GYN Care for Survivors of Sexual Trauma

• Understand the prevalence of sexual trauma

• Recognize signs and symptoms of sexual trauma 

• Elicit an appropriately sensitive history in patients with suspected trauma

• Perform trauma-informed pelvic exams 

• Provide appropriate gynecologic counseling, treatment plans, and resources to patients with a history of sexual trauma

Sexual Violence is a prevalent public health crisis in the United States, affecting over half of women and one in three men in their respective lifetimes.1 Patients who have experienced sexual trauma are more likely to experience chronic pelvic pain and sexual dysfunction.2,3 Additionally, these patients are less likely to engage in routine OB/Gyn care, including cervical cancer screening, which may have significant health consequences.2 

Given the prevelance and impact of sexual trauma on patients, the American College of Obstetrics & Gynecology (ACOG) has proposed guidelines for how to care for victims of sexual violence. This trauma informed care approach outlines the creation of an environment that emphasizes safety – physical, psychological, and emotional – for survivors.4 That being said, studies have seen that the majority of OB/Gyn residents do not feel prepared to screen for and address sexual trauma.5 

In order to enhance education on this important concept, this module uses a patient case to demonstrate how to use trauma informed care when taking care of a patient with a gynecologic concern. The module demonstrates proper care using Substance Use and Mental Health Services Administration's (SAMHSA’s) Trauma Informed Approach. This model is grounded in four assumptions: realize, recognize, response, seek.6 

Realize6: All people at all levels of the organization or system realize the impact of trauma on all realms (behavioral health, physical health, criminal justice, etc.) and understand the potential mechanisms and paths to recovery. 

Recognize6: All people at all levels of the organization or system are able to recognize the signs and symptoms of trauma. 

Response6: All people at all levels of the organization or system understand the multifactorial impact of trauma and, therefore, respond by integrating knowledge into a trauma-informed approach for policies, procedures, and practices. 

Seek6: The trauma-informed approach seeks to actively resist re–traumatization through avoiding triggers, using sensitive language, etc. 

You are a generalist  OB/Gyn working in your outpatient gynecology clinic. The next patient is Angela. She is a 26 year old female that is presenting with a complaint of one week history of new vaginal discharge. Angela was a no show to her first appointment. Her histories are below.

PMH: mild-intermittent asthma & major depressive disorder with no past hospitalizations

PSH: denies

OB/Gyn: G0

• LMP 3 weeks prior 

• Menarche 13/q28 days/5 days, light flow

• No hx STIs, cysts, fibroids, polyps, or endometriosis 

• Never received pap smear 

Medications: Zoloft 50mg QD & Albuterol PRN

Allergies: NKDA

FHx

• Mother (living): healthy

• Father (deceased): HTN, HLD, passed from pancreatic cancer at 68

• No siblings 

• No children 

SHx: denies alcohol, tobacco/vaping, and other drugs. Getting her masters in Public Health. 

You enter the exam room and introduce yourself to Angela. She is sitting next to the exam chair, fidgeting with her hands. She says hi without making eye contact and appears annoyed. You grab a chair to sit across from Angela and begin.

Grabbing a chair: Speaking with a patient at their eye level has been shown to make patients feel more comfortable. 

What are some ways that a physician can use their body language to create an accepting presence? 

Answer (Highlight the following text for the answer): Face the patient, Eye contact, Hands in view, Arms uncrossed, Not blocking the door

What are some signs of previous trauma that Angela is showing?

Answer (Highlight the following text for the answer): Angela missed her first appointment and appears slightly agitated/annoyed. Frequently missing healthcare appointments and signs of agitation are common in victims of trauma.8 

You: Tell me a little bit about what brings you in today, Angela.

Angela: I’ve been having this weird discharge for the past week and I don’t know what it is. 

You: Okay, I’m glad you felt comfortable coming in. Can you tell me a little bit more about this? 

Angela: It started about a week ago. I’ve just been having more discharge than normal and it has this weirdly strong smell. I’m not having any itching or burning like with a yeast infection though. Also the discharge is a bit more yellow than usual. I thought about trying Monistat but felt it might be better to come in instead. 

You: Are you experiencing any abdominal pain or burning or pain with urination? Or any blood in your urine or change in smell?

Angela: No abdominal pain. I’ve had a little burning when I pee and I feel a bit like I’ve had to go more often. No blood or change in smell. 

You: Thank you for sharing all of this. May I ask you some more personal questions about your gynecologic health?

Angela: Yes that’s fine.

Learning Point #1: Patient should be fully clothed during the history portion of the visit to decrease vulnerability.7

Learning Point #2: Giving patients autonomy by asking them if it is okay to proceed with questions that may be difficult for them seeks to decrease the risk for re-traumatization.6,7 

Learning Point #3: Use a combination of open- and closed- ended questions when you are screening a patient for trauma. It is also important to avoid questions that are leading or are nonspecific.8,9 

Here are some "ideal responses" to guide the clinical interview when screening a patient for trauma

• “We ask everyone these questions, so none of them are targeted at you in any way. We know that many women have experienced violence in their lives. I’m going to ask you some questions on this topic, since we know that experiencing violence can impact your health. Answering these questions may be uncomfortable, so please let me know if you need to take a break at any time. 

• Have you ever been in a relationship where your partner has threatened you, physically harmed you, or thrown/broken/punched other things? 

• Have you ever been in a situation in which another person tried to force you to have unwanted sexual contact? Examples of sexual contact include intercourse, oral sex, touching private parts, or an inability to provide consent.”

Learning Point #4: It is important to always start off these conversations by building trust. Studies show that patients will not feel comfortable disclosing their experiences without a sense of trust in their physician.8,9 

Learning Point #5: When asking patients about violence, they are more likely to disclose when you ask them specific questions. Words to avoid, as they are associated with less patient disclosure, are “abuse,” “rape,” and “domestic violence.”10 

Angela discloses that her ex-boyfriend forced her to have non-consensual intercourse two weeks ago. She is tearful as she tells the story. Angela states “maybe I deserved it” after recounting how she “broke his heart” last month. 

What are some ways that you can help Angela feel heard and supported in this moment? 

Answer (Highlight the following text for the answer): Empathize with Angela, validate how difficult it must have been for her to disclose this, and thank her for sharing. Emphasize that this is not her fault – “the only person responsible for assaulting you is the person who assaulted you.” Ask how you can best help her.8,9 

Learning Point #6: Self-blame and guilt are common in victims of trauma.8,9 

You let the patient know that you are now going to step out of the room and that they can get undressed from the waist down and use the sheet to cover themselves. You also inform her that you routinely bring in your nurse into the exam room to act as a chaperone and assistant during the examination, so that she knows who to expect ahead of time. 

Physical exam

You knock, re-enter the room, and begin your general physical exam. It reveals the following

Vitals: Pulse 86, BP 124/78, RR 14, Temp 98.2ºF, O2 saturation 99% on room air 

General: Well-appearing, in no acute distress. Fidgeting in chair next to exam table

Cardiovascular: Regular rate and rhythm. No murmurs or gallops auscultated. 

Abdominal: Normal active bowel sounds. Soft, non-tender, non-distended. No rebound tenderness or guarding. 

Extremities: Warm, well-perfused, non-edematous. 

What are some non-specific but common signs of sexual trauma during the physical exam?

Answer (Highlight the following text for the answer): Flinching/jumping to physical touch, pulling away from the examiner/moving up the table, increased pelvic floor tone, tightened gluteus muscles.

It is comforting to patients to hear you let them know that the exam findings are normal (if they are) as you go along. Patients may dissociate during the exam, as this commonly occurs with sexual trauma survivors. If this occurs, stop the exam until the patient returns to full consciousness.7 Dissociation is a disconnection from reality – a cognitive mechanism used for self-protection. It may be difficult for you to recognize dissociation and for some patients to recognize it in themselves. Some signs that the patient may be dissociating include if they “space out,” are confused/disoriented, or if they cannot feel the exam.11 

You are now ready to move onto the pelvic exam. 

What are some examples of things you should say before beginning and during the pelvic exam? 

Answer (Highlight the following text for the answer): Before I begin, I want to ask if there is anything that can make you feel more comfortable for the exam? For example, bringing in a support person to be with you in the room or listening to music that you like.

• It can be difficult sometimes to tell if someone is uncomfortable. What is the best way for you to tell me when you feel this way and therefore need me to stop the exam? Some people say “wait,” “stop,” or “one second.”

• I will not go ahead with any part of this exam until you let me know that you are ready.

• Would you prefer for me to let you know what I’m going to do before performing any part of the exam? 

• I can see that this is making you tense. It is a very normal reaction to tense up during the exam. I think it might help you if you try to let your muscles melt into the bed.

Pelvic Exam Findings

External Genitalia: no erythema, lesions, or abnormalities. 

Vagina: vaginal walls pink and moist with rugae. No lesions present. 

Cervix: mild cervical bleeding with manipulation. Mucopurulent discharge emerging from cervical os. 

Bimanual Exam

Uterus soft, non-tender, mobile, and midline. No cervical motion tenderness. No palpable adnexal masses or adnexal tenderness. 

Angela is a 26 y/o female with PMH asthma and MDD here for one week history of symptoms and physical exam findings concerning for infectious cervicitis after an isolated event of sexual trauma. Urine pregnancy test, serum STI evaluation, Nucleic Acid Amplification Test (NAAT), and wet mount microscopy collected for final diagnoses.  

Learning Point #7: In a patient encounter where someone has recently experienced sexual trauma, it is important to always consider obtaining a pregnancy test and full STI panel (HIV, Syphilis, Chlamydia, Gonorrhea, Trichomonas, Hepatitis) and consider providing emergency contraception and empiric STI treatments.

What treatment would you most likely offer this patient empirically?

Answer (Highlight the following text for the answer): 100mg PO Doxycycline BID, 500mg PO Metronidazole BID, and 500mg IM Ceftriaxone x1 given empirically to patients after a sexual assault to cover chlamydia, trichomoniasis, and gonorrhea (respectively) 

Learning Point #8: Contraception options should be discussed with the patient. Many survivors of sexual violence may prefer private forms of contraception. Engage them in the conversation! 

Angela’s tests come back positive for Chlamydia Trachomatis infection. All other results are negative. 

How do you narrow Angela’s empiric antibiotics given her positive NAAT for Chlamydia Trachomatis?

Answer (Highlight the following text for the answer): Discontinue Metronidazole and continue 100mg Doxycycline BID for 7 days12

What follow up does the patient need? 

Answer (Highlight the following text for the answer): Patient requires 3 month follow up appointment for Chlamydia retesting to assess for reinfection.12 

What are some resources that you can provide the patient for support given her trauma? 

Answer (Highlight the following text for the answer): The following materials/contact information for various support groups should be given to the patient.13

Emergency Resources 

• Crisis Text Line: https://www.crisistextline.org/texting-in

  • Text HOME to 741 741 

• National Suicide Prevention Lifeline: https://suicidepreventionlifeline.org

  • 1-800-273-TALK 

• SAMHSA National Helpline: www.samhsa.gov/find-help/national-helpline 

  • 1-800-662-HELP 

Mental Health Provider Organizations and Directories 

• International Society for Traumatic Stress: https://istss.org 

  • “Find a clinician” tool

• EMDR International Association: https://www.emdria.org

  • Searchable database of trained therapists

• Postpartum Support International: https://www.postpartum.net 1-800-994-4773

  • Text 503-894-9453 

• American Psychological Association: https://locator.apa.org 

Intimate Partner Violence and Sexual Assault 

• National Domestic Violence Hotline: https://thehotline.org

  • 1-800-799-SAFE 

• Love is Respect (for teens): www.loveisrepsect.org

  • Text LOVEIS to 22522 1-866-331-9474 

• Rape, Abuse & Incest National Network: https://www.rainn.org 

  • 1-800-656-HOPE 

Provider Toolkit 

• Council of Patient Safety in Women’s Health Care Support after a Severe Maternal Event Bundle: https://safehealthcareforeverywoman.org/patient-safety-bundles/support-after-a-severe-maternal-event-supported-by-aim 

1. Basile KC, Smith SG, Kresnow M, Khatiwada S, & Leemis RW. (2022). The National Intimate Partner and Sexual Violence Survey: 2016/2017 Report on Sexual Violence. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

2. Meltzer-Brody S, Leserman J. (2011). Psychiatric Comorbidity in Women with Chronic Pelvic Pain. CNS Spectrums, 16(2), 29-35. doi:10.1017/S1092852912000156

3. Basson R, Gilks T. Women's sexual dysfunction associated with psychiatric disorders and their treatment. Womens Health (Lond). 2018;14. doi: 10.1177/1745506518762664 

4. Caring for patients who have experienced trauma. ACOG Committee Opinion No. 825. American. Obstet Gynecol 2021;137:e94–9.

5. Stevens NR, Holmgreen L, Hobfoll SE, Cvengros JA. Assessing Trauma History in Pregnant Patients: A Didactic Module and Role-Play for Obstetrics and Gynecology Residents. MedEdPORTAL. 2020 Jul 20;16:10925. doi:10.15766/mep_2374-8265.10925 

6. Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. 

7. Ades V, et al. An Integrated, Trauma-Informed Care Model for Female Survivors of Sexual Violence: The Engage, Motivate, Protect, Organize, Self-Worth, Educate, Respect (EMPOWER) Clinic. Obstetrics & Gynecology. 2019;133(4): 803-809. doi:10.1097/AOG.0000000000003186 

8. Clark SM. (2023). Caring for Patients Who Have Experienced Sexual Trauma [PowerPoint presentation]. UTMB Health, Galveston, TX.

9. Dodd C, Calvert B. (April 2023). Caring for Patients Affected by Trauma [PowerPoint presentation]. UTMB Health. 

10. Paranjape A, Rask K, Liebschutz J. Utility of STaT for the identification of recent intimate partner violence. J Natl Med Assoc. 2006 Oct;98(10):1663-9.

11. Schwartz M, Galperin L, Masters W. Post-Traumatic Stress, Sexual Trauma and Dissociative Disorder: Issues Related to Intimacy and Sexuality. US National Criminal Justice Reference Service (NCJRS). March 17, 1995. https://www.ojp.gov/pdffiles1/Photocopy/153416NCJRS.pdf 

12. Hsu K, Marrazzo J, Bloom A. (2023, July 14). Treatment of Chlamydia trachomatis infection. UpToDate. https://www-uptodate-com/contents/treatment-of-chlamydia-trachomatis-infection?search=chlamydia+doxycycline&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H5623067 

13. Nagle-Yang S, Sachdeva J, Zhao LX, Shenai N, Shirvani N, Worley LLM, Gopalan P, Albertini ES, Spada M, Mittal L, Moore Simas TA, Byatt N. Trauma-Informed Care for Obstetric and Gynecologic Settings. Matern Child Health J. 2022 Dec;26(12):2362-2369. doi: 10.1007/s10995-022-03518-y