Long-term physical and psychological health effects.

illustration by hana cisarova for AJN

According to the Centers for Disease Control and Prevention, in the U.S., “one in three women and one in six men have experienced sexual violence involving physical contact at some point in their lives.” The report notes the high correlation between sexual violence and a range of adverse health effects like respiratory and gastrointestinal disease, chronic pain, and insomnia.

Not surprisingly, the terror of sexual violence is also correlated with post-traumatic stress disorder (PTSD) and its symptoms. These symptoms fall into four broad categories:

  • reexperiencing
  • hyperreactivity
  • avoidance
  • and negative emotions and thoughts about self or the world

Medical environments as triggers.

For survivors of sexual violence, medical environments can feel dehumanizing and present trauma reminders that intensify underlying post-traumatic stress. In addition, such environments can undermine protective routines and carefully delineated personal boundaries. Physical examination, being undressed, or receiving personal care can trigger powerful automatic fight–flight–freeze responses.

These responses may appear as physiological changes such as alterations in breathing and pulse, involuntary movements, or as hypervigilance, fear, anger, dissociation, withdrawal, or anxiety. Interventions like the insertion of a catheter or medications that decrease alertness or require suppositories can register subconsciously as threatening for someone who has survived rape. So can the loss of privacy, immobility, having others enter without knocking during the night.

Research has found a correlation between childhood sexual trauma and having been betrayed by those who perpetrated the abuse or failed to protect. This wound of betrayal can further undermine a patient’s ability to trust medical staff or feel safe in institutional environments like hospitals or long-term care facilities.

Moving beyond labels like ‘oppositional’ or ‘noncompliant.’

Nurses not familiar with the signs of post-traumatic stress and the prevalence of sexual violence are often mystified as to why some patients have intense, seemingly disproportionate, reactions to certain situations, disease symptoms, and/or medical procedures. Further complicating the clinical encounter, patients who have been sexually assaulted may have developed longstanding patterns of silence, secrecy, isolation.

Lack of awareness can lead nurses to label such patients as oppositional or noncompliant. Some may be judged as having poor social and coping skills; others may be labeled with psychiatric issues like paranoia or personality disorders. This lack of awareness can impede nurses’ ability to connect with and provide effective care for such patients. It can also result in a patient being retraumatized or refusing further care.

Core values of ‘trauma-informed care.’

The Substance Abuse and Mental Health Services Administration has identified core values which should guide “trauma-informed” care. Among these are:

  • recognizing the widespread prevalence and impact of psychological trauma
  • being aware of the signs and symptoms of trauma in patients, clients, families, and coworkers
  • responding with knowledge that integrates trauma into policies, practices, and procedures in an attempt to reduce the risk of retraumatization

A heightened awareness of a possible sexual trauma history.

Nurses may not know with certainty whether a patient has been sexually traumatized. But by being aware that any patient may have been, and by learning basic strategies for creating safety and trust (asking permission before touching, attuning to potential fight–flight–freeze responses, going slow when explaining procedures, knowing how to modify environments that are triggering or soothe a patient’s intense emotions or troubling thoughts), they will be better able to provide support to those who have long carried painful, often secret, memories of having been sexually traumatized.

Scott Janssen, MA, MSW, LCSW, is a hospice social worker. His Viewpoint column, “Letting Patients and Families Interpret Deathbed Phenomena for Themselves,” appeared in the September 2015 issue of AJN, and his most recent post for this blog was “Honoring the Moral Concerns of Caregivers Afraid of Giving Morphine.”

(Further reading: In the October 2016 Reflections essay, “The Traumatized Patient,” nurse practitioner Margaret Adams sensitively describes the varied manifestations of patients who bring a hidden history of trauma to the clinical encounter. The article will be free until February 15.)