PTSD Information for Women's Medical Providers
A National Center for PTSD Fact Sheet
By Erica Sharkansky, Ph.D.
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.
Physical consequences
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 recent 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
Psychological consequences
The most widely studied psychological consequence of sexual assault is Posttraumatic Stress Disorder (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. Twenty-six and a half percent of the women who reported
molestation as their most traumatic experience 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.
Symptoms of PTSD include re-experiencing the trauma, avoidance of situations
associated with the trauma, emotional numbing, and hyper-arousal. 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 from altered awareness or attention to flashbacks
and out of body experiences. Dissociation is usually triggered by a strong emotional
reaction such as feelings of terror, surprise, shame, or helplessness, or such
as 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.
Although invasive procedures are the most dramatic examples of trigger
events that occur in the medical setting, a number of other features in the
medical office setting may evoke 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 discomfort
whereas women who had not been sexually traumatized reported that physical
discomfort was their most common reason for discomfort.
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 you can 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 (Robohm
& Buttenheim, 1996). 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 planning care.
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.
Related Fact Sheets
Female
sexual assault
Defines sexual assault among females and gives an overview of its immediate
and long-term effects
Primary
care and PTSD
What primary care providers should know about the effects of PTSD and trauma
on mental and physical health
Primary care and PTSD
What do primary care practitioners need to know about PTSD?
Screening
for PTSD
An overview of screening and referral procedures to be used in primary care
settings
References
1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
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