I've been thinking about this issue a lot lately. I was fortunate to be able to attend a workshop last week on IPV and, specifically, on tools that health care providers can use to address the needs of patients who may be experiencing violence at home. The workshop portrayed doctor's offices and hospitals as fertile grounds for opening up lines of communication about violence against women. As a health care provider of sorts (I currently work as a counselor in an abortion clinic and will be starting my nurse-midwifery training next year), I left this workshop feeling optimistic and engaged. Unfortunately, my excitement was soon deflated when a close friend, who has a past history of sexual assault and a subsequent history of post-traumatic stress disorder, recounted to me an extremely violating and triggering experience she had at a medical facility that same week. Her story got me thinking about the medical establishment as a place where sensitivity to past trauma is hardly the norm. If it is true that most women have at least some interaction with the medical system at some point in their lives and that many of these women will also experience sexual assault or IPV at some point in their lives, it stands to reason that understanding post-traumatic responses should be a top priority for the medical community.
The first and perhaps the most important thing that came out of these conversations is the importance of shifting the power dynamics that are involved in most doctor-patient relationships. Doctors are almost always in positions of power relative to their patients. They wear white coats. They have education, prestige, the power to diagnose, and the almighty prescription pad that may even provide a cure. One of the best doctors I've ever had (and this is huge for me to say because this doctor happened to be a gynecologist and a dude, which is something I never thought I'd be cool with) began our interaction by ceding all power and control to me. Before he began to insert my IUD, before he even put my legs up in the stirrups, he sat down, looked me in the eyes and said, “You're the boss. You are in control. I answer to you. You can tell me to stop at any point and I will.” I was shocked. And then I was shocked about being shocked because it all seemed so simple and so obvious.
For my good friend, we'll call her Rachel, it was the feeling of losing control of her body that triggered a post-traumatic response. Rachel was rushed to the hospital when she began having severe and unusual vaginal bleeding. The bewildered EMTs (all male) couldn't muster the courage to even say the word “vagina” and instead asked her if she had any history of problems with “that region.” She said no but tried to explain to them her history of PTSD and why it would make this experience—lying in an ambulance, strapped to a stretcher in a pool of her own blood, surrounded by strange men, some of them rookie EMTs, who had clearly never dealt with anything like this before—particularly difficult. The EMTs nodded, their faces clearly showing that she had said something important but the conversation went no further. At the hospital, she was met with a revolving door of doctors and nurses, all of whom poked and prodded, casually dropping words like “hemorrhage,” “blood transfusion,” and “miscarriage.” They never stopped to explain what was happening, what might be wrong, or what they were going to do about it. All the while, she fought back tears and tried to keep from dissociating as a way to cope with the memories of past trauma. She attempted to explain to each of them what was happening to her body, why it was that she was shaking and sobbing, that, no, she wasn't in any pain. One doctor even made the egregious error of doing an internal (or transvaginal) ultrasound without explaining that the ultrasound probe would be going inside Rachel's vagina, not on her abdomen as she expected.
The doctor that Rachel felt most comfortable with is the one who took the time to listen, who offered to go at her pace, paid attention to verbal and physical cues, and allowed her to set the tone of the interaction. Rachel went to the hospital that day expecting to be triggered. When I asked her to reflect on the experience as a whole, she told me that she had to weigh her options before even deciding to go. Were her symptoms serious enough? Was it enough of an emergency to risk bringing back feelings she had tried so hard to work through? Would having children someday in a hospital be worth it? It's scary and sobering to imagine how many women in Rachel's position just don't go to the doctor when they need to. Or how many women are experiencing PTSD and don't even know it. The one thing I'm sure of is that doctors and nurses need to do better.
I am pleased to say that another amazing friend of mine is working to help medical students become great doctors. Amy Littlefield works as a gynecological teaching assistant (GTA) at a major medical school here in the Northeast. As a GTA, she helps coach 2nd year med students through the often terrifying process of doing breast and pelvic exams. (I say terrifying because at least one med student has fainted during an exam.) Amy explains everything from what to look for down there to what not to say during those lengthy and often awkward silences.
I asked her to share with me some of the tips that she regularly gives to students. Something that stuck out for me is the emphasis she places on explaining exactly what's going to happen, what tools will be used, and what the patient can expect to feel. She also stresses the importance of eye contact, of validating the patient and using positive language. She might instruct a student to say something like, “I am going to insert two fingers into your vagina. I'll then use my other hand on your lower abdomen to palpate your uterus. You may feel some pressure. Your uterus is healthy and you're doing great.” That's doesn't sound so hard, right? But when compared to the alternative, a rushed exam with little or no explanation that leaves the patient feeling confused, uncomfortable, or violated, a few words and a little extra patience can make all the difference.
Even for a patient who hasn't suffered any type of trauma, a visit to the gyno can provoke serious anxiety. Women are regularly taught to be ashamed of their bodies and thus it's not surprising that having a stranger poke around down there feels unpleasant at best. On the other hand, a routine gynecological exam can be a great educational opportunity, especially for young women who are just learning about their reproductive anatomy. I'll never forget this one particularly rad gynecologist I had in college. As she peered between my legs, she told me I had a beautiful cervix and asked if I wanted to see it. Her enthusiasm might have made me laugh but it also reminded me that my body is not only normal, it's healthy and awesome and beautiful.
So on behalf of women everywhere, especially women like Rachel who carry the scars of trauma as they face the daily realities of a society that rarely respects women, I'm asking doctors to take the extra time to listen to their patients, to respect their bodily integrity and autonomy. There are no blank slates when we put our feet in those stirrups. We've all got some issues to work through.
I want to say a HUGE thank you to all of the amazing women in my life who've shared their stories and wisdom with me. Thank you for being my teachers, my co-conspirators, and my friends. Together we are building a world we can believe in.
Chantal Tapé is a self-described birth geek, doula, and soon-to-be-midwife. She currently resides in the smallest state, where she can be found drinking beer with other hairy feminists. In her free time, she also enjoys cake-baking, dance parties, and talking about abortion.
[i] “What is Sexual Assault?” Fact Sheet, National Sexual Violence Resource Center. <http://www.nsvrc.org/sites/default/files/Publications_NSVRC_Factsheet_What-is-sexual-violence_1.pdf>
[ii] Intimate Partner Violence During Pregnancy: A Guide for Clinicians. Centers for Disease Control and Prevention. <http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/>
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