Feature

Q&A: Helping patients with sexual assault trauma in the current public climate

Image of Michelle Riba
Michelle B. Riba

In the United States, about one in three women and one in six men experienced some form of contact sexual violence during their lifetime, according to the CDC’s National Intimate Partner and Sexual Violence Survey 2010 to 2012 State Report.

The National Intimate Partner and Sexual Violence Survey (NISVS) data also revealed an estimated 23 million U.S. women (19.1%) have experienced completed or attempted rape at some point in their lives. Approximately 8.5 million women in the U.S. reported having first experienced completed rape before the age of 18 years, according to the CDC. The report highlighted that 49.5% of multiracial women, 45.6% of American Indian/Alaska Native women, 38.9% of non-Hispanic White women, 35.5% of non-Hispanic Black women, 26.9% of Hispanic women and 22.9% of Asian/ Pacific Islander women experienced some form of contact sexual violence during their lifetime in the United States.

In addition, 2010 to 2014 statistics from the U.S. criminal justice system reported by The Rape, Abuse & Incest National Network (RAINN) showed that only 310 out of every 1,000 sexual assaults are reported to police, meaning about two out of three go unreported.

Sexual harassment and assault also take a long-term toll on women's health. A study presented at The North American Menopause Society Annual Meeting and simultaneously published in JAMA Internal Medicine examined the prevalence of sexual harassment and assault and its long-term impact on women’s health in more than 300 women.

The study found that 19% of participants reported workplace sexual harassment, 22% reported a history of sexual assault, and 10% experienced both exposures, according to a press release. The research showed that sexual harassment was tied to higher blood pressure, greater likelihood of hypertension and clinically poorer sleep quality, while sexual assault was tied to clinical depressive symptoms and anxiety.

Now more than ever before, women and men are sharing their personal stories of sexual assault, advocating and uniting against sexual harassment and misconduct, and taking action in activism movements like #MeToo.

“A broader based strategy to prevent sexual violence, stalking and intimate partner violence can be focused on providing opportunities to empower and support girls and women with the intent of having an impact on the economic security, employment or other socioeconomic aspects of their lives,” the CDC investigators wrote in the NISVS report’s executive summary. “When prevention is not possible, systems have to be in place to support victims and lessen the harms of violence. This could take the form of victim-centered services such as support groups, crisis intervention, and advocacy, or treatment for victims to address many of the psychological consequences of victimization.”

To delve deeper into how doctors can best help patients whose own trauma is triggered by the current public investigations of sexual assault in the news today, Healio.com/Psychiatry spoke with Michelle B. Riba, MD, professor in the department of psychiatry at University of Michigan, associate director of the University of Michigan Comprehensive Depression Center and past president of the American Psychiatric Association. – by Savannah Demko

Comforting crying woman
About one in three women and one in six men in the U.S. experienced some form of contact sexual violence during their lifetime, according to a CDC report.
Source: Shutterstock.com

How can physicians create a safe, trusting environment for sexual assault victims to open up about their experiences?

The first thing, to create a safe, trusting environment, is the essence of a good doctor-patient relationship. Then, physicians can invite and speak to patients about their willingness to talk about their experiences, provide the safeguards and information to make them aware of why this is being discussed and what would be done with this information, and how this can be helpful. Physicians can involve them in this process.

How can doctors approach a patient whose own trauma is brought to the forefront by the current public dissection of a sexual assault?

It really has to do with the nature of the doctor-patient relationship. If the patient is an ongoing patient, in what context is one seeing the patient? Is the patient coming in for other aspects and asking to talk about other issues? Is there something in the patient’s history that’s being stirred up again? Have the doctor and patients talked about this before, and is the patient coming in because something is getting stirred up again? Is a new patient coming from the emergency room? It depends on the context or why and what the situation is for this coming up. It differs from patient to patient. There could be a patient who is going into the ER because this is getting stirred up or an ongoing patient of somebody’s who happens to have an appointment at that time or an ongoing patient is making a special appointment to talk about it. It depends on the reason and context.

Should clinicians approach young victims of sexual assault, like college students, differently?

Every interaction has to be personalized because every patient is different. It depends on the age, the developmental status of the person and what happened. Not only sexual assault, but also other traumas. It can also depend on educational levels, their support and understanding, the outcome of the assault, and more. Everybody is different, and the context is very personalized. There’s always something that needs to be addressed in a specific manner. The same thing with elderly patients, and with any patient for that matter.

Prior research has reported that sexual assault is linked to poorer mental health and even suicide. What can clinicians do to address this connection?

As part of a first or an ongoing evaluation of patients, clinicians always ask about history of trauma, which can be sexual, emotional or physical. It can lead to other psychiatric conditions that come up such as depression, anxiety, PTSD, substance abuse, which untreated, can lead to suicide. These are very important questions to ask every patient, male and female. It’s very important not to believe this is only a female issue. Everybody needs to be asked about their trauma.

How can different medical specialists (psychiatrists, pediatricians, primary care physicians, etc.) work together to collaboratively address sexual assault?

All clinicians and providers should go through certain training in medical school and residency and be supervised well. When in training, they should learn how to ask these questions, what to do in terms of follow-up, and how to provide patients safe harbor if they are in a situation that is dangerous and violent relating to others that they are living with. It’s very important for all of us to be aware of resources, how to communicate — not just using the chart, but by phone — and help people get the care they need and stay safe.

Image of woman at a psychiatrist office
Source: Adobe Stock

What is the take-home message for clinicians?

I had a patient who had been sexually assaulted many years ago and it came up again this week. In some ways, it’s a good opportunity for clinicians — if their patients feel they would like to talk about their experiences — to see how they’re doing now. Trauma stays with people forever, so it’s very important to give people not just one time to talk about it, say, during an evaluation, but it may come up again in a different way. Clinicians need to take the time and listen for the cues.

If you listen very carefully, sometimes people may look like they’re hesitating to want to say something. If the clinician feels rushed, patients pick up on that and might feel it’s not the right time to bring things up. It’s important to try and make time and listen for all kinds of issues. This week it’s sexual assault trauma, but there are other issues that come up and are of timely importance to listen for. We’re all busy, so sometimes it’s easier said than done. But, there are important moments, and this is probably one of them.

Conversations with each other are important; staying away from some of the politics to really talk about the real issues and emotions that are coming up. It can be very difficult to sort out. For each generation, there are different ways to think about this and address it. For many people, these issues were not talked about in a safe, kind or thoughtful way. So, there’s an opportunity.

References:

CDC. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010-2012 State Report. https://www.cdc.gov/violenceprevention/pdf/NISVS-StateReportBook.pdf. Accessed on Oct. 1, 2018.

RAINN. The Criminal Justice System: Statistics. https://www.rainn.org/statistics/criminal-justice-system. Accessed on Oct. 1, 2018.

Thurston RC, et al. JAMA Intern Med. 2018;doi:10.1001/jamainternmed.2018.4886.

Disclosure: Riba reports no relevant financial disclosures.

Image of Michelle Riba
Michelle B. Riba
 

In the United States, about one in three women and one in six men experienced some form of contact sexual violence during their lifetime, according to the CDC’s National Intimate Partner and Sexual Violence Survey 2010 to 2012 State Report.

The National Intimate Partner and Sexual Violence Survey (NISVS) data also revealed an estimated 23 million U.S. women (19.1%) have experienced completed or attempted rape at some point in their lives. Approximately 8.5 million women in the U.S. reported having first experienced completed rape before the age of 18 years, according to the CDC. The report highlighted that 49.5% of multiracial women, 45.6% of American Indian/Alaska Native women, 38.9% of non-Hispanic White women, 35.5% of non-Hispanic Black women, 26.9% of Hispanic women and 22.9% of Asian/ Pacific Islander women experienced some form of contact sexual violence during their lifetime in the United States.

In addition, 2010 to 2014 statistics from the U.S. criminal justice system reported by The Rape, Abuse & Incest National Network (RAINN) showed that only 310 out of every 1,000 sexual assaults are reported to police, meaning about two out of three go unreported.

Sexual harassment and assault also take a long-term toll on women's health. A study presented at The North American Menopause Society Annual Meeting and simultaneously published in JAMA Internal Medicine examined the prevalence of sexual harassment and assault and its long-term impact on women’s health in more than 300 women.

The study found that 19% of participants reported workplace sexual harassment, 22% reported a history of sexual assault, and 10% experienced both exposures, according to a press release. The research showed that sexual harassment was tied to higher blood pressure, greater likelihood of hypertension and clinically poorer sleep quality, while sexual assault was tied to clinical depressive symptoms and anxiety.

Now more than ever before, women and men are sharing their personal stories of sexual assault, advocating and uniting against sexual harassment and misconduct, and taking action in activism movements like #MeToo.

“A broader based strategy to prevent sexual violence, stalking and intimate partner violence can be focused on providing opportunities to empower and support girls and women with the intent of having an impact on the economic security, employment or other socioeconomic aspects of their lives,” the CDC investigators wrote in the NISVS report’s executive summary. “When prevention is not possible, systems have to be in place to support victims and lessen the harms of violence. This could take the form of victim-centered services such as support groups, crisis intervention, and advocacy, or treatment for victims to address many of the psychological consequences of victimization.”

To delve deeper into how doctors can best help patients whose own trauma is triggered by the current public investigations of sexual assault in the news today, Healio.com/Psychiatry spoke with Michelle B. Riba, MD, professor in the department of psychiatry at University of Michigan, associate director of the University of Michigan Comprehensive Depression Center and past president of the American Psychiatric Association. – by Savannah Demko

Comforting crying woman
About one in three women and one in six men in the U.S. experienced some form of contact sexual violence during their lifetime, according to a CDC report.
Source: Shutterstock.com
 

How can physicians create a safe, trusting environment for sexual assault victims to open up about their experiences?

The first thing, to create a safe, trusting environment, is the essence of a good doctor-patient relationship. Then, physicians can invite and speak to patients about their willingness to talk about their experiences, provide the safeguards and information to make them aware of why this is being discussed and what would be done with this information, and how this can be helpful. Physicians can involve them in this process.

How can doctors approach a patient whose own trauma is brought to the forefront by the current public dissection of a sexual assault?

It really has to do with the nature of the doctor-patient relationship. If the patient is an ongoing patient, in what context is one seeing the patient? Is the patient coming in for other aspects and asking to talk about other issues? Is there something in the patient’s history that’s being stirred up again? Have the doctor and patients talked about this before, and is the patient coming in because something is getting stirred up again? Is a new patient coming from the emergency room? It depends on the context or why and what the situation is for this coming up. It differs from patient to patient. There could be a patient who is going into the ER because this is getting stirred up or an ongoing patient of somebody’s who happens to have an appointment at that time or an ongoing patient is making a special appointment to talk about it. It depends on the reason and context.

Should clinicians approach young victims of sexual assault, like college students, differently?

Every interaction has to be personalized because every patient is different. It depends on the age, the developmental status of the person and what happened. Not only sexual assault, but also other traumas. It can also depend on educational levels, their support and understanding, the outcome of the assault, and more. Everybody is different, and the context is very personalized. There’s always something that needs to be addressed in a specific manner. The same thing with elderly patients, and with any patient for that matter.

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Prior research has reported that sexual assault is linked to poorer mental health and even suicide. What can clinicians do to address this connection?

As part of a first or an ongoing evaluation of patients, clinicians always ask about history of trauma, which can be sexual, emotional or physical. It can lead to other psychiatric conditions that come up such as depression, anxiety, PTSD, substance abuse, which untreated, can lead to suicide. These are very important questions to ask every patient, male and female. It’s very important not to believe this is only a female issue. Everybody needs to be asked about their trauma.

How can different medical specialists (psychiatrists, pediatricians, primary care physicians, etc.) work together to collaboratively address sexual assault?

All clinicians and providers should go through certain training in medical school and residency and be supervised well. When in training, they should learn how to ask these questions, what to do in terms of follow-up, and how to provide patients safe harbor if they are in a situation that is dangerous and violent relating to others that they are living with. It’s very important for all of us to be aware of resources, how to communicate — not just using the chart, but by phone — and help people get the care they need and stay safe.

Image of woman at a psychiatrist office
Source: Adobe Stock

What is the take-home message for clinicians?

I had a patient who had been sexually assaulted many years ago and it came up again this week. In some ways, it’s a good opportunity for clinicians — if their patients feel they would like to talk about their experiences — to see how they’re doing now. Trauma stays with people forever, so it’s very important to give people not just one time to talk about it, say, during an evaluation, but it may come up again in a different way. Clinicians need to take the time and listen for the cues.

If you listen very carefully, sometimes people may look like they’re hesitating to want to say something. If the clinician feels rushed, patients pick up on that and might feel it’s not the right time to bring things up. It’s important to try and make time and listen for all kinds of issues. This week it’s sexual assault trauma, but there are other issues that come up and are of timely importance to listen for. We’re all busy, so sometimes it’s easier said than done. But, there are important moments, and this is probably one of them.

Conversations with each other are important; staying away from some of the politics to really talk about the real issues and emotions that are coming up. It can be very difficult to sort out. For each generation, there are different ways to think about this and address it. For many people, these issues were not talked about in a safe, kind or thoughtful way. So, there’s an opportunity.

References:

CDC. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010-2012 State Report. https://www.cdc.gov/violenceprevention/pdf/NISVS-StateReportBook.pdf. Accessed on Oct. 1, 2018.

RAINN. The Criminal Justice System: Statistics. https://www.rainn.org/statistics/criminal-justice-system. Accessed on Oct. 1, 2018.

Thurston RC, et al. JAMA Intern Med. 2018;doi:10.1001/jamainternmed.2018.4886.

Disclosure: Riba reports no relevant financial disclosures.