It is well known that symptoms of childhood sexual abuse can manifest into adulthood, yet there is inadequate discussion of how these residual effects can hinder a person's ability to access and benefit from health care.
Imagine 80-year-old Sarah as she lies in her hospital bed. The nurse knocks and briskly enters, informing Sarah it's time for her Lovenox injection. “This one goes in the belly,” she says, smiling, as she reaches for the blankets. Sarah doesn't say a word but clutches the blankets tightly to her chin. The nurse sighs. The last thing she has time for is another “difficult” patient. “Come on, Sarah,” she says. “You're going to get a blood clot if you don't let me give this to you.” She looks at the clock, then at Sarah, then at the door as she hears the call light in the next room. Shaking her head, she walks out of the room, documenting the injection as “refused.” Meanwhile, Sarah lies with her panic, silently clutching the blankets, just as she did when she was a child.
Childhood sexual abuse often results in posttraumatic stress disorder (PTSD). Adult survivors with PTSD physically and emotionally react to “triggers,” situations or other stimuli reminiscent of details of the initial trauma. This response, a result of the brain's fight, flight, or freeze reaction, can be uncontrollable, and manifests in various ways. Some survivors avoid medical treatment altogether in order to avoid triggers. Shame, anxiety, and depression can cause patients to feel unworthy of having their medical needs met. In Sarah's case, having the blankets pulled off her triggered the memory of her uncle sexually abusing her as a child.
While estimates of the percentage of adults, male or female, with a history of childhood sexual abuse vary widely, it is likely that we are unknowingly caring for abuse victims on a regular basis. The stigma of sexual abuse may remain particularly strong for the geriatric population. A common theme in the childhood experiences of older generations was that children were “to be seen and not heard”; for this and other reasons, many stories of sexual abuse have remained untold. Shame is silencing.
What new models of therapeutic relationships are needed to make patients like Sarah feel safe? In a qualitative study by Gesink and Nattel (BMJ Open, 2015) of childhood sexual abuse survivors' experiences of cancer screening, participants felt most supported by “compassionate” care, in which providers related to survivors “by understanding, empathizing, and mitigating potential sources of suffering.”
Providing compassionate care involves being mentally present and learning new communication styles to reduce anxiety and empower survivors. It means being mindful of body language, tone of voice, or behaviors (like talking while facing a computer) that could come across as intimidating or dismissive.
Physical exams, bathing, inserting urinary catheters, and administering enemas are just a few of the ways nurses interact with patients in potentially triggering areas of the body. Typical safety measures focus on fall prevention, medication errors, or infection control. Simply following a care plan is not enough. As the danger is invisible, awareness is crucial.
Working with the patient is key. Since feeling powerless over one's body is a common trigger for patients, asking patients' permission and giving them control is essential for building trust. If nurses are prepared for such interactions, they can start to create positive experiences for patients, resulting in a more trusting attitude toward the health care system.
As it is reasonable to assume many survivors will not reveal their trauma history, a safe protocol would be to treat every patient as if they were a survivor. Make eye contact. Ask before touching. Explain before doing. As nurses, we can do better. It's time to address the elephant in the exam room.