According to the Centers for Disease Control and Prevention, 1 in 4 children in the United States experiences maltreatment, such as physical, emotional or sexual abuse, at some point in their lifetime. The Agency for Healthcare Research and Quality adds that 1 in 5 girls is sexually assaulted by age 13.
Trauma-informed care helps create a secure and trusting environment for adolescent gynecology patients. In knowing how to navigate this delicate terrain and incorporate the tenets of this method at your practice, you can deliver care for young patients while preserving their comfort at all times.
The Principles of Trauma-Informed Care for Youth
The effects of trauma can carry into the exam room: For more than 40 percent of adolescent patients, a routine vaginal exam can trigger repressed traumatic memories, according to the Journal of Obstetrics and Gynaecology Canada. Taking post-traumatic stress disorder (PTSD) into account during exams has become such a pressing issue in the gynecology field that the National American Society for Pediatric and Adolescent Gynecology (NASPAG) explored the topic in its 2019 annual conference in a session titled "Creating a Safe Space: Applying a Trauma-informed Approach to the Care of All Girls and Young Women."
Trauma-informed care aims to recognize and validate a patient's past trauma — from sexual assault or domestic violence to accidents and previous clinical experiences — and understand how the relationship between PTSD and pelvic exams affects their behavior and care.
When delivering trauma-informed care, the American College of Obstetricians and Gynecologists suggests the following best practices:
- Make sure your patients feel physically and emotionally safe.
- Build trust.
- Prioritize your patients' choices and control.
- Promote empowerment.
The U.S. Substance Abuse and Mental Health Services Administration and Health Resources and Services Administration's Center for Integrated Health Solutions advise practitioners to understand the prevalence and impact of traumatic events; recognize the signs and symptoms of trauma; respond by integrating knowledge about trauma into policies, procedures and practices; and avoid re-traumatizing patients.
Making Changes in Your Practice
For a young patient who has experienced trauma, simple changes can make a huge difference during a visit. Begin by asking your adolescent patient open-ended questions like, "Is there anything I should know about your history before we get started?" or "Have you been to the gynecologist before?" to foster trust and quell anxiety.
Understand that your patient sees you as an authority figure, and asking them to undress for a physical exam may cause feelings of shame or powerlessness. Rather than telling them to remove their clothing, try asking, "Are you ready to change?" Use the terms "undergarments" or "underwear" rather than "panties" and "exam table" instead of "exam bed."
Other simple practices, such as completing a health history and talking for a few minutes before asking your patient to change, can tip the power balance and give a young person a greater sense of control.
Simple Exam Modifications
Slight tweaks to standard practices can go a long way toward preserving patient comfort. For example, if your adolescent patient needs an ultrasound to diagnose gynecological symptoms, prop up their head so they can watch what you are doing or offer a mirror to provide a clearer view.
Before any procedure, explain why you need to touch your patient and ask whether they are ready for you to proceed. Provide a running commentary describing your actions. For example, "You'll hear a clicking sound while I adjust the speculum." Request and respond to feedback throughout the visit: Ask, "How are you doing?" or "Can we continue?" If the answer is no, take a break until your patient is ready to move on.
If a patient is particularly tense about a Pap smear, self-inserting the speculum is one option that offers a greater sense of control. Consider doing the same for vaginal swabs for testing for sexually transmitted diseases.
Don't Let Trauma Be a Barrier to Excellent Care
A trauma-informed pelvic exam requires paying attention to nonverbal signs of distress, such as tensing, flinching or blushing. A young patient who stops responding to your questions may be shutting down emotionally as a coping mechanism. If you see any of these signs, pause the exam and continue at another appointment if necessary.
By being attentive, prioritizing communication and putting patient comfort first, you can build stronger doctor-patient relationships and help promote better health outcomes among adolescents with a history of trauma.
