How PCPs can identify, discuss sexual assault with adolescent patients
SAN FRANCISCO — Although young victims of sexual assault will rarely immediately disclose the event to their health care provider, there are still ways PCPs and pediatricians can identify symptoms and initiate discussion, according to a presenter at the 2016 AAP National Conference and Exhibition.
Tonya Chaffee, MD, MPH, FAAP, director of the Teen and Young Adult Health Center, at the Zuckerberg San Francisco General Hospital, told attendees that victims may seek them out for services related to sexual assault, particularly STI and pregnancy testing. In addition, common signs and symptoms of sexual assault can include insomnia, anorexia, physical injuries, with later and long-term symptoms including suppression of feelings, cutting, eating disorders, depression, PTSD, suicidality and, among males, erectile dysfunction.
“It’s not something that people necessarily want to disclose and sometimes they are afraid of what happens with that information,” Chaffee said.
According to Chaffee, when discussing possible sexual assault, health care providers can ask directly — “Have you ever been pressured or forced to have sex?” — or take a more measured approach. In the latter approach, if a patient presents with a concern, a provider can initiate conversation by normalizing their complaints.
Chaffee offered an example: “There are many reasons young people have your symptoms. In some cases, it is because someone has forced them to have sex. Is this a possibility with you?”
“Some teens have sex for the wrong reasons, like feeling pressured to do so,” began another example. “Have you ever had sex and said ‘No’?”
Other similar questions may also be successful, she added.
“These are just 2 possible ways, and I’m sure some of you have your own way,” she said. “But, again, saying it’s very common for people to have these symptoms, and asking if this is a reason why can be effective. I can’t tell you how many disclosures I’ve had from just asking it that way.”
Patient barriers to disclosing a sexual assault include not being ready, denial, guilt or low self-esteem, and fear of parents, a partner, the police or the mandated reporting system, Chaffee said. In addition, victims in a sex-same relationship often opt not to disclose an assault due to fear of revealing their sexual orientation or identity.
If a patient does disclose a sexual assault, providers should offer validation by stressing that the patient did not deserve to be assault, that it is not their fault, and that what happened to them is a crime, Chaffee said.
In addition, providers should ask if the patient has any immediate safety concerns, address any medical issues, and respect the patient’s wishes regarding how much information they wish to divulge. They should also connect the patient with appropriate trauma-informed counseling.
An important aspect to keep in mind, according to Chaffee, is mandated reporting. Although most discussions between physicians and patients are confidential, all 50 states legally require health care providers to report child sexual assault as soon as they become aware. This often prevents adolescents from disclosing a sexual assault to physicians, and providers should attempt to strike a balance between mandated reported requirements and the confidentiality of the patient.
According to Chaffee, providers can help make victims feel more in control by having them sit in on the telephone call reporting the disclosure. In addition, the provider can allow the victim to control what information is included in the report.
“The big thing is letting the person take control of the situation,” Chaffee said. “They already feel like things have been out of control, so when you are making that report, have them help you. Let them decide what they want to report and what they don’t want to report. That gives them a little empowerment in the process.” – by Jason Laday
Chaffee T. On and off campus: Care of the adolescent after sexual assault; AAP National Conference & Exhibition; Oct. 22, 2016, San Francisco.
Disclosure: Chaffee reports no relevant financial disclosures.