Trauma Informed Gynecological Care

For most women and people assigned female at birth, the idea of going to the gynecologist is harrowing at first. Doctors offices are sterile and cold, and being half naked, showing your pubic area to a virtual stranger is an uncomfortable situation. At best, the visit can go smoothly. The doctor is kind and understanding, and the pelvic exam is uncomfortable, but not painful. At worst, the doctor can be cold and rude, and the pelvic exam can be incredibly painful and even traumatic. The insertion of an IUD, a common birth control method, is regularly described by patients as one of the worst pains they have felt in their life (Maguire, Morrell, Westhoff & Davis 2013). With a good doctor, even that experience can be a tough one. But with a bad doctor, the experience could create further trauma.

For patients with previous trauma, such as sexual assault, a gynocological exam can seem like a horror story. Even though the exam is done in a non-sexual manner, it deals with a part of the body that can be used in a sexual way. Sexual assault is not an anomoly in American society, and so there is a number of patients who might have trauma related to their pelvic region. In this paper, I will discuss the reasons that trauma informed gynecological care is essential for good health.

One of the most common forms of gynecological care is getting a pelvic exam and a pap smear. Pap smears are swab tests performed in order to test for cervical cancer. They can also be used to test for different STIs and possible inflammation and abnormalities in the vaginal region (John Hopkins Medicine 2019). They are recommended to start when a patient is 21 years old (Ackerson 2012). Contrary to popular belief, one does not need to have been or currently be sexually active in order to receive a pap smear (John Hopkins Medicine 2019). Cervical cancer is caused by HPV, and without a pap smear, it would be hard to diagnose until it was already advanced. The disease affects twelve thousand women a year, and over 50% of those diagnosed had not been to the gynecologist in the last five years (Ackerson 2012).

Since it’s a routine cancer screening, it’s essential that women and people assigned female at birth get tested (Razi, Walfisch, A., Sheiner, E. et al, 2021). But, a pap smear is an uncomfortable test to go through, although the procedure is quick and relatively easy (John Hopkins Medicine 2019). It involves the insertion of a speculum, and then the doctor inserting a swab to collect cervical cells. If the patient is comfortable and there are no complications, the biggest risk in the pap smear is some spotting after the test (John Hopkins Medicine 2019). But for a patient that has a history of trauma, the insertion of a foreign object into the vagina can be difficult, and more than just uncomfortable. A gynocological exam can trigger past trauma in someone with a history of sexual violence (Gorfinkel, Perlow, E., & Macdonald, S. 2021). Since 1 in every 3 woman has experienced some form of sexual violence, this is a large percentage of patients who are at risk for an adverse emotional effect (Gorfinkel, Perlow, E., & Macdonald, S. 2021)!

It’s also worth noting that most patients don’t really know what the purpose of the pap smear is. When researcher Kelly Ackerman studied this topic in 2012, she found that only 2 out of the 15 women interviewed accurately explained what a pap smear was for (Ackerman 2012, pg 683). Half of them did not know what was a risk factor for cervical cancer, and some of them did not even know what cervical cancer was (Ackerman 2012, pg 683). They still went and got a pap smear, and had a pelvic exam. This is most likely because patients trust that doctors know more about medicine than the patient, and so they trust that the doctor is performing the exam out of medical necessity (Hawley 2015).

Even if a patient trusts that the doctor has their best intentions in mind, it does not erase the possible trauma that an exam can dig up. When Ackerman interviewed patients with trauma about their pap smear and pelvic exam, almost all of them had an emotional reaction when talking about the examination (Ackerman 2012, pg 683). Some of them needed music to distract themselves, and some had to disassociate entirely during the exam. There was also the need for another woman in the room, especially if the doctor performing the exam was a male (Ackerman 2012, pg 683). The need for a female provider to be performing the pap smear and pelvic exam is expressed by most women (Razi, Walfisch, A., Sheiner, E. et al, 2021). This could possibly be out of the belief that a female provider would understand a woman’s anatomy and needs more.

Having pap smears and pelvic exams are important for the general health of a female patient. For patients with sexual trauma, they might have issues in their pelvic area that had been caused by their sexual assaults (Razi, Walfisch, A., Sheiner, E. et al, 2021). Women who have suffered domestic violence are also more likely to suffer from STIs (Ackerman 2012). Without proper medical care, these issues could then affect their whole body. Sexual violence can cause many health effects, both mental and physical. Adding to it the fear of going to the gynecologist, and a survivor of assault can feel paraylzed with fear and indecision. There has been evidence showing that survivors of sexual violence are less likely to attend a gynecological exam until absolutely necessary (Razi, Walfisch, A., Sheiner, E. et al, 2021).

From a scientific and medical rationale, having trauma informed gynecological care could possibly improve cancer prevention. Since women who have faced sexual violence are less likely to attend their pap smears, they are thus less likely to be diagnosed with cervical cancer until it’s far too late. Having doctors be trauma informed also means that there is higher patient satisfaction, and patients would feel more comfortable being honest with their provider. Women feel like they can trust their providers the most when there is open and honest communication, and when they feel that their provider listens to their concerns (Razi, Walfisch, A., Sheiner, E. et al, 2021). When a patient doesn’t feel safe talking to their provider, or when the provider makes a mistake, distrust begins to grow between the patient and the provider (Hawley 2015). In addition, if a provider does not believe the patient about the amount of pain they are in, then the patient can develop negative feelings against their provider. In a study on IUD insertion, researchers found that doctors believed that the procedure was less painful than what the patient felt. The patient felt that the pain level of the procedure was at 64%, whereas the doctors thought it was at 35% (Maguire, Morrell, Westhoff & Davis 2013, pg 23). That is almost half the amount of pain actually felt by the patient. When the difference in feeling between doctor and patient is so starkly different, it can lead to patients feeling that a doctor is dismissing their pain.

Politically, practicing trauma informed and trauma sensitive gynecological care could help distance the field from its racist and traumatizing past. Modern gynecology is closely linked to the work of doctor James Marion Sims. Sims practiced on enslaved Black women, who were not able to give proper consent for the surgeries that were performed on them (Zellars 2018). Not only did Sims perform surgeries on these enslaved women, he also possibly would have some of them be impregnated, just so that he could once again attempt surgeries on them. They also were not given anesthesia for the painful procedures (Zellars 2018). People have been rightfully upset about gynecology’s history, and its continuation of Sims’s methods. If doctors were able to be more patient, comforting, and trauma informed, it could show that they do not condone the terrible things that were done in order to understand the female anatomy.

Medicine has a bit of a racism issue. Gynecological research was conducted on Black women who were not given adequate anesthesia (Zellars 2018). The women that were interviewed by Kelly Ackerman were mainly poor and Black (Ackerman 2012). And the majority of the women used in the pain assessment study by Maguire, Morrell, Westhoff and Davis were latinx (Maguire, Morrell, Westhoff & Davis 2013). These are two studies done on the topic and not a whole representation of all people getting gynecological exams, it is worth noting. Medicine has a history of experimenting on Black people, especially in the United States (Zellars 2018). Addressing that past, as well as showing that gynecology is supportive of trauma informed care allows patients to feel more comfortable.

Trauma informed care also shows that gynecologists believe victims of sexual violence, and are supportive of their recovery. It also would show that they understand the staggering amount of their patients who have dealt with such ordeals. Talking with patients about what will happen during the appointment gives them the ability to feel safe. Additionally, doctors are able to give better care when a patient can communicate with them, and they know that the exam is performed with full consent of their patient (Hawley 2015). Showing support for survivors also means that doctors and providers create an environment in which their patients feel they can be honest and disclose their trauma. The women interviewed about their pelvic exams all express that none of them told their doctors about their past trauma unless they had been asked about it (Ackerman 2012, pg 685).

So what does trauma informed gynecological care look like? It is completely based on making the patient comfortable, while also allowing the provider to do a good job. Patients are first walked through the procedure verbally. If they do not consent to a certain part of the exam, then it can be left out. Patients also are treated with dignity, only take off the clothes they need to, and doctors are gentle and understanding of possible cultural differences (Gorfinkel, Perlow, E., & Macdonald, S. 2021). If the patient refuses to do a pelvic exam or a speculum insertion, then the option of doing a self test will be presented to them (Gorfinkel, Perlow, E., & Macdonald, S. 2021). A self-test can be a urine sample, but it mainly involves allowing the patient to insert the instruments in themselves. Patients are also able to do a swab test for STIs by inserting the swab into the vagina themselves (Gorfinkel, Perlow, E., & Macdonald, S. 2021). Allowing the patient the option of a self test frees them up from the nervousness or trauma that can arise from having a provider do it.

The pap test should preferably be done with a doctor that the patient knows well, so that they do not have to be vulnerable in front of a stranger (Ackerman 2012). Exams should also be as short as possible (Gorfinkel, Perlow, E., & Macdonald, S. 2021) , but they should under no circumstance be rushed (Ackerman 2012). Doctors should keep in mind that for most of their patients, getting their exam will be an awkward or uncomfortable situation, even in the best of circumstances. In order to alleviate this awkwardness, doctors can perform more trauma informed exams (Ackerman 2012).

Trauma informed care is important in all fields of medicine, but in the field of gynecology, it’s an absolute need. When doctors and providers are trauma informed, they are able to be better to their patients. Patients feel more comfortable going to their doctor for sexual issues and would be more likely to get pelvic exams. In addition, trauma informed care can lead to higher rates of early cancer detection, since it would allow women who are nervous about a pelvic exam to be more willing to attend their own. It would also bring gynecology into a nicer age, where the focus is on the individual, and making sure they feel good. Trauma informed care can be good for doctors as well, as it allows them to provide better care, and get to know their patients.

References:

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Gorfinkel, Perlow, E., & Macdonald, S. (2021). The trauma-informed genital and gynecologic

examination. Canadian Medical Association Journal (CMAJ), 193(28), E1090–E1090. https://doi.org/10.1503/cmaj.210331

Hawley. (2015). Trust and distrust between patient and doctor: Trust and distrust. Journal of

Evaluation in Clinical Practice, 21(5), 798–801. https://doi.org/10.1111/jep.12374

Maguire, Karla & Morrell, Kathleen & Westhoff, Carolyn & Davis, Anne. (2013). Accuracy of

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(2021). metoo? The association between sexual violence history and parturients’ gynecological health and mental well-being. Archives of Gynecology and Obstetrics, 304(2), 385–393. https://doi.org/10.1007/s00404-021-05977-0

Zellars, R. (2018, October 25). Black subjectivity and the origins of American gynecology.

AAIHS. Retrieved April 15, 2022, from https://www.aaihs.org/black-subjectivity-and-the-origins-of-american-gynecology/