Supporting Survivors of Sexual Abuse

Rebecca Smith, 28, endured a series of sexual assaults between ages 17 and 21. When she became pregnant for the first time at age 23, she told her OBGYN about her traumatic past. The reaction surprised and comforted her.

“She made sure everybody was respectful, and one of the things I liked most was that she would tell me whenever she would be touching me, and she would always ask me if I was okay,” Smith said.

Yet even with these warnings, Smith said she experienced moments when the scars of her past trauma were inflamed and she needed time to regain her composure. Again, her physician stepped up. “She was very gentle with her words, and she told me it’s not my fault that any of this happened and that I needed to be okay with speaking up for myself and telling her what I needed,” Smith recalled.

“The only thing she did that wasn’t great is that when I was pushing, she told me not to scream,” Smith said. Having the option to cancel appointments at the last minute without a financial penalty would have been helpful, she added, “because there were some days that I couldn’t do it, and you didn’t really know until you showed up.”

Unfortunately for many survivors of sexual assault, Smith’s experience is not the norm. Many women who have been abused report rough or insensitive handling from their OBGYNs, whose clinical practice involves touching areas of the body that are physically and emotionally fraught and recalling medical histories that are difficult to share. As a thread on Reddit suggests, some women have even reported feeling mocked by nurses until they revealed their history of sexual assault.

In recent years, however, the model of trauma-informed care has become more widespread. Professional organizations, hospitals, and state agencies have begun making an explicit effort to be more sensitive to the impact of trauma on a person and the specific needs of those with a history of sexual trauma.

Managing the prenatal and obstetric care of patients with a history of sexual assault or childhood sexual abuse requires an understanding of trauma-informed care and taking steps to reduce the risk for re-traumatization, according to pregnancy care providers and survivors who discussed their pregnancy and birth experiences.

The American College of Obstetricians and Gynecologists (ACOG) in 2021 issued a committee opinion on caring for patients who have experienced trauma, a document which emphasizes the need for clinicians to become familiar with the trauma-informed approach to care. That means understanding the effect of trauma on a person, helping support their sense of personal agency, and creating “opportunities for survivors to rebuild a sense of control and empowerment.”

The ACOG statement speaks more broadly to any and all kinds of trauma rather than sexual abuse and assault in particular.

That’s partly by design, said Colleen McNicholas, DO, an OBGYN in St. Louis who helped write the statement.

“The reason you don’t see specific ‘do this, ask this’ [recommendations] is because the topic is so sensitive, and survivors have such different experiences with their history and what they want people to know and how they want it approached that it’s really challenging from an institutional standpoint” to have specific guidelines, McNicholas said. “Having said that, there are definitely some principles and approaches that everybody should be taking.”

Uneven Care

Not everyone does. Smith had a bad experience with an anesthesiologist during the delivery of her first child.

“He had me take my gown off completely and made my husband sit on the other side of the room,” Smith said. “He was hurting me repeatedly, and when I told him, he said, ‘No, it’s not me, it’s your contractions.’”

Smith’s nurse became “furious,” she recalled. The nurse sent the doctor out of the room and told her colleagues not to let him go in again without another nurse present. When Smith told her OBGYN after the birth what happened, they assured her the anesthesiologist would never touch her again.

With her second pregnancy 2 years later, however, Smith had a different physician to whom she did not reveal her history of assault — in part because she felt she would be less likely to relive the experiences. In retrospect, she said, that was a mistake. During the delivery, her baby’s heart rate plunged, sending the doctor into command mode and prompting him to begin yelling orders to nurses in the room.

“The second he touched me after he started freaking out, my brain started going back to the assault,” Smith said. “I think his anxiety sparked my anxiety, and the anxiety sparked the memories.”

CJ, a 48-year-old American expatriate in Mexico City, Mexico, had had bad past experiences with other physicians, so in her first pregnancy at age 37, she decided to let her clinicians know about her history, which included sexual abuse as a toddler, a sexual assault in her 20s, and another in her early 30s. She asked her OBGYN to prepare her for each step that would happen, letting her know what touching would occur and when so that she could be ready.

“She was very sweet and open to that,” CJ said. “She said, ‘Okay, I’m going to put my hand on your thigh. Then, I’m going to put my glove on,’ everything step by step, but I felt like I really had to advocate for myself given past histories with other doctors.”

Some of those experiences involved the doctor acting cold or detached or not making eye contact with her, but that detachment was enough to be “triggering sometimes,” she said. Instead, providers should make space for patients who haven’t learned yet how to advocate for themselves.

“That’s part of trauma-informed care too, finding different opportunities in different ways to give people the chance to speak up because they might not feel comfortable,” she said.

Listening for Cues

Indeed, the onus should not be on the patient. Experts say one step is having a conversation with the patient before they change into a gown for their first appointment. That moment is an opportunity to glean relevant information about their history.

“I don’t specifically say, ‘Do you have a history of sexual assault,’” McNicholas said. “What I might say is, ‘Is there anything about your previous experience with these kinds of exams or with your sexual history or experience that will make this exam or this experience more challenging for you?’”

Sometimes that conversation means an exam may not happen that day, but then the clinician can help the patient plan for the next appointment to determine ways to increase their comfort, such as bringing along a partner, friend, or family member. “It has to be individualized to the patient,” she said.

Some patients may not feel comfortable disclosing a history of sexual assault. Hannah Cutts, a certified nurse midwife who works at a federally qualified health center in Chicago, said she assumes “almost everybody who comes through the clinic doors has some exposure to trauma,” whether sexual, medical, or another form of abuse. She therefore tries to give them as much control as possible over every aspect of their care because “lack of control tends to be a real trigger,” she said.

She shows them the speculum before placing it, explains each thing she will do before doing it, and reminds them they are in charge and can ask her to stop at any point. For those with a known history of sexual trauma, she asks whether they want the explanations. Some do, others don’t.

“For some people, dissociating is easier,” Cutts said. She also does not assume that disclosing their history of trauma will be productive: “I really don’t try to dig very deeply into people’s history unless they volunteer it.”

Deena Blumenfeld, a former doula and childbirth educator, said clinicians also should be alert to nonverbal clues that may indicate a history of trauma. Examples might include avoiding eye contact or frequently keeping their eyes on the floor, a closed posture, or handles held tightly in the laps. During an exam, observe the patient’s breathing for changes or if their eyes widen. These signs are cues to stop and ask if the patient is experiencing a surge of anxiety and needs something comforting, such as their partner to hold their hand or a nurse to join them.

“I can’t emphasize enough that for all situations of maternity care, the more doctors and nurses can explain to patients what is happening, why it is happening, and what choices they have, that’s empowerment for patients,” Blumenfeld said. She encourages healthcare providers to use person-centered language and keep the mindset of being one of the “helpers” of the sort Mr Fred Rogers described in tragic or traumatic events.

A 2018 qualitative study included perspectives from 20 women with a history of sexual trauma who had given birth within the previous 3 years. Women expressed a desire for “clear communication about their history between prenatal care provider and the labor and delivery team” and control over who was in the labor room during exams and how exposed their bodies were during labor. They also wanted to be asked about their preference for a male provider and for their care team to avoid language that might remind them of their past trauma.

Simply asking patients what they need or what works for them can be particularly helping in giving them a sense of agency, McNicholas said.

“If you are in tune with trauma-informed care and you are paying attention to the patient in front of you, you can almost always sense that they are having some anxiety or feeling really nervous,” she said. “I will oftentimes say things like, ‘I’m sensing that you might be a little bit anxious about this exam. Is there anything I can do to make this easier for you?’”

Caring for a patient throughout their pregnancy offers physicians and midwives an opportunity to build trust and develop a relationship with their patient, but those who may be most vulnerable often arrive at the hospital without having received prenatal care and without any preexisting relationship with a clinician.

“The important thing to recognize in that circumstance is that those patients are actually at significant risk of not getting this kind of trauma-informed care,” McNicholas said. “I think the healthcare system as a whole tends to view folks who have not had prenatal care with a certain level of judgment.”

Ann Gilligan, RN, worked as a sexual assault nurse examiner before shifting to labor and delivery. Gilligan, who practices in the Twin Cities, Minnesota, said standard questions during intake ask about abuse occurring at home but not about a history of sexual abuse or assault. Developing a protocol to screen for a history of sexual assault is important, she said, and could be done gently.

“What we typically do with questions that are a little bit personal is that we preface it,” she said. “We say, ‘This is to help me give you better care, care that you deserve, so I’m going to ask you a couple personal questions, and I’m doing it alone for your privacy.’”

Many of the practices McNicholas and Cutts describe, such as informing patients of what to expect and asking permission to touch them, are ones healthcare providers should be offering to everyone anyway, especially given that approximately 1 in 4 people have experienced sexual violence in their lifetime, Gilligan said.

Practicing with a trauma-informed approach to care means a scheduled 10-minute visit may sometimes last 30 minutes or may fail to achieve what the clinician had planned or expected.

“I think in this world where patients are rightfully demanding a better experience of healthcare, we need to be taking the time to approach it in that manner,” McNicholas said. “They know what they deserve, and they should be able to find that.”

None of the sources quoted in this story reported having any financial conflicts of interest.

Tara Haelle is a science/health journalist based in Dallas.