No one looks forward to a pelvic exam. But for patients with a history of sexual abuse, assault or other violence, even a routine examination can be extremely distressing. These patients may experience discomfort, flashbacks or further trauma, which can lead to avoidance of future pelvic exams.
Research suggests that women with a history of sexual trauma are more likely to feel uncomfortable during a pelvic exam and more likely to skip gynecological checkups such as cervical cancer screenings. Clinicians can use empathetic strategies when weighing if a trauma-informed pelvic exam makes sense for these patients and help them overcome this barrier to care.
When Are Pelvic Exams Warranted?
Before considering how to do a pelvic exam for a patient who has experienced trauma, clinicians should weigh whether to perform it. Pelvic exams have long been viewed as an integral part of an OB/GYN checkup. For years, clinicians have used them along with routine Pap smears as a way to screen for gynecologic cancer, infection and asymptomatic pelvic inflammatory disease.
However, studies on the topic do not strongly support the use of routine pelvic exams for screening asymptomatic, nonpregnant patients without an increased risk of specific gynecologic conditions. As a result, the American College of Obstetricians and Gynecologists (ACOG) recommends that pelvic examinations only be performed when indicated by symptoms or by a medical history of conditions such as cervical dysplasia, gynecologic malignancy or in utero diethylstilbestrol (DES) exposure. The ACOG believes that the choice to perform a pelvic exam should be a shared decision between patient and physician.
Consequences of Sexual Abuse
Clinicians can help inform that decision by talking with patients about sexual abuse and assault. You are likely to see patients who have experienced sexual trauma: According to the Centers for Disease Control and Prevention's National Intimate Partner and Sexual Violence Survey, an estimated 43.6 percent of women have experienced some form of unwanted sexual violence, including rape, sexual coercion and unwanted sexual contact.
Such violence can lead to lasting psychological and physical effects, according to a study published in the Journal of the American Osteopathic Association. Assault survivors sometimes experience lifelong post-traumatic stress disorder, anxiety, chronic headaches, gastrointestinal problems and genital and reproductive symptoms, including pelvic pain. For these reasons, it is crucial for clinicians to weigh the potential benefits and risks of performing pelvic exams on patients with a history of sexual violence.
Starting the Conversation
The conversation about sexual abuse can begin as early as intake, both for new patients and as part of check-in prior to routine visits. Some questions you may want to ask patients include:
- Have you experienced sexual violence or unwanted sexual contact?
- Do you feel safe at home and with your partner?
- Has anyone ever threatened you with violence?
- Are you willing to discuss issues related to sexual abuse, rape, assault, incest or coercion?
Based on the answers, you can provide reassurance and resources if appropriate. Do not hesitate to offer a patient help with reaching out to a domestic abuse hotline or crisis center if you discover abuse. If a patient is open to discussing past trauma, the conversation may evolve into one in which a clinician is able to talk more specifically about a trauma-informed pelvic exam, including if and when one might be necessary.
By providing a safe and open environment for patients with a history of sexual assault, physicians can foster shared decision-making and improve patient trust and satisfaction.
