A history of sexual violence reduces the likelihood of people having timely genital or gynecologic examinations
In Canada, more than half of transgender people, 1 in 3 women, and 1 in 8 men report experiencing sexual violence.1 Genital examinations trigger flashbacks and increase symptoms of anxiety in about 50% of people who have experienced sexual assault.2,3 Given this high prevalence, trauma-informed care starts with the assumption that all people have experienced sexual trauma.
Trauma-informed examinations are performed “with” patients, ensuring that they feel safe, have control and are offered choices
The goal is optimal support while avoiding triggers or exacerbating trauma symptoms.1 Health practitioners should use gender-neutral language; be sensitive to cultural, historical and gender issues; and explain to patients what to expect both before and during the examination.
Patient preferences should be established before the examination and these should be accommodated
Patients may prefer to choose the timing of the examination (e.g., the current health care encounter or a future appointment), and may prefer to have a support person present during the examination.3 They may wish to self-collect samples or self-insert instruments.
Preserving patients’ dignity helps them to feel empowered during the examination
Practitioners should leave the room when patients disrobe and dress. This validates patient dignity and allows time for them to formulate questions. During the examination, the patient’s body should be covered, exposing only those areas it is necessary to expose and for the shortest time required. Findings should be shared only when the patient is fully dressed.4
People who decline an examination should be offered self-testing
Studies of self-testing for human papillomavirus and sexually transmitted infections have shown high rates of participation, ease of self-collection of specimens, and effectiveness of interventions.6 Cervical and vaginal self-sampled specimens for Chlamydia trachomatis and Neisseria gonorrhoeae yielded test sensitivities of 94%–99% and specificities of 97%–99%; vaginal self-sampled specimens for Candida albicans, dubliniensis, parapsilosis and tropicalis showed test sensitivity of 90%–94% and specificity of 90%–93%.6 Results of self-collected samples were similar to those from clinician-collected samples. Urine testing is 98% sensitive and 99% specific for C. trachomatis and N. gonorrhoeae and may be used instead of cervical swabbing in those who do not wish to collect vaginal specimens.5 Kits may be obtained cost free at local laboratories in Canada.
Footnotes
Competing interests: Iris Gorfinkel reports receiving grants from GSK, Merck, Urovant Sciences and Johnson & Johnson. Between 1991 and 1995, Dr. Gorfinkel received payment for expert testimony for sexual assault service operated through Shaughnessy Hospital and later B.C. Women’s Hospital. Dr. Gorfinkel has also received lecture fees from GSK, CME Outfitters and Doctors Nova Scotia; holds stock in Johnson & Johnson and Merck; and was the co-chair of a Shingrix (GSK) advisory board. Dr. Gorfinkel has contributed to the following in the forms of medical writing and presentations, some with pay: CBC Radio and Television; Zoomer Radio and Television; Global News, CTV News, Bored Panda; The Globe & Mail; CMAJ; Canadian Family Physician. No other competing interests were declared.
This article has been peer reviewed.
References
- 1.Experiences of violent victimization and unwanted sexual behaviours among gay, lesbian, bisexual and other sexual minority people, and the transgender population, in Canada, 2018 [juristat]. Cat no 85-002-X. Ottawa: Statistics Canada; 2020. Available: https://www150.statcan.gc.ca/n1/en/pub/85-002-x/2020001/article/00009-eng.pdf?st=W5wDOStd (accessed 2021 June 2). [Google Scholar]
- 2.Frecker H, Scheim A, Leonardi M, et al. Experiences of transgender men in accessing care in gynecology clinics [24G]. Obstet Gynecol 2018;131:81S. [Google Scholar]
- 3.Sexual violence: support and prevention — quick facts. Ottawa: uOttawa. Available: https://www.uottawa.ca/sexual-violence-support-and-prevention/quick-facts (accessed 2021 June 2). [Google Scholar]
- 4.Pearl C. trauma-informed pelvic exams. New York: Reproductive Health Access Project; 2015. Available: https://www.reproductiveaccess.org/resource/trauma-informed-pelvic-exams/ (accessed 2021 June 2). [Google Scholar]
- 5.Chlamydia trachomatis and Neisseria gonorrhoeae: nucleic acid amplification testing. Toronto: Public Health Ontario; updated 2019. Available: https://www.publichealthontario.ca/-/media/documents/lab/lab-sd-005-chlamydia-gonorrhoeae-sensitivity-specificity.pdf?la=en (accessed 2021 June 2). [Google Scholar]
- 6.Gaydos CA, Beqaj S, Schwebke JR, et al. Clinical validation of a test for the diagnosis of vaginitis. Obstet Gynecol 2017;130:181–9. [DOI] [PMC free article] [PubMed] [Google Scholar]