ARCHIVED: Chapter 6: Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse – Guidelines: encounters with patients

Guidelines for Sensitive Practice: Encounters with Patients

Introductions and negotiating roles

In all health care settings, steps must be taken to ensure that the first moments of an encounter set a tone consistent with Sensitive Practice. By introducing oneself, explaining the nature of the appointment, and asking patients how they wish to be addressed, practitioners convey respect for their clients and begin to build a positive relationship with them.

Steps must be taken to ensure that the first moments of an encounter set a tone consistent with Sensitive Practice.

Further, before beginning any intervention, health care providers must ask clients about their expectations for care. Doing so establishes a relationship that involves two-way sharing of information and control. It also creates an opportunity for the clinician to gain quick insight about potential apprehensions, which can help to avoid triggering negative reactions. In long-term health care relationships, the periodic revisiting of roles and responsibilities allows for renegotiation and communicates genuine compassion and concern.

Undressing for someone in a position of authority transports many survivors back to their abuse and leaves them feeling powerless, vulnerable, and filled with shame.

Clothing

Few issues highlight survivors' difficulties in health care settings as much as the need for removal of clothing. While practitioners often take for granted the need to disrobe and to don an examination gown, undressing for someone in a position of authority transports many survivors back to their abuse and leaves them feeling powerless, vulnerable, and filled with shame:

“If I had to take off clothing ... for a male [clinician] it's ... hard because there's the trust issue there and for me there was a lot of guilt and shame ... I struggle with body image and sometimes ... I feel powerless then.” (Man survivor)¹⁵⁹

While the standards of care for certain examinations require removal of clothing, survivor and clinician participants alike urged all health care practitioners to consider the following:

• Discuss clothing requirements with patients and collaborate with them to find an agreeable solution (e.g., allowing clients to wear their undergarments throughout the exam or inviting clients to wear their own abbreviated clothing such as bathing suits or shorts).
• Leave the room while the patient is changing.
• Provide a variety of sizes of gowns for all body sizes and instruct the patient about whether the opening is to be at the front or back.
• Avoid paper gowns whenever possible (they were widely described by survivors as so flimsy that they escalate feelings of vulnerability).
• Do not assume that all men are comfortable baring their chests.
• Meet patients when they are fully clothed (e.g., to make contact, ascertain the reason for their visit, or perform a health history).
• If clients need to disrobe for an examination or procedure, explain what will happen next, what level of undress is required, and why. Before proceeding, ask whether the client agrees to proceed with what has been explained and ensure that the client's questions have been fully answered.
• Expose only the body area necessary for the specific intervention at any one time.
• Cover clients' bodies as soon as exams are completed to minimize the length of time that they are exposed.
• Meet with clients again once the examination or procedure is finished and they have re-dressed to offer health teaching, provide an opportunity for questions, and say goodbye. While this may take a few extra minutes, it brings closure to the interaction and allows the client to leave on equal footing.

Task-specific inquiry

A task-specific inquiry involves asking patients about their preferences for or potential difficulties with a specific examination, procedure, or treatment. It provides an opportunity for patients to offer health providers information that is directly pertinent to the present situation without any reference to past interpersonal violence. Task-specific inquiry should be used during an initial meeting with a patient, before any new examination or procedure, and any time body language suggests that the patient may be uncomfortable or experiencing difficulty. Regardless of other factors, it should also be done intermittently during interactions as an ongoing invitation to offer feedback or to identify problems.

Task-specific inquiry should be used during an initial meeting with a patient, before any new examination or procedure, and any time body language suggests that the patient may be uncomfortable or experiencing difficulty.

Task-specific inquiries involve a combination of closed- and open-ended questions that offer patients an opportunity to share anything that they consider relevant. A closed-ended inquiry might be, "Have you ever had difficulty with examinations/procedures like this one?" If the individual answers in the affirmative, then an open-ended question - such as "What can I do to make this easier for you?" - can help to minimize the patient's discomfort. Before the examination begins, extend a broad invitation to share relevant information (e.g., "Is there anything else I should know before we begin?").

Health care providers should recognize that, while asking for this information may seem safer than talking about past abuse, survivors may still experience it as difficult. If an individual's nonverbal cues indicate tension or anxiety, the practitioner may need to ask very specific questions such as, "Do you have any discomfort having your blood pressure taken?" or "Do you have difficulty when someone touches your knees?" Survivor participants urged clinicians to:

“Pick up on obvious things: You seem very anxious, is there something that you are uncomfortable with or is there something I should know? ” (Man survivor)

There are many reasons that people experience specific discomforts and sensitivities during health care encounters - some of these relate to past abuse, but others do not. Therefore, while task- specific inquiry should be used for all patients, clinicians should be careful not to assume that a patient who offers a task-specific disclosure is an abuse survivor.

“Asking if [the individual] has any issues or any concerns or are they uncomfortable, either physically or emotionally, is a really good way to start.” (Woman survivor)

One woman suggested that clinicians:

“Start out with, What are your experiences with a dentist [/doctor/massage therapist etc.]? How often do you go? What are your fears? ” (Woman survivor)

Inquiries about sensitivities, discomforts, and difficulties can also be included on questionnaires that are part of an initial assessment. Some survivor participants told us that they are more comfortable with this approach. The practitioner may invite an individual who indicates having difficulty with a number of components of an examination to outline the issues in writing. Regardless of the mode used to elicit this information, it is vital to the sensitive health care of all clients.

“[It] would be even better ... if every time you went into a [practitioner's] office, they gave you a little survey ... asking you ..., Do you have a problem with getting undressed, or being touched? It would be great if they did that, cause then they'd have an idea of what kind of person they're dealing with when that person walks in that door. They're prepared that person's prepared, because they think, or they'll know that the doctor or the physiotherapist has an idea of what they're going to be dealing with. That if this person says, Mm, I don't feel comfortable with that, they're going to know. They're going to understand ... And I think that would be fantastic, if they did that. So then both parties would be aware of things.” (Woman survivor)^164p.93

It is important to note, however, that task-specific inquiry should not be reserved exclusively for examinations involving touch. While touch can be problematic for many survivors, other health care interventions that clinicians may see as innocuous (such as standing behind a client during an examination, taking a pulse or blood pressure, or immersing a painful swollen hand in ice water) can also provoke discomfort and trigger painful reactions.

Task-specific inquiry should not be reserved exclusively for examinations involving touch.

Practitioners also need to be aware that, although they should make task-specific inquires prior to any examination, some individuals may not be able to talk about their difficulties until they develop a rapport with their health care provider. Further, the ability or willingness to talk about task-specific difficulties may be a function of the survivor's stage of healing; certain components of an exam may be well tolerated at some times and problematic at others.

Body language should be explored as cues signalling that an individual may be experiencing difficulty.

Clinicians should not assume that an individual has disclosed all task-specific difficulties during previous interactions. Survivors who have been conditioned to be passive or to defer to authority may need ongoing permission and encouragement to talk about difficulties on a regular basis. Body language - such as trembling, flinching, tensing muscles, changing breathing patterns, flushing, crying, or dissociating (i.e., appearing spaced-out, distant, or blank) - should be explored as cues signalling that an individual may be experiencing difficulty:

“ We send out signals ... to people that we have been abused ... I was sending signals out, and I don't think the people were listening really and picking up on them ... [I would] cringe and move and I often said What are you doing? ” (Woman survivor)^143p.252

When these cues are evident, practitioners should explain that the exam or procedure will be easier to complete if the patient can relax, and then ask for assistance in discovering another approach to that component of the exam (e.g., "Would it help if I gave you a mirror to help you to see what I am doing?"). Addressing an individual's apparent discomfort in these ways is vital to establishing and maintaining rapport; ignoring these things can undermine feelings of safety and trust.

Documenting task-specific difficulties or preferences can be done in a way that identifies the sensitivity or difficulty without any reference to past abuse. In deciding what to include in the patient's record, practitioners should ask themselves what other clinicians need to know in order to provide the best care. When practitioners learn about task-specific sensitivities for the first time only after a patient experiences an adverse reaction to part of an exam (or treatment), they should record the unexpected response as soon as possible after the incident, including both objective (who, what, when, where, how, and how much) and subjective (what the patient and others report about the event) information.

TABLE 2 - A brief summary of task-specific inquiry

Task-specific inquiry involves asking patients about their preferences for or potential difficulties with a specific examination, procedure, or treatment. It provides an opportunity for patients to offer health providers information that is directly pertinent to the present situation without any reference to past interpersonal violence.

Use combination of closed- and open-ended questions to offer patients an opportunity to share anything they consider relevant.

An initial closed-ended question such as:

"Have you ever had difficulty with examinations/procedures like this one?
If the individual answers in the affirmative, follow-up using an open-ended question such as:

"What can I do to make it easier for you?"
Before beginning an exam, offer one addi-tional opportunity to disclose something the patient thinks might be relevant:

"Is there anything else I should know before we begin?"
When a clinician notes discomfort, return to task-specific inquiry. For example,

"Every time I go to stand behind you to take a look at your back you seem to tense up. Do you have difficulty with having someone standing behind you or touching your back?"

If the patient responds in the affirmative:

"What can I do to make this part of the exam easier for you?" For survivors who verbally deny discomfort but whose body language suggests the opposite, task-specific inquiry is likely to facilitate feelings of safety for the survivor; explain that carrying out the exam with the patient's body more relaxed is ideal, and ask the patient's assistance to discover another approach to that component of the exam. For example,

"Would it help if I gave you a mirror to help you see what I am doing?"
Documentation of task-specific disclosures can be done in a way that identifies the sensitivity or difficulty without any reference to past abuse. Focus on communicating the information that will assist other healthcare professionals to avoid the difficulties or to problem solve with the patient to minimize the difficulties.

General suggestions for examinations

In keeping with the principle of information sharing, it is important that health care providers not assume that their patients know what they are doing or understand why they are doing it. Thus, it is important that they provide a running commentary of an examination or procedure explaining what is being done and why. Further, repeated invitations for questions are crucial:

“I found quite often when you go to a health care practitioner, they automatically assume that you have some kind of knowledge of their job outline ... And why should I know? I didn't go to school for that, so it's really frustrating. And they expect you to know something about it. ” (Woman survivor)^143p.255

Repeated invitations for questions are crucial.

While interactions with clients may be routine by clinicians, for many survivors, health care environments are strange and frightening places. Simply being in such environments can challenge an individual's ability to ask questions or to verbalize their needs. This fact cannot be emphasized strongly enough:

“I feel very (pause) almost frightened. To some degree the fight or flight syndrome kicks in where I'm ready to hit the floor and head for the door. I know it's because of problems that I've had as a kid. But at the same time those feelings come over me and then I lose all train of thought as to what I'm there for, what I want to ask him, I forget what day it is.” (Man survivor)

While employing the following strategies for sensitively conducting an examination or treatment may require extra time, they are important for establishing rapport, trust, and safety - and they may actually save time in the long run:

• Complete the initial health history “before ”asking the client to remove any clothing required for the physical examination.
• Invite patients to make a list of questions and concerns for each future appointment in order to reduce their sense of anxiety.
• Encourage questions throughout the encounter.
• Allow enough time to help individuals understand fully what is being done.
• Seek a balance between offering descriptors of symptoms ("Would you describe the pain as sharp or dull, throbbing or aching?") and encouraging survivors to find their own words. This strategy can be particularly important since many survivors have learned to ignore their bodies and may require extra time to describe their symptoms.
• Move on from topics that are making individuals seem uncomfortable or questions that they are having difficulty answering, and return to them later.
• Use a written Informed Consent Form that uses readily understandable language and avoids abbreviations, jargon, and technical terms.
• Inform patients that consent can be withdrawn at any time, without penalty to them.
• Pay close attention to language to ease the patients' anxiety (e.g., ask patients to change rather than to get undressed, use the term examination table rather than bed, and use the terms underwear or undergarments instead of panties ).

Throughout the physical examination:

• Avoid using too many closed-ended yes- or-no questions. (Intellectually challenged individuals may try to answer in a way to please the clinician. Because the prevalence of childhood abuse is even higher among disabled individuals than it is among children without disability, clinicians need to be particularly attentive to nonverbal cues when working with these patients.)
• Do not approach patients from behind and, because some individuals startle easily, avoid quick, unexpected movements.
• Notify patients before shifting focus from one area of the body to another.
• Explain the rationale for examining areas of the body other than the site of the symptom.
• Encourage individuals to ask that the examination or treatment be paused, slowed down, or stopped whenever it is necessary to lessen their discomfort or anxiety.
• Inform patients when procedures/ examinations are likely to be uncomfortable and collaborate with them to minimize the discomfort by soliciting and responding to feedback throughout the procedure (e.g., ask, "How are you doing? Can we continue?" and, if they say "No," take a break until they can continue).
• Avoid glib or false assurances which sound dismissive or indicate lack of understanding of their concerns (e.g., instead of saying "Trust me" or "Don't worry, you'll be fine," say "I know this is difficult for you. How can I help you to feel more comfortable?").

Even though employing these strategies may require some extra time, they are important for establishing rapport, trust, and safety - and they may actually save time in the long run.

Time

• Most of the survivors we spoke with recognize the time pressures under which health care practitioners work and do not expect exceptional treatment. The following three suggestions are offered by survivor and health care practitioner participants as ways to use the available time more effectively:
• Inform clients at the outset of an appointment/interaction how much time you have to spend with them and negotiate how best to use it. In a clinic setting, a health care practitioner might say, "We have 15 minutes for this appointment, what do we need to focus on?" or "We have 15 minutes and I plan to ... Is there anything else that you need or want?" A health care practitioner in a hospital emergency department might say, "My name is ... I am a Registered Nurse and will be looking after you. We are very busy here today, so you may have to wait an hour or more to see a doctor." The nurse might go on to say, "I need to get some information from you and then I'll be in and out every 15 minutes or so to check on you. Please use the call button if you need me."
• Aim to keep interruptions (from assistants, colleagues, pagers, cell phones, BlackBerries, phone calls, etc.) to a minimum. Eight or ten minutes of uninterrupted time allows the health care practitioner to focus on the patient and is more likely to achieve the objectives of the interaction than 20 minutes of interrupted time.
• Use both verbal and nonverbal communication to convey interest and attention. For example, when a health care practitioner conducts office interviews while standing with his or her hands on the door knob or abruptly leaves patients to take telephone calls without any explanation, the message to patients is that the practitioner is not focused on them.

Throughout this project, we have heard repeatedly that short-term interactions pose the greatest difficulty for integration of Sensitive Practice because of the reality of time pressures. Survivor and health care practitioner participants alike urged that while it may take some commitment and ingenuity to incorporate the principles of Sensitive Practice in short-term interactions, it is important to make the effort to do so.

Informed consent

Obtaining informed consent for examination and treatment is an important part of practitioners' responsibility to their clients and is regulated by professional/licensing bodies as well as legislation. Clinicians are urged to ensure that they are thoroughly familiar with all appropriate sources of information about informed consent. Informed consent involves: (a) explaining the health problem; and (b) making recommendations for addressing the problem (which must include: a discussion about the nature, benefits, material risks, and side-effects of treatment; alternative courses of action; and likely consequences of not having the treatment). Written consent forms are part of the process of obtaining informed consent in many health care settings and health care providers are urged to draft written consent forms in plain language.

This section highlights aspects of informed consent that are particularly pertinent to survivors. Because survivors have had early experiences of boundary violation, it is essential that practitioners be particularly attentive to obtaining consent which goes beyond the standardized forms and which is an ongoing aspect of their work with patients:

“When I was a child ... you might say yes [consent] to [one thing] but, my God, you didn't know that you were ... going to be taken elsewhere and what was going to happen. So it's where you're going.” (Man survivor)

In many instances, it is necessary to seek consent for each separate component of an examination or procedure:

“Ongoing [consent is required] it's not a blanket consent when you're touching me.” (Man survivor)

The nature of that consent, however, can vary by circumstance. Some men indicated that inquiring about their comfort was synonymous with asking for consent once an examination had begun. For yet other survivors, once trust had been established, the need for the practitioner to repeatedly seek consent for each segment of a procedure was unnecessary:

“As the trust builds in our relationship you would get to a point that perhaps you wouldn't need to ask me and perhaps I would get to a point where I would say, You don't need to ask me for permission any more. We're now at a point where I trust you and I know you're not going to hurt me ... But there are some instances where health practitioners need to ask for permission to go to those places. (” Man survivor )

Clinicians are urged to ensure that they are thoroughly familiar with all appropriate sources of information about informed consent.

The inclusion of other individuals in any examination/procedure requires additional consent. It is important to inquire about student participation when the student is not present. In addition, even if clients have previously agreed to student involvement for other procedures, always reconfirm their willingness to have the student present, especially during sensitive examinations. Some individuals may agree to have a student present for part of the examination but not for all of it:

“She just told me that ... she was bringing a student into the room with her and that she would be helping remove the packing. She didn't ask permission ... I think it's a privilege for a student to be in that situation and you still need to be respectful of how a patient feels about you being there. (Woman survivor) ”

In all circumstances, the onus for ensuring that the patient is fully informed and consents to what is happening is on the practitioner.

In all circumstances, the onus for ensuring that the patient is fully informed and consents to what is happening is on the practitioner:

“When [the practitioner] came back, right before she was going to [proceed with further treatment], she'd ask me again, Are you comfortable with this? Is everything all right? And do you understand what I'm doing? And that was so much easier, because one minute you can feel comfortable, and the next minute, you could feel uncomfortable ... so she gave me an opportunity that, if I were to change my mind and feel uncomfortable, all of a sudden, for whatever reason, she would know, and I'd be able to say something. So I felt like I was in control, and I did have the say of what was going on.” (Woman survivor)^143p.254

All forms of physical touch, from all types of practitioners, can provoke anxiety.

The clinician's responsibility to monitor and respond to the client's verbal and nonverbal communication cannot be overstated. Some survivors may be working to overcome the passivity towards authority figures they learned as children:

I don't think it's good enough to just say, At any point if you are uncomfortable ... because some people will say, Okay I understand, and may never say anything because ... we're just taught to not say anything. We just don't question. I know there are a lot of people out there like me, and we would say, Okay, yeah, I hear ya! and then wouldn't say a word no matter what. So I think on the part of the health care practitioner they'd be doing those people a great service by checking and rechecking. It doesn't have to be every minute but perhaps as they move on to another sensitive stage of whatever they're doing, just recheck. How are you doing? I'm going to be doing something different now, if at any point you feel uncomfortable, let me know and we'll proceed from there. (Man survivor)

To establish a context for ongoing informed consent, practitioners must:

• Allow ample time for patients to explore concerns, ask questions, and decide whether or not they want to proceed;
• Seek consent for each component of an examination or treatment;
• Obtain consent before bringing in students to observe or work with individuals;
• Keep in mind that the onus of ensuring that the client's consent is truly ongoing is on the clinician;
• Respond to the client's verbal and nonverbal communication when discerning consent.

Touch

“I rarely go to the doctor; I only go when I absolutely have to and also for physicals. I would just disassociate, that was my only way of coping with that ... any time they touched me.” (Woman survivor)

Most survivors we spoke with told us that all forms of physical touch can provoke anxiety. This includes touch from all types of practitioners and in a wide variety of situations, from having blood pressure taken or blood drawn to undergoing a complete physical exam:

“Touch is difficult, but if I feel safe, then I can tolerate more.” (Man survivor)

Survivor participants agreed that having information before and while being touched is crucial to their sense of safety:

“Information and knowing just before you're going to be touched that it is coming [helps], so, it isn't sort of a shock to you that you are being touched.” (Man survivor)¹⁵⁹

An understanding of the dynamics of abuse and some of the difficulties behind survivors' experience of touch can help health care practitioners develop strategies to use during interventions that require touch:

“When people used to touch me, it took me right back to the sexual abuse and the physical abuse ... Health care practitioners, if they see their patients sort of backing off or shutting down a bit, they should investigate why.” (Man survivor)

For some survivors, the use of touch by the clinician to explain a physical problem or as a component of treatment may be difficult:

“[Some clinicians] have automatically assumed that it's okay for them to go, Okay, well we're going to work ... on these muscles [as they touch me] ... because we need to strengthen this because this does this and ... It's not meant [to be sexual touching] ... Once I've gone home and calmed down, [and I] thought that they did [not do] anything inappropriately sexual. But at the time, when you first get triggered, it's an extremely difficult situation to deal with. It triggers a lot of memories ... and then you completely lose whatever you are there for.” (Man survivor)

Other survivors spoke of continuously monitoring and reacting to the intent and quality of touch they receive.

“If you're with [health care workers who are] aggressive ... in the way that they touch you, then you're instantly intimidated and then it's not safe any more.” (Woman survivor)

No one approach to touch is appropriate for every client. Gentle touch, which may be appropriate for some, may be experienced by others as sexually suggestive:

“As far as gentle touch goes, you would want a firm but not aggressive touch. Something that's too soft can be seen as an advance on you.” (Man survivor)

Despite the fear and anxiety that many survivor participants experience with touch, some told us about its positive aspects:

“I think that touch for healing ... has its place based on my own experience and it helps for rebuilding trust.” (Man survivor)

Because touch is such a fundamental issue for survivors of childhood sexual abuse, health care practitioners - before and during any encounters which involve touch - must:

• Recognize that, for many survivors of childhood sexual abuse, no touch is routine;
• Provide patients with information about the reason for and nature of the touch which is involved in any examination or procedure;
• Be sensitive to the intent and nature of all touch, and discuss patient reactions to different types of touch;
• Create a context wherein responses to touch can be freely articulated and the healing nature of touch can be explored.

Pelvic, breast, genital, and rectal examinations and procedures

Understandably, pelvic and breast exams for women and genital and rectal exams for men and women were cited as being the most difficult parts of a physical exam. Some survivor participants described how these examinations triggered flashbacks for them:

“It can trigger ... physical night sweats and severe rectal pain, enormous inexplicable attacks of anxiety.” (Man survivor)

Others are unable to tolerate such exams at all:

“I don't think I would allow anybody to touch me now ... nobody would get an internal on me. No. I will not allow myself to be that vulnerable again.” (Woman survivor)

Participants suggested that practitioners begin by describing the usual sequence of an examination and ask individuals whether they need to adapt it in any way:

“And you know, they take your blood pressure and I said, You know you'd better do the Pap smear first and then take the blood pressure because right now it will be off the charts and after it will be okay. ” (Woman survivor)

“I think being uptight about the actual procedure also made it very difficult for me to talk in general about the other parts of the examination or the other questions they had to ask about the pregnancy or about that kind of thing ... The question-and-answer thing was always before the actual physical exam and I would be really stressed out and really kind of paralyzed feeling, and so I don't think I ever gave really great information because of that. So maybe having the physical exam first would have helped, get it all over with first, get yourself all back together again Or have someone come with you, which I never did, but I suppose that would have [helped].” (Woman survivor)

There is no single approach that is appropriate in every situation.

Because there is no single approach that is appropriate in every situation, it is important to:

• Use task-specific inquiry before the exam to learn about anticipated difficulties and negotiate with the individual to minimize discomfort;
• Offer a running commentary about what you are doing;
• Pay attention to nonverbal signs of distress (e.g., tense muscles, flinching, "spacing out," facial flushing, tears, or stuttering) and ask for the client's feedback about ways to decrease difficulty;
• Minimize the time a patient must remain in a subordinate position;
• Drape parts of the body not being examined;
• Allow patients to wear clothing on parts of their body not involved in the examination (e.g., chest, arms, feet, etc.);
• Offer clients a mirror with which to watch the examination or treatment;
• In some cases, suggest to a tense patient that she insert the speculum herself, allowing her to have some control over the intrusion;
• When possible, conduct pelvic examinations with the woman's head and upper body slightly elevated, as described below:

“I had been seeing [my family physician] for one and a half years. I kept postponing my physical and the MD noticed that. She kept bringing it up and reminding me until I finally told her that I was frightened of laying flat on my back in a paper gown. She told me that it would not be a problem for me to be partially sitting up throughout the whole examination including the pelvic exam. Now she tells all of her patients that that is an option. She told me that it had been an important conversation for her.” (Woman survivor)¹⁵⁹

Body position and proximity

Both women and men survivors spoke about the difficulty they experienced being in certain positions, partially clad, with a fully clothed clinician standing over them. Health care practitioners can approach the topic of positioning in the same manner as they do other aspects of the examination or treatment: explain the rationale for the proposed position, obtain consent, monitor for signs of distress, and offer a running commentary:

“[I had to lie on my stomach] and I was really uncomfortable. Finally, I told him, I can't do this. I didn't tell him why. I said ... I can't lay on my stomach; can I do it some other way? [He said,] Oh yeah, well you can sit up. So there was an alternative.” (Man survivor)

“I don't like somebody standing behind me, but if they [must] ... the explanation is important. (Man survivor) ”

Health care practitioners can approach the topic of positioning in the same manner as they do other aspects of the examination or treatment: explain the rationale for the proposed position, obtain consent, monitor for signs of distress, and offer a running commentary.

Other participants talked about experiencing difficulty when a clinician had to be in certain positions or was in close physical proximity, as is the case when practitioners examine the eyes, ears, and oral cavity or carry out treatments such as spinal adjustment.

Pregnancy, labour and delivery, postpartum

“[Pregnancy is] a very vulnerable [time] ... for women that have been sexually abused. Like for me it was a little bit scary because I wasn't sure how the end result would be, like during my labour, would I have flashbacks?” (Woman survivor)

There is evidence that childhood sexual abuse survivors: are more reluctant to address their health care needs, have poorer relationships with caregivers, have more anxiety and fear about labour and delivery, report disappointing birthing experiences, are (re)traumatized by the birth experience itself, have more emotional problems in the postpartum period, and experience more problems with breastfeeding and parenting.

While childbearing is a profound experience for most women, it can be particularly difficult for women with histories of childhood sexual abuse. In their book When Survivors Give Birth, Penny Simpkin and Phyllis Klaus ^151p.33 describe pregnancy as: “A time of monumental change for women a time when the past, present, and future all come together, a time of openness, a time of vulnerability. Being pregnant causes memories of one's own childhood to surface. Past events are stirred up. The present evokes the paradox of excitement over the baby on the one hand, and fears and anxiety on the other. ”

According to these authors, some survivors welcome pregnancy as a sign that they are "normal" and develop a growing trust and confidence in themselves as their bodies change to support a new life. For others, however, the experience of pregnancy stirs up memories of past childhood sexual abuse. In her personal account, Christine,42 an incest survivor, describes not having conscious memory of her abuse until sometime after her third child was born. In retrospect, that knowledge has helped her to understand the difficulties she had with each of her pregnancies: the tears she shed for no apparent reason after every prenatal visit; her severe nausea and vomiting; her long, slow, overdue labours; and the serious postpartum depression. It also explained her life-long shame and distrust of her body, her high need for control, and her life-long struggles with depression. Although she remembers the practitioners who attended her during and after her pregnancies as being caring individuals, none of them ever asked whether she had a history of abuse.

There is some evidence that, compared with women who do not have histories of childhood sexual abuse, survivors: are more reluctant to address their health care needs, have poorer relationships with caregivers, have more anxiety and fear about labour and delivery, report disappointing birthing experiences, are (re) traumatized by the birth experience itself, have more emotional problems in the postpartum period, and experience more problems with breastfeeding and parenting.^{76,84,92,130,134,148,151,180,182}

In the Western world, "good" prenatal care involves frequent contacts with health care practitioners (physicians, nurses, midwives, ultrasound technicians, lab personnel, etc.) and typically includes a number of examinations, tests/procedures, and treatments that may prove difficult for some survivors. Debra Hobbins⁸⁴ offers the following list of perinatal experiences that might trigger memories of past childhood sexual abuse:

• Disrobing;
• Genital exposure/examinations;
• Raised side rails;
• Restraint or entrapment in bed by equipment (such as fetal monitor leads, belts, blood pressure cuffs, or oxygen masks);
• Being drugged (pain medications);
• Delayed or absent response to calls for assistance.

We encourage health care practitioners who work closely with women through pregnancy, birthing, and the postpartum period to read Penny Simpkin and Phyllis Klaus's When Survivors Give Birth for more specific and detailed guidance concerning the provision of safe and respectful care.

This list underscores the importance of inquiring about violence and abuse during health history taking with all patients:

“I was afraid of how the care would be, because they didn't know in my first pregnancy, they didn't know at all, they didn't ask and I didn't feel comfortable with telling them because of where I was at and I didn't have that voice to be able to speak out and say, you know, this is what I need and this is what happened to me and I need you to understand this and I need you to help me if I zone out.” (Woman survivor)

A practising midwife who participated in our second study told us that she may spend the first two to three prenatal visits just chatting with clients and waits for them to let her know when they are ready for a physical assessment. She tries to minimize invasive procedures and possible triggers as much as possible, performs only necessary interventions, and tries to be flexible (e.g., allowing women to perform certain procedures - such as swabs - themselves).

The principles and guidelines for Sensitive Practice presented in this Handbook are a useful foundation for perinatal care. We encourage health care practitioners who work closely with women through pregnancy, birthing, and the postpartum period to read Simpkin and Klaus's When Survivors Give Birth ¹⁵¹ for more specific and detailed guidance concerning the provision of safe and respectful care.

Oral and facial health care

Although the guidelines for Sensitive Practice are pertinent to all types of practitioners, there are special concerns for practitioners who work with the mouth, jaw, and face. Because childhood sexual abuse may be oral in nature, many survivors have difficulty tolerating various aspects of oral or facial health care (e.g., the body position they must assume during treatment, the physical proximity of the clinician, and the smells and textures of certain materials such as latex gloves or alcohol):

“Too many things in my mouth at once ... You're making me hold my mouth open too long because you have to do that when somebody's forcing you to do oral sex, like when you're a child, like, cause your mouth is too small. (Woman survivor) ”

Many survivors have great difficulty tolerating various aspects of oral or facial health care.

This means that knowledge of a patient's past history of abuse is extremely relevant to oral and facial health care:

“Because I was anticipating [difficulty with] a certain procedure I said, I think you should also know that I am a sexual abuse survivor and ... maybe that's part of my reaction here. ...So if I happen to freak out when he's poking around in my mouth, that he would have more information there and would know more of what he's dealing with.” (Man survivor)

Oral health care can regenerate the feelings of powerlessness and vulnerability that survivors felt as children:

“You have no control because you're in the chair, your mouth is frozen and you're pretty much at the mercy of that person.” (Man survivor)

The practitioner who can help the survivor feel some sense of control during treatment will be addressing the patient's abuse-related fears and laying the groundwork for greater compliance during treatment.

The practitioner who helps the survivor to feel some sense of control during treatment can allay abuse-related fears and increase the likelihood of greater cooperation during treatment. As noted earlier, sharing information and asking permission before performing a procedure can reduce the patient's feelings of anxiety and powerlessness.

“[The dentist] would talk his way through what he was doing. He would say, Now I'm going to clean your teeth or Now I'm going to spray a little water on that tooth, it may be a bit sensitive. He doesn't overdo it but he explains everything he does, so that I have a very clear sense of where he's going and what he's doing next. And that has been extremely helpful.” (Woman survivor)¹⁵⁹

Although practitioners may perceive these frequent explanations and step-by-step consent as repetitious, they are valuable to the apprehensive patient. Intermittently inquiring about a patient's comfort and following up on negative body language are also helpful, as are establishing hand signals to indicate the need to stop.

“Most of the time [the dentist says] You know the signals, right? And I go, Yeah. And he'd always review the signals ... This is what you can do for yes, this is no, this is stop. ” (Man survivor)^157p.1280

Allowing breaks during an appointment or, when possible, breaking a long appointment into two shorter ones can be helpful options for many patients.

“[When I told my dentist that I was having problems that day, he responded,] Well, what do I need to do? Are you comfortable in the chair? Are we going to need more breaks today? ... There's just an unbelievable level of respect with this man. He's fabulous.” (Woman survivor)

Childhood sexual abuse survivors also can feel uncomfortable being in a reclining position in a dental chair with practitioner in close proximity:

“I feel really trapped in the chair, in a very vulnerable position you know, where you have your mouth open, you're laid back. For me a lot of my trauma occurred, like, when I was in a laid back position ... and [so having a health care provider] ... over the top of me, I find that very threatening.” (Man survivor)

While supine positioning cannot be avoided, the initial exchange of information and obtaining of consent should be done while the patient is still sitting upright. Furthermore, reclining may be accepted more readily if patients are given an ongoing explanation of what is being done and are offered the opportunity to watch part of the treatment using a mirror.

Survivors also talked about difficulties with materials that were reminiscent of condoms and other objects used during abuse:

“Dentists, for me, even on a good day, [are] a total, absolute nightmare. I'll tell you why. Number one, the gloves smell like condoms ... I can't ground myself, so ... I am back there [being abused] . . . it's not the dentist any more.” (Woman survivor)^157p.1280

While gloves are a necessity, opting for gloves made of vinyl or other materials may be an alternative that helps patients who seem particularly anxious about the smell or sensation of latex.

Because many survivors believe that they are bad or undeserving, they expect to be judged harshly. This makes it critical that oral health practitioners use a supportive, nonjudgmental tone when presenting treatment options in instances of dental neglect.

A further issue that arises in oral care is evidence of neglect. In many instances, neglect of oral health may indicate fear of treatment or that a patient does not consistently value or care for his or herself or his or her body. In such cases, fears can compound: the fear of treatment that keeps a patient from treatment can be a source of shame and can lead to a fear of being reprimanded for the neglect:

“When they do my teeth they are going to say, Oh you haven't been taking care of them, you should have come in before. ” (Man survivor)^157p.1280

While patients deserve and expect a realistic evaluation of their oral health, they may find it difficult to hear a poor prognosis for a condition that may have been preventable if it had been treated in a timely fashion. Because many survivors believe that they are bad or undeserving, they expect to be judged harshly. This makes it critical that oral health practitioners use a supportive, nonjudgmental tone when presenting treatment options. Instead of reprimanding their patients, oral health practitioners can engender trust by asking how they can best help patients take better care of their teeth.

Survivors indicated that, while oral health care was difficult for many of them, working with practitioners to address the difficulties together often resulted in a positive experience:

“He ... doesn't ignore what I tell him. He has compassion ... He listened to me. He addressed my situation ... When it's over ... I feel really great. I really do. Like he's so gentle, he's so kind, soft-spoken, yeah, he's amazing.” (Woman survivor)

To minimize the strain which many childhood sexual abuse survivors experience with oral and facial care, practitioners are encouraged to:

• Undertake the initial exchange of information and obtaining of consent while patients are still sitting upright;
• Opt for gloves made of vinyl or other materials for patients who are anxious about the smell or sensation of latex;
• Establish and use hand signals for "stop" and always respond promptly to them;
• Share information with patients on an ongoing basis;
• Address patient comfort on an ongoing basis by frequently checking in with patients and using task-specific inquiry;
• Follow up on negative body language;
• Allow breaks during an appointment or divide long appointments into two shorter ones;
• Offer patients the opportunity to watch part of the treatment using a mirror;
• Address issues of oral health care neglect in a supportive, nonjudgmental tone and offer to collaborate with patients in finding a way to take better care of their teeth.

Care within the correctional system

The proportion of childhood sexual abuse survivors is higher within the correctional system than in the general population. Prevalence rates of childhood sexual abuse among incarcerated women range from 47% to 90%;97,152,162 among men, these rates are 40% to 59% (for sexual and/or physical abuse).91,131

The strict health care protocols which are standard procedures within the prison health care system dramatically decrease the likelihood that childhood sexual abuse survivors will seek health care.

Two of the men who participated in our studies were incarcerated in federal institutions at the time of their interviews. They spoke about feeling unsafe when seeking health care not only because of the lack of privacy and confidentiality but also because of standard procedures used within the prison health care system. While the need for strict health care protocols is understandable, it is likely that such protocols dramatically decrease the likelihood that childhood sexual abuse survivors will seek health care:

“[When I went to the clinician for a topical nonprescription medication for haemorrhoids, she] wanted to physically check ... I was thinking, No, no that's not necessary ... So she refused me treatment ... [and told me,] If you're refusing [to let me examine you] then I can't give you anything, so I'll just assume that there's nothing wrong with you. ” (Man survivor)

It is likely that similar difficulties exist for women survivors as well, as has been documented by Pamela Dole,⁵¹ a physician who worked in the US correctional system. Although further study is warranted, we urge clinicians who work in the correctional system to examine current practices and seek ways to introduce the principles and guidelines of Sensitive Practice.

After any physical examination

When ending any interaction, it is essential that practitioners establish a sense of equality with their patients. This will need to be handled differently in different settings:

• In clinic or office settings, see patients when they are fully dressed for health teaching and before they leave an appointment.
• In hospital settings, allow patients who are remaining in hospital garb to regain composure and experience themselves being recognized as a whole person (e.g., shake hands and say good-bye).
• In all settings, invite final questions and, when appropriate, provide a briefly stated plan for future meetings.

Questions for reflection

• Might any of my current practices be interpreted as insensitive by survivors? What needs to change?
• In what ways might I adapt my own practice to incorporate specific guidelines?
• Do any of these guidelines seem unrealistic or unworkable in my practice? What are some alternate ways of following such guidelines?
• How committed am I to incorporating these guidelines into my routine practice and into the routine practice of those who assist me in my work? What does this level of commitment mean to my clients?
• How aware am I of nonverbal communication of discomfort? Do I follow up on these indicators with my clients?
• Am I aware of resources in my community to which I can refer survivors for care outside my scope of practice? Is this information readily available?