Review & Opinions

Questions about a history of sexual abuse in the routine examination

Alessandra H. Rellini & Jaime L. Harrington
The University of Vermont, Psychology Department, Burlington, VT.

Whether patients are seeking medical attention for gynecological problems, low sexual desire, or urological concerns, asking questions about a history of sexual abuse (SA) provides important information about the etiology of their problems. Indeed, research has repetitively shown a positive relationship between SA and mental and/or physical health. For example, SA survivors have high rates of chronic yeast infections, headaches, weight changes, and back pain. While SA survivors tend to have more medical concerns, they surprisingly utilize medical services less than the rest of the population; this is particularly true for gynecological and urological related problems. Among the many reasons why SA survivors choose not to go to the doctor are fear of being taken advantage of by someone in authority, discomfort from being without clothes and from flash backs that may occur during the visit. Information about a past history of abuse can provide pivotal information on the origins of the medical problems and allows clinicians and patients to openly discuss techniques to reduce anxiety during the clinical assessment.

Despite the evidence that links medical and mental health with a history of SA, most clinicians avoid asking about past sexual trauma. A number of myths cause clinicians to shy away from this topic, including the beliefs that asking questions will cause pain to the patients, or that the patients will perceive the questions as a boundary crossing, and the uncomfortable belief that there is nothing the clinician can provide to the patients to improve their current situations. Fortunately, accurate information on the topic helps dispelling these myths and increases the likelihood that clinicians will include questions about SA as part of their routine assessments.

The myth that asking a question about a history of SA causes pain to the patient has been repetitively disproved by research on trauma and its sequelae. Studies on trauma disclosure by Pennebaker and colleagues found that, despite a momentary increase in reported distress, people experience positive health effects after they disclose their past traumas. It has been proposed that repressing traumatic memories increases the amount of stress experienced by the individual and the disclosure of this information provides an opportunity to let go of this stress. Therefore, despite the potential emotional distress the clinician may witness when asking questions about SA, patients are likely to experience long term benefits from disclosing their histories. In addition, asking questions about past trauma as part of a routine assessment sends the implicit message that it is safe to discuss these issues with a health professional. Also, introducing this topic in the routine of the clinical assessment normalizes these experiences and this helps patients feel less alone. Unfortunately, these patients are more certainly not alone, since in the US, a conservative estimate of SA that occurred before the age of 16 points to 28% of the female and 10% of the male population.

While clinicians show concerns about crossing personal boundaries by asking about SA, the patients' perspectives are likely to be quite different. Having to undress in the clinician's office and completing a standard gynecological or urological examination already requires individuals to bend their personal boundaries. Fortunately, clinicians trained as urologists and gynecologists have a wealth of training on how to approach sensitive topics with a patient. The same rules used to conduct a physical exam or to collect a sexual history with a shy patient apply to asking questions about SA. The sensitive clinician is able to present the SA questions as part of a routine while keeping in check their personal reaction to the information disclosed, and showing warmth and understanding. During this assessment, helping patients to limit how much of their trauma to share is a skill important not only for keeping the visits brief, but also for helping patients not to disclose too much and too fast in a setting where prompt mental health services are not available. Standardized questionnaires can be useful for collecting brief information about a SA history, especially when few follow-up with close-ended questions to assess the impact of the SA on the individual's sexual life. Indeed, it is important not to assume that SA is the direct cause of their problem since this varies greatly from patient to patient.

Many clinicians believe that asking about SA is not efficacious in their practice because they do not have immediate solutions for the pain expressed by the patients. An alternative perspective considers the beneficial effect that these questions would have on the patients' health, such as increasing the likelihood of the patients to seek future medical care and increasing the patient-clinician rapport. The clinician is a gate to future medical treatment by providing referrals to community resources (i.e., support groups and counseling/psychiatric services). In addition, showing interest and an awareness of the difficulties encountered by survivors of SA often strengthens the trust of the patients in the clinician.

Clinicians' questions about SA are instrumental for opening a discourse on techniques to increase the patients' comfort during the examination. A description of what the examination will consist of prior to beginning the procedure decreases patients' anxiety. Also, explicitly agreeing that the patients can choose to stop the examination at any point increases the patients' sense of control. For those examinations when the clinician cannot stop immediately, the identification of times when the procedure allows for a pause can be experienced positively by the patients. Finally, having a nurse who is of the same sex as the patients may dissipate stress related to a history of SA. However, these techniques should be openly discussed with the patients since what is soothing for some may be the cause of distress for others.

Although there are benefits in the mid- to long-term effects of disclosing a history of SA, certain responses by the clinicians could cause an unexpectedly adverse effect in the patients. The inexperienced clinician may be inclined to either overly express compassion or to show little feelings when patients disclose a history of abuse. Matching the affect expressed by the patients at the time of the disclosure is an effective way to build rapport and to encourage the development of trust. This skill requires to step outside of the interviewer role and to pause to observe the affective responses of the patients rather than listening only to the content of their answers.

While there is no immediate relief that the clinician can provide for patients distressed by their past trauma, much can be gained from a clinical assessment that includes a few questions on past SA experiences. Inquiring about SA not only provides key information on the etiology of the medical condition, but it also provides a platform on which to strengthen a fragile clinician-patient rapport and explore future heath care options.