Pelvic Examination in a Patient with a History of Sexual Abuse

As providers who perform pelvic exams, the nature of what we do is routine for us, making it easy to forget that it is a deeply personal, vulnerable, and potentially triggering encounter for our patients. According to the Centers for Disease Control (CDC), about 50% of women, transgender and non-binary people, and roughly one third of men, have a history of nonconsensual sexual contact. It is advisable to assume that every patient we see could have a history of sexual trauma and proceed accordingly.

Our skills and conduct become part of the trajectory of people’s experience and may generate trauma, compound existing trauma, or, alternatively, create an atmosphere of trust and safety which can assist in patients’ potential for healing. Not only does creating understanding and clear expectations improve the humanity of the experience, but it likely informs our assessment. As a pelvic health physical therapist, I observe tissue health and mobility, resting position, muscle function, and presence of pain. If patients feel unsafe or tense, findings will be impacted by their guarding, bracing, or even dissociating during an exam.

Before the Exam
At the outset, using patients’ preferred name and their pronoun conveys respect. Pre-exam questions and comments color people’s experience of the moment and their memory of the encounter. Asking “What would be helpful for me to know about past pelvic exams that made them difficult or more comfortable for you?” and inquiring about whether the person would prefer to be told about findings during or after the exam informs us. Stating clearly that we want them to communicate with us during the exam, especially if they feel pain or request the exam be discontinued at any point improves trust. Personally, immediately before touch I have patients give me a nod indicating they are ready for my exam to begin. 

During the Exam
We reduce distress and build trust with strategies like giving a patient the option to place the speculum themselves and explaining each next step including where they will feel contact from your hand or instrument. Having their own coat or sweater draped over them is often comforting.

After the Exam
Words carry immense weight and these days our patients may either have no familiarity with terms and concepts we use or may have learned from unreliable sources. Comments about the appearance or health of genitals can be triggering. Use of the term “prolapse” often generates distress about what this means for their body. It is our responsibility to check what people hear and understand about what we have said to them. 

Patient reports of feeling unsafe/unhappy with the way a provider performed an exam are much higher than they should be. In individuals with a history of trauma, the impact of this is particularly devastating to mental health and may create undesirable health outcomes if they cannot tolerate healthcare visits. Despite our time-pressed clinical schedules, setting the exam room as a safe space to be examined and to communicate with providers is crucial.