Table 3.

Physical exam and procedures: recommendations for a trauma-informed physical exam.

Recommendation	Rationale
Mitigate vulnerability and increase patient comfort with clothing and draping	Being in the ED is a stressful and vulnerable experience which is aggravated by the common necessity to disrobe. One way to improve patient comfort and to avoid triggering survivors of sexual violence is to allow the patient to keep as much clothing as possible, while still maintaining the capacity for an effective exam. When a patient must be disrobed, maintaining patient modesty improves comfort. When a robe or drape must be moved, requesting that the patient move the article themselves grants them more control over what is happening to them [39].
Guide the patient through the exam with supportive language	When performing any physical exam or procedure, describe what will be happening and why, and give warning before touching the patient. Encourage the patient to tell you if they are uncomfortable, in pain, or afraid prior to initiating the exam. In cases when the patient is hearing or visually impaired, take care to inform the patient of your presence so as not to startle, and before each physical interaction. Allowing the patient some control over the pace of the procedure or exam, when possible, allows them to maintain some control over what is happening to them and can decrease the feeling of being trapped. Another way in which language can be modified is through use of de-personalized terms- omitting “your” and replacing it with “the” and omitting the phrase “for me” while doing portions of the physical exam, such as in “take a deep breath for me”. Do not request that they “relax”, instead use a phase such as “open” or “release this muscle”, when necessary. Providing clear, consistent information with appropriate boundaries which actively seeks to avoid terms which may be linked to traumatic experiences, or which contain unintentional innuendo should be avoided [39,55].
Defer Exams and Procedures that may not need to be done	Sometimes, the harm of the exam via mistrust and re-traumatization may outweigh the benefits, such as the experience of a pelvic exam for persons with a history of sexual assault.
Position yourself within the patient’s line of sight	When performing a physical exam or doing a procedure, remain in the patient’s line of sight and if possible, at the same eye level as much as possible. Examples include performing a pulmonary exam from the patient’s side, a thyroid exam from the front, and positioning the patient during a pelvic exam such that they are propped up in a way that they can see you [39].
Be Clear in Describing Procedures	When a procedure or sensitive physical exam must be performed, consider modifications to improve patient comfort. For example, a patient may be taught to self-insert the speculum during a pelvic exam.