Paediatric health care in the #MeToo era: Advocating for survivors of sexual violence

Abstract

We are witnessing a momentous cultural shift in how we understand, respond to, and resist sexual violence. Rise of the #MeToo movement has ignited a viral wave of consciousness raising, dialogue, and advocacy on an international scale. Women and girls have been empowered to share their stories of sexual assault, bringing to light the widespread prevalence of gender-based violence. As the shame and blame that have silenced victims gradually diminish, we anticipate a continued upward trend in sexual assault disclosure among youth, and corresponding increase in demand for trauma-informed paediatric sexual assault services. It is our collective responsibility to prevent revictimization and retraumatization by the very systems designed to help. In this critical lens commentary, we strongly advocate for heightened awareness and improved responsiveness among paediatric health care providers and policymakers to effectively and ethically meet the diverse needs of the growing number of young survivors who take the brave step of speaking out and reaching out.

Sexual violence is a pervasive public health problem and gendered human rights violation. We are experiencing a critical transformation in how we understand, respond to, and resist sexual violence. Originating from the seminal work of Tarana Burke and signifying the power of digital feminist activism, the #MeToo movement gained online traction in October 2017 and has since ignited a wave of consciousness raising, dialogue, and advocacy on an international scale. Millions of women and girls have been empowered to share their stories of sexual assault and harassment across social media platforms, bringing to light the widespread prevalence of gender-based violence, sexism, and misogyny. As the social stigma and shame that have effectively silenced victims for so long slowly diminish, more and more are speaking out and reaching out. This has opened the floodgates to adult and paediatric sexual assault services, placing new and increasing demands on an already strained system. As we approach the 1-year mark of the proliferation of #MeToo, we critically reflect on our current model of trauma-informed paediatric health care and advocate for more awareness, better preparedness, and improved responsiveness among paediatric health clinicians and systems to effectively and ethically meet the diverse needs of the growing number of young survivors who take the brave step of reporting their abuse and seeking help.

SEXUAL ASSAULT IN CANADA: THE SCOPE OF THE PROBLEM

Sexual assault is the only violent crime that has not observed a steady decline in Canada (1). It is estimated that one in three females are affected by sexual violence in their lifetime (2), with 22% of girls experiencing sexual abuse in childhood (3). As the paediatric clinical leaders for the Ontario Network of Sexual Assault/Domestic Violence Treatment Centres, a network of 35 hospital-based programs offering comprehensive care to those who have experienced interpersonal violence, we have witnessed an 11% increase in sexual assault cases between 2016/2017 and 2017/2018 (4). This remarkable surge in demand for sexual assault services in Ontario parallels that reported across Canada, likely attributed, in large part, to the #MeToo effect (5,6). Women and girls appear to be coming forward in record numbers to share their experiences of sexual violence and get the medical and mental health care they require for healing. The unprecedented media attention has fostered communities of support online, which we, as paediatric health care providers and policymakers, must emulate offline to ensure that those who need and seek help have access to safe, respectful, inclusive, and compassionate care.

TRAUMA-INFORMED PAEDIATRIC CARE: THE NEED FOR MULTILEVEL SURVIVOR-CENTRED SERVICES

Sexual assault can lead to profound adverse sequelae over the life course, including sexually transmitted infections, unwanted pregnancy, post-traumatic stress, anxiety, depression, substance abuse, and suicide, in addition to substantial economic costs to impacted sectors such as health (7,8). Survivors of sexual violence, many of whom carry a heavy burden of shame, often delay disclosure and health care out of fear of being disbelieved, blamed, or judged. It is our collective responsibility in paediatrics to prevent revictimization and retraumatization by the very system designed to help. With the goal of promoting physical and psychological safety and recovery, effective sexual assault care demands a multifaceted, multidisciplinary, trauma- informed approach at individual, organizational, and systemic levels (9).

Creating a climate wherein child and adolescent survivors feel safe, welcomed, and heard begins with a commitment to engaging in an ongoing process of critical self-reflection on deeply held biases and assumptions related to gender, sexuality, abuse, and blame. Paediatricians and allied health clinicians, such as nurses and social workers, must be acutely aware of the pervasiveness of sexual assault among youth and associated trauma effects, prepared to validate disclosures and respond nonjudgmentally, and equipped with the evidence-based knowledge and skills necessary to provide clinical best practices (10–11) in a developmentally appropriate, forensically sound, and culturally safe manner or referrals to specialized services. Recognizing the importance of restoring their sense of power and control, survivors (or guardians of those incapable of consent) should be well-informed of their rights and choices with regards to the physical examination, testing for infections and pregnancy, documentation and collection of forensic evidence, confidentiality and its limitations, presence of an emotional support person, and observation by trainees in teaching settings. Guided by universal trauma precautions and principles of informed consent, clinicians must be sensitive to traumatic sensorial reminders that may be triggered by the clinical interview or physical examination (e.g., certain types of touch, body positioning, confined spaces). Empowering youth with knowledge of sexual health and consent, abuse prevention strategies, police and child protection investigation processes, victim services and court support, and trauma therapy resources can greatly aid their recovery. For young survivors, supporting and educating parents and caregivers is vital to promoting physical safety, emotional wellbeing, and resilience.

We must actively engage, listen to, trust, and affirm the voices of child and adolescent survivors to best inform their care. Hearing the trauma narratives of others can take an emotional toll. It is crucial for helping professionals and organizations to be mindful of the inevitable cumulative effects of vicarious traumatization and take steps to mitigate them at individual and institutional levels. A trauma-informed approach is supported through meaningful collaboration and partnerships across professions, programs, and systems. Child and Youth Advocacy Centres are one example of a coordinated, multisector, multidisciplinary, trauma-informed model of care taking shape across Canada (12).

BEYOND PRIMARY CARE: THE ROLE OF PAEDIATRIC HEALTH CARE IN SOCIAL JUSTICE AND ADVOCACY

As the #MeToo movement continues to gain momentum, paediatric health clinicians and policymakers should anticipate upward trends in sexual assault awareness and disclosure prevalence, and a corresponding increase in demand for acute and ongoing trauma-informed medical and mental health services. Our capacity to sufficiently support child and adolescent survivors, however, relies heavily on shifting cultural, political, and economic landscapes. Welcomed financial investments have recently been made through federal and provincial government initiatives to combat sexual violence, such as It’s Time: Canada’s Strategy to Prevent and Address Gender-Based Violence (13) and It’s Never Okay: An Action Plan to Stop Sexual Violence and Harassment (2). Transitions in political leadership raise significant concern for the sustainability of these important gains.

The role of paediatricians and allied health care providers in responding to sexual violence should not begin and end with the clinic visit. Taking a firm stance against sexual violence entails confronting its root causes through an intersectional feminist lens (14) that recognizes the interconnections of gender and other sources of oppression and privilege based on social category (e.g., race, class, age, sexual orientation, ability), resisting gender-based ideologies and rape culture, and raising consciousness to effect systemic and structural change. On a health systems level, for example, impactful advocacy efforts include lobbying governments for responsive legislation and sustainable funding for accessible paediatric sexual assault services; educating paediatric health leaders and policymakers on the epidemic of sexual violence and coinciding need for interprofessional training on best practice guidelines; and ensuring organizational policies and procedures support trauma-informed approaches to inclusive paediatric care. More broadly, we should urge survivor-centred child welfare and criminal justice system responses to sexual violence, and commit to collaborative community partnerships to tackle education, prevention, and intervention together. The #MeToo era continues to usher in new and important opportunities to advance awareness, improve care, and motivate change. We, as paediatric health care providers, must rise to this challenge as we move forward in solidarity with child and adolescent survivors of sexual violence.

Funding Information: There are no funders to report for this submission.

Potential Conflicts of Interest: All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.