PTSD: National Center for PTSD
Sexual Trauma: Information for Women's Medical Providers
Sexual Trauma: Information for Women's Medical Providers
How common is sexual trauma among women?
Estimates vary, but studies suggest that about 13% of women have experienced a sexual assault at some time during their lives (1). Estimates for child sexual abuse are higher, with 27% of women reporting this experience (2). In some samples (e.g., Veterans and current military), these rates tend to be higher.
Consequences of sexual assault
Although many women who have been sexually assaulted function quite well, others have considerable difficulties. Many of the problems experienced by these women may present themselves in the primary care setting. These difficulties include interpersonal, social, physical, and psychological problems that may last for many years. Women who have experienced sexual trauma are also likely to be high consumers of healthcare.
Numerous physical problems occur with greater frequency among women with sexual assault histories than among women who have not experienced sexual assault. These problems include: diabetes, obesity, arthritis, asthma, recurrent surgeries, chronic pelvic pain, irritable bowel syndrome, back pain, headache, eating disorders, poor reproductive outcomes, digestive problems, and hypertension.
Women reporting a history of childhood sexual abuse also report higher rates of numerous problems including venereal disease, pelvic inflammatory disease, surgical evaluation of pelvic pain, respiratory problems, gastrointestinal problems, and neurological problems.
Sexual trauma and healthcare utilization
Given that women with sexual assault histories report more health problems than women without known sexual assault histories, it is not surprising that the experiences of childhood and adult sexual trauma are associated with increased healthcare utilization and costs.
A study examining HMO health care utilization found that women who reported a history of childhood sexual abuse were more likely to visit the emergency room and had annual total health care costs that were significantly higher than those without abuse histories (3). These differences were observed even after excluding the costs of mental health care. Adult sexual trauma victims also appear to utilize high levels of health care (more physician visits and higher outpatient costs) even when compared to women who have been victims of other types of crime (4).
Although women who have experienced sexual assaults may have considerable mental health symptoms, these symptoms are significantly more likely to present in medical settings than in mental health settings (5).
The most widely studied psychological consequence of sexual assault is PTSD. Data from a large-scale study comparing the effects of different types of traumatic events suggest that the experience of a sexual assault may be more likely to lead to PTSD than other types of traumatic events (6). In this study, 45% of the women who reported having experienced a rape met criteria for PTSD. This was significantly higher than the 38.8% rate of PTSD among men who had experienced combat.
Sexual assault appeared to be extremely difficult for men as well (65% of men who had been raped met criteria for PTSD), but the proportion of men in the study who experienced a rape (0.7%) was significantly smaller than the proportion of women who did (9.2%).
The experience of childhood sexual trauma was also associated with high rates of PTSD. Of women who reported molestation as their most traumatic experience, 26.5% met criteria for PTSD. This percentage was significantly higher than the percentage of men who reported having been molested who also met criteria for PTSD.
Sexual assault survivors in the medical setting
Symptoms of PTSD include re-experiencing the trauma, avoidance of situations associated with the trauma, emotional numbing, and hyperarousal. Any of these symptoms can present in and around the medical setting. Perhaps the most dramatic trauma-related symptom medical providers may see is dissociation. Dissociation can involve a range a phenomena including altered awareness, attention to flashbacks, or out-of-body experiences. Dissociation is usually triggered by a strong emotional reaction such as terror, surprise, shame, or helplessness, or feeling trapped or exposed.
Several aspects of the medical setting may increase the likelihood that PTSD symptoms will be observed. For example, the types of procedures performed in medical offices (particularly those performed as part of yearly physicals, gastrointestinal exams, and gynecological exams) can potentially trigger a posttraumatic reaction in patients who have experienced sexual trauma. In particular, pelvic exams, colonoscopies, endoscopies, and other procedures that involve placing an instrument into a bodily orifice may be sufficiently reminiscent of the sexual trauma to evoke a posttraumatic reaction.
In addition, a number of other features in the medical office setting may act as trauma reminders. These include being touched (even in a typically nonthreatening place), the power differential between patient and provider, the removal or absence of clothing, and the focus on bodily pain or disorder.
In one study, a large percentage of sexual trauma survivors reported having an unpleasant experience during their gynecological exams (7). These unpleasant experiences included overwhelming emotions, unwanted or intrusive thoughts, having traumatic memories triggered, body memories, and feelings of detachment from the body. The survivors did not report many of these experiences to the providers.
In this same study, both women who had and women who had not experienced childhood sexual trauma reported that they had anxiety during their pelvic exams. However, the women who had been sexually traumatized reported that having their sexual organs examined was the primary reason for anxiety whereas women who had not been sexually traumatized reported that physical discomfort was their most common reason for anxiety.
Because sexual trauma survivors may anticipate these difficulties, they may repeatedly cancel appointments for exams or avoid telling their providers about symptoms (e.g., blood in the stool) that might cause the provider to order an invasive test.
What can providers do?
It is generally a good idea to find out whether a female patient has been sexually traumatized. Although most gynecological providers do not ask women about their history of sexual trauma, the overwhelming majority of women indicate that they would like to be asked this question (7). Few survivors are likely to offer this information without being prompted.
In addition to knowing about your patient's history, you can do the following to make it more likely that the patient will successfully complete a medical examination. These suggestions will allow the exam to proceed with as little emotional distress as possible and will decrease the likelihood that the survivor will avoid care in the future.
- Reduce the power differential between you and your patient.
- Greet the patient in your office (not exam room) while she is still fully dressed.
- Give the patient as much control as possible.
- Provide health education materials.
- View the patient as an expert about herself. Ask her what might help reduce her stress during the exam.
- Ask her to predict what will be the most difficult parts of a procedure.
- Take a break during the exam if necessary.
- Provide the patient with as much choice as possible.
- Engage in dialogue throughout exam.
- Explain everything you will do in advance and as you do it.
- Listen carefully to any concerns.
- Check in regularly throughout the exam about the patient's level of anxiety.
- Remind the patient why you are performing this exam.
- Plan and allow extra time. Schedule these patients for slower days or late appointments.
- Be prepared and willing to reschedule the exam if necessary.
- Talk with the patient about her job or family in order to distract her from the exam.
- Consider using relaxation techniques (although for some trauma survivors this is contraindicated) and involve a mental health provider in care planning.
If symptoms do occur
Despite your best efforts to provide a safe and comfortable atmosphere for your patients, posttraumatic symptoms may occur during an exam. If this happens, don't panic. Try to use grounding techniques with the patient.
- Speak in a calm, matter of fact voice and avoid sudden movements.
- Reassure your patient that everything is okay.
- Continue to explain what you're doing.
- If possible, stop the procedure.
- Ask (or remind) the patient where she is.
- Offer her a drink of water, an extra gown, or a warm or cold washcloth for her face.
- Go with her into a different room to provide a change of environment.
- Resnick, H.S., Kilpatrick, D.G., Dansky, B.S., Saunders, B.E., & Best, C.L. (1993). Prevalence of civilian trauma and Posttraumatic Stress Disorder in a representative national sample of women. Journal of Consulting and Clinical Psychology, 61, 984-991.
- Finklehor, D., Hotaling, G., Lewis, I.A., & Smith, C. (1990). Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors. Child Abuse and Neglect, 14, 19-28.
- Walker, E.A., Unutzer, J., Rutter, C., Gelfand, A., Saunders, K., VonKorff, M., Koss, M.P., & Katon, W. (1999). Costs of health care use by women HMO members with a history of childhood abuse and neglect. Archives of General Psychiatry, 56, 609-613.
- Koss, M.P., Koss, P.G., & Woodruff, M.S. (1991). Deleterious effects of criminal victimization on women's health and medical utilization. Archives of Internal Medicine, 151, 342-347.
- Kimerling, R., & Calhoun, K.S. (1994). Somatic symptoms, social support, and treatment seeking among sexual assault victims. Journal of Consulting and Clinical Psychology, 62, 333-340.
- Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic Stress Disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060.
- Robohm, J.S., & Buttenheim, M. (1996). The gynecological care experience of adult survivors of childhood sexual abuse: A preliminary investigation. Women and Health, 24, 59-75.