask your doctor any
    questions.
  • Ask your doctor exactly
    what will happen both before and during the exam.
  • Ask your doctor to slow
    down and be patient with your exam and extend the exam if necessary.
  • If the provider or
    atmosphere of the clinic is unwelcoming or you simply feel as though you cannot
    finish your exam, you can end the checkup whenever you want.

If you’re specifically going for a gynecological exam, you can also ask for less invasive versions of common gynecological procedures.

For example, during the speculum test, you’re welcome to ask for a pediatric speculum if the adult size one feels too uncomfortable for you.

Red FlagA doctor who dismisses or doubts your
questions should be a major red flag.

While the thought of undergoing a gynecological exam might be uncomfortable, there are a number of ways to prepare yourself.

What to expect during a gynecological exam:

Breast exam. The breast exam is done to check the breast for lumps, skin changes, and nipple discharge, as well as check nearby lymph nodes.

Pelvic exam. The pelvic exam consists of four main exams:

  • External genital exam:
    The external genital exam involves a physician visually examining your vulva and labia for abnormalities and STDs.
  • Speculum exam:
    The speculum exam involves a physician inserting a speculum into your vagina to separate the walls of the vagina to allow the physician to examine your cervix for atypical discharge, lesions, or STDs.
  • Pap smear: The
    pap test follows the speculum exam (with the speculum still inserted in the vagina) and involves the physician taking a sample of cervical cells to screen for cancerous and precancerous cells in the cervix.
  • Bimanual exam: After the pap test is the bimanual exam which involves the physician inserting a gloved finger into the vagina while pressing down on the low pelvis with their other hand to check the size of your ovaries and uterus and check for painful areas.

Urine test. The final step of a gynecological checkup may include a urine test where physicians request a urine sample in order to check kidney health, for signs of pregnancy, and for various infections.

The following are strategies to implement before, during, and after the exam:

Before the exam

Avoid caffeine

Be sure to avoid caffeine and any other stimulants the day of the exam that may increase anxiety.

Manage expectations

Write down a list of all the things you expect to happen during your exam and write an action plan for what you plan to do.

For example, if you’ll have a pap smear that day, think about breathing or visualization exercises you could do if you were to be triggered.

Consider questions you might have

Write down any questions you have for your doctor and make sure to ask them before the visit.

Bring someone with you

Take a friend or family member along. They can help you to ask questions and act as emotional support.

During the exam

Be proactive

Make sure to ask questions and voice any concerns with your provider.

If you would feel more comfortable keeping your socks or a skirt on during your exam, feel free to tell your provider that.

There are also multiple possible positions you can be in for many portions of the exams, so be sure to choose which you feel most comfortable in — not the position your provider is most comfortable in.

Keep yourself grounded

If you’re unable to stay present or experience a flash back, try some grounding techniques to center yourself.

Some helpful grounding techniques to use in a clinical setting include breathing exercises, making eye contact with a trusted companion (if you brought one along), taking a small walk within the clinical room, or saying mantras.

After the exam

Reward yourself

Once the exam is over, fill your day with rewarding and rejuvenating activities to ease your mind.

If an appointment doesn’t go as
plannedIf you encounter a physician that asks
invasive questions that leave you feeling triggered or altogether vulnerable,
you have the right to stop your exam at any point. After the exam it would be a
good idea to process what happened with a trusted confidante, advocate, or
friend. Also make sure to report any physician that acted inappropriately
during an exam.

As the caregiver, parent, partner, or friend of a sexual assault survivor, your support before, during, and after an exam can be paramount and can aid them in successfully navigating future medical exams.

Below are a few ways you can lend your support:

Before the exam

Organize

Help the survivor to organize their questions and concerns.

This is a necessary step to help ensure they’re fully aware and in control of everything they experience during their exam.

Communicate

Help them to communicate their fears and the possible triggers they believe will affect them the most during their medical checkups.

Plan

You may also want to work with them to devise a list of techniques they think they can utilize to help them in tough situations.

During the exam

Offer to join them

If they desire you to join them in their examination, acting as a supporter is critical to their comfort during invasive experiences.

Ask questions when appropriate

Stepping up and asking questions that they’re uncomfortable asking themselves is important.

After the exam

Check in

After the exam, it will help to talk to them and process what they went through.

Every 98 seconds, an American is sexually assaulted.

For this reason, it’s imperative that healthcare workers understand how to make their medical procedures as accommodating as possible.

Training for this should start in residency programs, says Dr. Jones.

“Specialized training as a sexual assault advocate, as well as counselor training, are also available as continuing education units/CMEs. There are online courses, literature, [and more] that provide a wealth of information on how to deal with this topic,” she explains.

Providers can also look to IPV Health for resources.

That said, providers need to, first and foremost, screen for sexual assault at the beginning of every checkup.

Screening for sexual assault must be done in a normalized conversational tone that emphasizes the importance of this knowledge for the patient’s overall health.

The process of screening should be conducted in two parts:

Part one should be a brief explanation as to why you’ll need to ask these questions.

A few examples of how to start this conversation include:

  • “Since I’m your doctor and we’re in a partnership regarding your
    health, I need to ask you questions about your sexual history that I ask all my
    patients about.”
  • “We know that sexual violence is common in the lives of many
    women…”
  • “Sexual violence can affect a person’s health…”

Part two should be the actual asking.

Some sample questions include:

  • “Have you ever been touched sexually against your will or without
    consent?”
  • “Have you ever been forced or pressured to have sex?”
  • “Do you believe you have full control over the sexual encounters
    you have with your partner?”

It’s believed that a striking number of women aren’t screened for sexual violence which is problematic.

Not all people are necessarily comfortable initiating a conversation about their assault. Providers who screen their patients remove the pressure to reveal sensitive information that some patients may feel uncomfortable bringing up on their own.

For those who aren’t comfortable with direct questioning, however, Dr. Jones suggests providing options to disclose what has happened through other means, such as a questionnaire with a line of questioning about sexual assault, abuse, and domestic violence.

Aside from screening, there are a number of ways doctors can help make medical exams and procedures as comfortable as possible for sexual assault survivors.

These include:

  • Fostering clinical spaces that are open, nurturing, and safe for
    all patients.
  • Being both sympathetic and empathetic toward the patient. This is
    a situation where listening skills become paramount.
  • Communicating every single factor of each procedure to their
    patients and why they’re doing it. This is particularly important for invasive
    procedures.
  • Welcoming a patient’s questions and being open to answering them.
  • Upholding all facets of a patient’s privacy.
  • Welcoming the companions and advocates that someone might bring
    along to their checkups.
  • Being open to elongating the appointment times for individuals who
    need more time.
  • Providing avenues for patients to discuss their recent or past
    experiences at a later date if they’re not ready to do so presently. This could
    be through a referral to a counselor or a hotline, and may prove to be
    beneficial beyond measure in the long run.

If you do have a patient that’s experienced sexual trauma, as a medical provider it’s extremely important for you to engage with the patient and empower them.

The following are a few do’s and don’ts of how to go
about doing this:

  • Do not
    try to investigate their assault or ask for details they may not remember or feel uncomfortable sharing with you.
  • Do not
    use words like rape, since not all people may feel their assault can be categorized by that word.
  • Do not
    use unclear or highly technical medical jargon that confuses the patient.
  • Do respond to your patient with validating and empowering responses to their revelation to you. For example, telling them that “I’m really glad you had the courage to reveal this to me” or “I want you to know that’s not your fault.”
  • Do ask the patient about what would make them comfortable and provide some options.
  • Do wholly explain every procedure you’re about to do and ask the patient if the touch you’re about to do is comfortable to them BEFORE you proceed.
  • Do leave your patient with education and resources about violence and health issues as part of the follow-up.

Providers are likely to encounter a number of female patients who have survived sexual trauma.

Creating clinical spaces that feel safe for them is imperative to creating a comfortable space that will enable them to get the necessary routine medical treatments they need to sustain a healthy life.

Tiffany Onyejiaka is a writer based in the Washington, D.C. area. She is a 2017 graduate of Johns Hopkins University where she majored in Public Health, Africana Studies, and Natural Sciences. Onyejiaka is interested in exploring the way health and society connect, particularly how health affects this country’s most disempowered demographics. She is also passionate about helping to craft dynamic social justice and change in her local community.