Imbuing Concepts of Trauma-Informed Care into Everyday Practice as Pelvic Health Physical Therapists

As physical therapists, we often see patients more often than any other healthcare provider. Many physical therapists in an outpatient setting may see their patients one to three times a week for several weeks and will have various moments throughout those sessions where they may be hands-on or in close physical proximity. As pelvic health therapists, the intimacy and vulnerability may be even greater due to some of the internal exams and interventions that come with the specialty. Due to this, it is more important than ever that pelvic health therapists, and all healthcare workers, engage in trauma-informed care. 

The Rape, Abuse, and Incest National Network (RAINN) reports that every 68 seconds, someone in the United States is sexually assaulted. This adds up to 463,634 victims on average each year that are aged 12 or older. 1 in 6 women has been the victim of an attempted or completed rape in her lifetime in the United States, and 1 in 10 victims in the United States are male. 

These statistics are staggering and eye-opening, and while sexual assault is not the only trauma that a patient may experience, it is increasingly likely that someone who has experienced sexual assault in their lifetime will walk into our clinics or hospitals. A retrospective study conducted in 2013 by Chichowski et al noted that this is especially so for pelvic health therapists. Researchers found that a history of sexual abuse was common among women with pelvic floor dysfunctions and these women were more likely to have chronic pelvic pain. 

So what are some ways that we can best be of service to those who have experienced trauma, particularly sexual assault? The American Academy of Family Physicians (AAFP) has the following tips for caring for survivors of sexual assault: 

1. Consider broadening screening to include questions about sexual assault as well as intimate partner violence. 
2. A more direct approach may work best, as patients may not know where to start with broad questioning. The AAFP recommends this phrasing: “I’m going to ask a few questions that will help me provide the best care for you. Many of my patients have experienced sexual violence. Has anything like that ever been done to you?” or “Many of my patients have experienced sexual violence, and I noticed you marked ‘yes’ on the screening questions. Is there anything I can do to help make the exam more comfortable or easier for you?” 
3. Provide support through continuity of care and a holistic approach to patient care. 
4. During the exam, ask explicitly for consent and permission to touch. Speak calmly and avoid sudden movements. Explain everything you are doing. Check-in regularly and provide reassurance. Offer items to help a patient feel more comfortable, such as a drink of water, an extra gown, or a washcloth. Offer to take a break, move the patient to a different room, or reschedule the exam if needed. 

Along with the previous tips, the Beth Israel Deaconess Medical Center’s Center for Violence Prevention and Recovery has the following advice on providing trauma-informed care: 

1. Offer trustworthiness and transparency by narrating tasks or procedures, focusing on patient interaction and making eye contact, and informing patients clearly about what to expect before, during, and after exams or procedures.
2. Offer collaboration and mutuality by establishing a relationship that is respectful, empathetic, non-shaming, and non-blaming. Allow the patient to make decisions about their goals and care, and invite the patient to ask questions. Focus on strengths and resources rather than what the patient may be lacking. 
3. Empower patients and give them a voice and a choice. Give options wherever possible and offer alternative explanations to parts of the examination or treatment plan if there is confusion. 
4. Recognize cultural, historical, and gender issues. Know how they may impact response to trauma, as well as intervention adherence or acceptance. Validate a wide range of emotions, be respectful of diverse cultural backgrounds, and use preferred/chosen names, pronouns, and native language whenever possible. 
5. If a patient cannot complete a certain intervention or part of the exam due to distress, normalize this experience and offer to reschedule the appointment. 
6. Allow the patient to get dressed before discussing next steps if any clothing was removed during an intervention or exam. 

All of these suggestions can be easily incorporated into our everyday practice to help patients feel safe, supported, and empowered. As pelvic health therapists, we demand a certain level of vulnerability and trust in our interactions with patients, and therefore it is our duty to provide chances for our patients to comfortably engage with us so that we may best work with them to ensure the best care possible. 

Disclaimer: You may notice that both the terms “survivor” and “victim” were used in this blog post, specific to the resource where the information was taken. It is suggested that you use patient-centered language and use terms that your patient feels most comfortable with. Some patients may refer to themselves as “survivors” or “victims” or another word altogether. It is best to mirror the language that your patient uses. 

Resources

1. Rape, Abuse, and Incest National Network, ed. Victims of sexual violence: Statistics. RAINN. https://www.rainn.org/statistics/victims-sexual-violence. Published 2022. 
2. Cichowski, S. B., Dunivan, G. C., Komesu, Y. M., & Rogers, R. G. (2013). Sexual abuse history and pelvic floor disorders in women. Southern medical journal, 106(12), 675–678. https://doi.org/10.1097/SMJ.0000000000000029 
3. Sherman MD, Hooker S, Doering A, Walther L. Communication tips for caring for survivors of Sexual Assault – AAFP Home. https://www.aafp.org/fpm/2019/0700/fpm20190700p19.pdf. Published 2019.
4. Center for Violence Prevention and Recovery, ed. Trauma-Informed Care Tips Sheet for Healthcare Providers. www.bidmc.org. https://www.bidmc.org/-/media/files/beth-israel-org/centers-and-departments/social-work/center-for-violence-prevention-and-recovery/bidmc-cvpr-trauma-informed-care-tips-sheet-062921.pdf. Published 2021. 

Written By: Maria Padrón, SPT

Author Bio: Maria Padrón is a second-year student physical therapist at Arcadia University. She is passionate about pelvic health and is excited to complete a clinical rotation with a pelvic health therapist in her upcoming terminal clinical education experience before graduating later this year. When Maria is not keeping up with coursework, she loves to cook, read, and write.