Cancer Care for Women With a History of Sexual Assault

I think most women will agree that GYN exams are the least favorite part of our year. Lying on the table in a lovely paper gown can leave you feeling, let’s just say... vulnerable. This feeling may be even more evident in a woman who has suffered a sexual assault, leaving a population of women in the dark about their need to receive ongoing GYN care and follow up.

In the United States, a sexual assault occurs every two minutes, and there are 207,754 assaults annually.¹ An astonishing 54 percent go unreported to the police, with 97 percent of rapists not going to jail for their crime.¹ Forty-four percent of victims are under the age of 18 at the time of their assault, with 80 percent being under the age of 30.¹

Two thirds of assailants are known to the victim, with 38 percent of rapists being a friend or acquaintance.¹ It may be surprising to note that one in six American women have been the victim of an attempted/completed rape, equating to approximately 17.7 female million victims.¹ In 2003, nine out of 10 rape victims were women.¹ American male rape (attempted/completed) accounts for 3 percent of cases, with 2.78 million male victims.¹

The effects of sexual assault are multi-factorial, and victims may suffer from several long-lasting effects. It's noted that victims suffer from more depression, PTSD, substance abuse, and suicide contemplation than the general population.¹ Compounding the issue is rape resultant pregnancy, which the Rape, Abuse & Incest National Network (RAINN) estimates accounted for 3,204 pregnancies in 2004 through 2005.¹ Women who have suffered sexual victimization are also more likely to participate in high risk behaviors and develop cervical lesions.²

Given the astonishing statistics above, we are undoubtedly going to come into contact, either on a personal or professional level, with someone who has been a victim of sexual assault. How do we deal with this as healthcare professionals, making sure these women are receiving comprehensive, preventative care?

The Journal of Family Planning and Reproductive Health Care published a study revealing that only 49 percent of childhood sexual abuse victims received cervical cancer screening, as opposed to 79 percent of the general population.² Researchers say that, "One way of coping with the trauma of sexual abuse is to control or avoid the triggers of trauma responses... Intimate gynecological examinations can be particularly stressful for women who have been abused because of the parallels with the abuse situation, for example, perceived loss of control, the power disparity, and the physical sensation of the examination."¹

When treating a GYN malignancy, several exams and invasive procedures, such as frequent follow up pelvic/rectal exams, pap smears, intravaginal sonograms, and vaginal brachytherapy, are part of routine care. This can be very challenging and stress-inducing for women who have been victimized, and some may chose to forgo screening, follow-up, or treatment.

Sarah Kelly, the Training and Development Manager of the Abuse Survivor’s Support Association, compiled a list of steps to improve the experience of sexual assault victims:²

• The survivor needs time and space to talk about their fears and anxieties of having the test.
• A friend or supporter should be present during the test.
• The smear taker must have an understanding and insight into the issues of childhood abuse, and the legacy of issues that adult survivors can face.
• Words or responses that would trigger anxiety or flashbacks for a survivor should be replaced with alternative "safe" words. For example, many smear takers would tell the woman to try to relax during the test. The word "relax" is often used by abusers and can be very frightening for survivors. An alternative is to agree a word in advance to use in discussions with the patient.
• A private and comfortable environment should be provided for undressing and for the smear test.
• A clear signal, that allows a woman to halt the test if she needs to, should be agreed to beforehand.

It's imperative that all women undergo GYN cancer screening, and it's especially important to reach out to those who have been victims of sexual assault. As providers, we must be cognizant of their emotions and attempt to make their experience more bearable and less stressful, so that we can offer these women the much needed GYN care that every woman deserves.

Does anyone have any specific experience with this? If so, how has it impacted your ability to provide care?

References:

• 1. Rape, Abuse & Incest National Network. Available at http://www.rainn.org/statistics.
• 2. Medical Daily. Available at http://www.medicaldaily.com/articles/12469/20121002/tips-help-sexually-abused-victims-overcome-fear.htm.