Pap Smears for Survivors of Sexual Abuse
The following article, with minor changes, is taken from the June 1999 HEPP News, a newsletter of the HIV Education Prison Project (www.hivcorrections.org). While references to prison remain, most of the points made in the article remain applicable to all women.
Pamela Dole has worked in corrections in both New York State at Bayview and works with nurse practitioner students at York Prison in Mystic, Connecticut. She realized some of her patients had difficulty keeping or completing appointments due to fear and anxiety from past or recent experiences of sexual victimization. The correctional setting, according to Dole, poses an especially difficult problem for victimized women because it increases their feelings of invaded privacy and loss of control.
Dr. Dole is participating in a landmark forensic project (the medical examination of death and injury when the cause is not known, especially when criminal activity is suspected) to decrease violence against women by educating nurses in Kimberly, South Africa. She feels further research is necessary to fully comprehend the impact of interpersonal violence on health seeking behaviors. Dole believes the key to caring for traumatized women is making the gynecologic exam a process in which the woman herself can work with the medical providers. "It can't be something done to them . . . it comes down to working from our hearts or places of compassion." Following is Dr. Dole's article for HEPP News.
As many as 60% of incarcerated women have histories of sexual abuse. It is therefore important to keep these histories in mind when approaching the examination of women in prison. Some of the issues that interfere with medical care, as reported by sexually abused women, include trust, authority, control, disclosure and not wishing to have her body touched during examinations. [In a different issue of HEPP News, the editors explain "control" as "wishing to control the time and place of the gyne exam," adding that, "Insensitive gynecological providers can become a major barrier to obtaining the routine gynecological screening that is so critically important for this high-risk population."] Given these themes, incarcerated women pose unique challenges to health care providers, who should not miss this opportunity for education, healing and health care in sensitive ways.
The first step in caring for sexually traumatized incarcerated women is to get them to keep gynecology appointments. A patient's desire to remain in control and her fear of the examination will often lead her to refuse care. As a result, refusals of gynecological care need to be brought to the attention of the medical director or nurse manager, as persistent refusals can lead to progression of underlying disease. Refusals may be viewed as an invitation for education, which is the first step in creating a caring and trustful relationship with the patient.
If she will remain within the facility for several weeks before being reassigned, the provider should begin with an interview only and reschedule the examination. This approach can be extremely beneficial in increasing trust and adherence over time [the patient's ability to follow through with her medical care]. Patients will feel respected for their feelings while becoming acquainted with the provider in a non-threatening situation.
The initial interview and history should include a routine OB/GYN history (childbearing and sexual organs) as well as information about incest and childhood molestation, sexual assaults and domestic violence issues. Often women have never been questioned regarding sexual abuse and may initially deny these experiences. However, questioning may cause them to experience flashbacks after a woman has left the clinic. Asking questions about sexual abuse during a second visit often produces an emotional release from years of shame and secrecy, allowing the patient to make her first disclosure of sexual victimization. It is important to provide reassurance that anxiety about gyne exams and the embarrassment surrounding the secrets of their childhood or adult sexual abuse are common feelings. Whenever possible the health care provider should avoid doing a gyne exam when a patient is suffering emotional stress and instead empower her to choose a time when she is ready to participate in the gynecological examination. This provides the possibility for increased communication and trust while helping the patient to begin the healing process.
Some women may not be ready to disclose their "secrets." Telltale signs and symptoms may provide clues to the provider. Some of these may include histories of the following, in the absence of disease: chronic pelvic pain (stomach and genital area); dysmenorrhea (painful menstruation); menorrhagia (abnormally heavy menstrual bleeding) or gastrointestinal illness. Other signs include eating problems, substance abuse, failure to maintain good women's health care screening (making sure everything is okay), and anxiety disorders (which can include panic attacks -- feeling overwhelmingly frightened, such as the feeling that you're going to die although nothing is threatening you). During an examination the provider may observe the following: the patient taking a long time to take off her clothes, statements like "how long will this take?" or "I hate these exams," twitchy toes during the examination, pulling back while the speculum is being inserted, arching of the back, and disassociation from the exam itself (separating herself, as if she wasn't there). Should these signs occur, the provider may want to stop the exam, allow the patient to sit up and cover herself, and then ask whether she would be more comfortable talking about her discomfort with the exam and reschedule the exam for another day.
At the time of the second exam, it is often helpful to have the patient sit on the table in her hospital gown, ready for the exam, and discuss how she is feeling. At this point it is also beneficial to let the patient decide whether or not to continue with the exam. Rarely does it take more than three visits to complete the exam.
Once a patient has chosen to have the gynecological exam completed, it is important to help her in remaining relaxed and to prevent disassociation. The most common mistake clinicians make is to tell the patient to relax instead of providing her with specific ways to do so. One method is to ask the patient to count her breaths. The provider can also ask the patient to tell a story, or to blow bubbles, which help her to breathe. Laughing together is a marvelous way to reduce stress. Other techniques may include guided imagery (talk her through a series of images, such as being in a forest with the sounds of birds chirping, the feeling of thick leaves underfoot, etc.), centering and the use of classical music (avoid music with words).
It is important to avoid revictimizing the patient by a rough and insensitive exam, during a gynecologic exam especially, when women feel vulnerable and embarrassed. Slow, gentle and supportive pelvic exams are essential. The patient may wish to be examined by a female health care provider. Women who develop a rapport (feeling comfortable and able to talk) with their health care provider are more likely to participate in their own health care, which reduces disease and long-term costs.
Notes: References listed in the original. To find a sensitive gynecologist, Planned Parenthood clinics are probably the best place to start.
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