In the United States, more than 300,000 people experience sexual abuse or rape every year, typically more girls/women than boys/men.
But not every survivor of sexual abuse will openly talk about their experiences or even report it. Physicians should tailor their approach to taking a sexual health history with this in mind, says Rachel Davidson, Ph.D., a psychologist who runs a private practice, Psyched Clinics, in St. Petersburg, Fla.
“In order to reach your largest net of patients, you want to phrase questions in a way that aren’t jarring,” Davidson says.
Rather than asking a direct question such as “Have you ever been assaulted,” a physician could try “Have you ever had any unwanted sexual experiences?” she advises.
Even before asking that question, she recommends providing a rationale. “You could start off saying ‘I just want to ask some questions that help me get a better understanding of your experiences and how that might affect treating you and your healthcare,’” she says.
It’s important to both make this a standard practice, and let patients know it’s a standard questions, so they don’t feel singled out, she says.
“It allows the patient to make a determination of what they consider a sexual trauma,” she says.
For there, the provider can determine if the information is relevant to the patient’s care or not.
If the patient reveals a sexual trauma, Davidson cautions physicians against taking too much information at that time. “It might be the first time they’re telling somebody about this. When somebody discloses that they’ve had some kind of intimate partner trauma, different people are going to be in different spaces in their ability to talk about it.”
Instead she recommends a physician offer up a mental health referral.
What is important to ask after a disclosure of sexual abuse or trauma is the date of the abuse, which can help determine the necessity of any treatment and relevant sexually transmitted infection screenings.
Davidson had a patient who shared an assault that had happened forty years prior. When she asked what had kept her from sharing that information sooner, the woman reported that no one had ever asked her about it.
However, even when a patient does not say they’ve experienced sexual trauma, Davidson suggests physicians leave the door open in case something should happen in the future.
When physicians take a patient’s “no” for an answer, she says, if someone simply wasn’t ready to discuss their trauma, it can discourage future disclosure.
She recommends a script such as, “’I’m glad to hear you haven’t had any sexual trauma. I ask because it’s something that can come up and I want to make sure we’re always able to provide services for that.’”
There may be some red flags physicians can look for that suggest an assault or abuse a patient doesn’t want to talk about that warrant a recommendation to speak to a mental health provider, she says.
“If they answer very abruptly or if they hesitate, become tearful or if their affect or facial expressions become really restricted, these may be signs that they’re not saying something because it brings up a lot of emotion for them.”
For physicians who find discomfort in asking these sorts of questions, Davidson recommends some role play with a colleague, friend or even just in the mirror. Survivors are sensitive to discomfort and may be likely to pick that up in a physician’s body language or tone of voice. She likens it to having to get used to asking her patients about suicidal ideation. “When I first started out, that was hard to ask about. But over time it just becomes more natural and it’s such an essential part of good care.”
Davidson stresses, “Very few survivors spontaneously disclose sexual assault histories if they’re not asked.”