By Bianca Palmisano | July 25, 2017
Owner, Intimate Health Consulting
Ask before kissing your date goodnight. Don’t grope strangers on the train (I mean, really, don’t grope anyone). Don’t force your children to give hugs or kisses to family members against their will. Our culture is becoming more accustomed to conversations around consent in intimate interpersonal relationships.
But we are still fairly unfamiliar with how to model and apply consent in professional relationships. This is particularly true when there is a power differential around knowledge, skills or resources. Perhaps in no profession is this differential more evident than healthcare.
A healthcare provider, be it a doctor, nurse practitioner, social worker or therapist, has spent years in formal schooling. Most have logged hundreds more hours in continuing education. Our culture expects these professionals to understand deeply the mechanisms by which they support wellbeing.
As patients, we are conditioned to accept that our provider’s knowledge is powerful. This perception has the potential to override some of our personal boundaries in the service of helping us be well (“You need to have an annual checkup before I can renew your prescription”).
But this very dynamic may sometimes reflect an unhealthy relationship around consent and bodily autonomy. This can exacerbate the sexual trauma that many people carry with them.
Whether you perform physical exams or procedures, facilitate health education, sit in chairs in an office, plan research, or administer a school district, here are four things every provider and educator should know about recognizing and supporting survivors of sexual trauma.
In the U.S., it’s estimated that 1 in 3 women and 1 in 6 men will experience some form of sexual assault in their lifetimes. Many of these experiences first happen when individuals are young. More than 4 in 10 female survivors of rape are assaulted before they are 18, as are about 1 in 4 male survivors of sexual violence.
So what are the chances that a health educator or provider of any discipline is likely to serve someone who has experienced sexual violence? I’d put it at about 100%.
When people hear about “sexual violence,” they often think of inaccurate or incomplete stereotypes—rapists hiding in dark alleys or wives being assaulted in their marriages. But sexual violence can take a variety of forms: date rape, catcalling, groping, stalking, childhood sexual assault and more.
Most survivors of physical sexual violence were assaulted not by a stranger but by someone they knew. Violence within relationships can happen to people of all genders and sexual orientations, of any age or appearance, of any personality style or socioeconomic status. Dismantling our assumptions about who may have experienced sexual violence is vital. If we imagine this is only an issue faced by timid heterosexual women, for example, we are likely to miss obvious signs that a client, student or patient is suffering.
Informed providers recognize that any action along the spectrum of sexual violence can be traumatizing—yes, catcalls on the street or sexual harassment at school can make it difficult for people to feel comfortable being open or vulnerable with a provider or educator. This is why it is so important for providers to acknowledge that a survivor’s physical and emotional responses to trauma are valid.
What are the physical, psychological and social elements of sexual violence? Some survivors don’t have the language to articulate the connection between their trauma and the responses they experience months and years later. Providers need to stay alert to other possible signs.
Some survivors may experience anxiety and sleeplessness, digestive issues, flashbacks or unexplained muscle aches from the “activating” impact of trauma. Others might report numbness, lethargy, dissociation or forgetfulness, indicative of a “depressive” response to the trauma.
Showing care and respect for someone who has experienced sexual violence can be fairly simple.
For example, before an exam or procedure, healthcare providers can ask questions such as, “How are you feeling about this exam?” or “How will I know if you are feeling uncomfortable or want me to stop?” Providers can explain the steps of an exam or the purpose of any personal questions they ask. It’s helpful let patients know they can skip a question or stop a procedure at any point if they become uncomfortable. This kind of conversation gives survivors permission and, more importantly, agency to set their own boundaries and stay in control.
In a health education setting, an educator talking about making healthy sexual choices might say, “Some young people find themselves in situations where they aren’t able to make the choice to say no to sex. If any of you have personal questions about this, you’re welcome to speak to me privately after the class.” Class agreements or ground rules might include provisions where students are allowed to step out of the class for a moment, or go to a “safe space” within the classroom if they need to.
When a provider or educator doesn’t take a survivor’s situation seriously, even if this is unintentional, the survivor can experience retraumatization—a sense of revisiting either the dynamics or the actual experience of the original trauma. Knowing some of the common signs can help prevent this (see an excellent list here).
Fatigue, aches, pains
Headaches, stomach aches
Anxiety, abrupt moods
Muscle aches and pains
Sensitivity to light/sound
Source: U.S. Department of Veterans Affairs.
Even with great conscientiousness and care, a survivor will sometimes be triggered during a classroom lesson, a visit with a healthcare provider or in other situations. There are some straightforward ways to intervene that can help the person better manage the trigger. Here are a few.
Validate. Listen and offer support. Avoid discounting the person’s experience.
Help the person get grounded in the (non-traumatizing) present. Ask them to curl and uncurl their toes or describe something in the room. This engages the person’s senses, allowing them to concentrate on what is happening in the immediate present and break through a flashback or emotional reaction.
Breathe together. Guide the person through a slow breathing exercise to help calm anxiety reactions. Ask them to keep their eyes open to help bring their attention to the present moment.
Suggest a small but challenging “thought” task. Ask the person to name all of the different types of animals (or vegetables or flowers or states) they can think of. Ask them to count upwards by 13 or say the alphabet backwards.
These strategies won’t necessarily immediately resolve the person’s discomfort. They do help lessen the power of the trauma response, giving the individual more agency to choose appropriate next steps.
Sexual violence is an undeniable element of our current society. It is absolutely crucial that we prepare ourselves to address its impact on those we serve.
My organization, Intimate Health Consulting, is committed to promoting greater competence for medical practitioners in these areas. We offer a range of on-demand webinars. I’ll also be joining eight other interdisciplinary educators for an upcoming summit on sexual health (September 22-23, 2017). We’ll be including some great information on trauma-informed care, along with many other sexual health topics.
Whatever your area of focus, I welcome you to this effort to bring awareness, understanding and practical skills to the delivery of care and services to people who have suffered trauma from sexual violence.
Bianca Palmisano is a sex educator and medical consultant. As the owner of Intimate Health Consulting, she specializes in training healthcare providers around issues of sexual health, as well as LGBT, sex worker and sexual assault survivor competency. She can be reached at email@example.com.