[TW: As noted in the title, this post includes discussion of trauma] Scroll to the end for tips on self advocacy with providers.
This country has a problem with consent. The courageous folks of the #MeToo movement have furthered the discussion around consent, sexual assault, and sexual harassment, bringing these important topics out of the shadows. I would like to spotlight another often overlooked facet of these issues - medical consent and trauma.
My job as a pelvic floor physical therapist is truly very weird. It involves asking people the most private details about their lives and some of the time, touching them in the most intimate places.
I know it takes a lot to come see me. I know many of my patients have struggled for years with pain, embarrassment, loss of function, and incomplete personal relationships due to their symptoms. Not only can it take a long time for them to find me, but it takes a lot of vulnerability, trust, and hope to sit across from me in that chair.
This means I am in a position of immense power. I have valuable knowledge and the potential answers to my patients’ problems. I may even hold the possibility of their recovery, the future that they’re striving for, in the palm of my hand.
This is dangerous because I don’t really feel so powerful from this side of the table. Pelvic floor PT isn’t where the money and influence is, in the context of the world. This is even true of my physician colleagues too. Although ob/gyns have way more power than I have, they rank about 12th on the list for highest paid physician specialists and don’t even get me started on pay for primary care physicians, nurse practitioners, midwives, or ED residents/interns who are also doing many pelvic exams…
This lack of insight into our power as providers can be a problem, because we may assume that when we say, “ok, so-and-so, I would like to do a pelvic exam now”, it implies there’s a choice for the patient, but I would argue that it doesn’t feel like a choice for them. How can a patient who desperately wants to get better say no to a provider who might have the answers?
Consider too the time constraints on health care providers. Their appointments are short and they need to get to the next patient, to documentation, through the day. Are they taking the time to examine a patient’s mental state looking for hesitation? For signs of trauma?
Let’s stack another set of issues onto the list: as providers, this is our everyday work experience. Sure, it may have been anxiety producing and awkward the first few times, but after a while, our days can feel like a revolving door of undressed pelvises and doing a pelvic exam becomes not a big deal for us, a blip on our radars…
But a patient’s experience is very different and it is paramount that providers keep this in mind.
This normalization of our jobs leads to the truly bizarre phenomenon of some providers casually discussing their weekends, lunches, or funny anecdotes while penetrating a patient with a speculum, ultrasound probe, or gloved finger. From the provider’s perspective, this may be an effort to make the patient feel relaxed and comfortable, but I say it negates the patient’s experience and is akin to gaslighting.
How can a patient feel heard or validated if they experience anxiety, pain, or mental discomfort when their provider is acting like a pelvic exam is as everyday as a handshake? How can a provider truly monitor the reactions of their patients if they don’t acknowledge and respect the intimacy and intensity of the experience?
Let’s add too that a patient may not disclose trauma experiences to providers. Even if a provider specifically asks about sexual trauma and abuse, patients may not mention it. This makes sense. It takes a lot of vulnerability to tell a complete stranger about one of the worst experiences of your life. Also, some patients may not be aware that they endured trauma, or haven’t had the therapy to process it, but their past experiences left them with an overwhelming dread of being touched and this potentially paralyzing anxiety may show up during an exam.
How many providers include questions about medical trauma when taking a history? I would guess very few. But medical trauma happens. I’ve had patients with endometriosis who went to the ED because of crippling pelvic and abdominal pain, certain they must be dying, who then suffered through an excruciating pelvic exam only to be told there’s nothing physically wrong with them; that it’s all in their head. I feel palpably the anguish of my patients with vaginismus who are terrified of speculums because of past experiences seeking medical care. I lift up the voices of my patients across the gender spectrum who have been misgendered in a provider’s waiting room, and disrespected and mistreated in the office - probed deeply with potentially unnecessary questions about their sexuality and surgical history, while missing the questions needed to diagnose their pain or symptoms, reducing them to a single dimension of their lives. These bad experiences can understandably breed a lot of distrust in providers.
Providers need to earn a patient’s trust before many people will share their trauma and that may take time and demonstration of competent and compassionate care.
In the meantime, providers should treat everyone they see as if they have experienced trauma and they must keep in mind the power dynamics at play.
As providers, we should never forget the vulnerability we ask of patients when we request that they take their clothes off.
Providers need to remember both sides of the word patient. Yes, there is the medical meaning, but there is also the exhausted and desperate patience embodied by those looking for a provider, the time spent on the appointment waitlist, sitting in the waiting room, and the effort to explain once again their symptoms in hopes that this new provider will help. Providers must show respect for those seeking care and act with their own patience by truly taking the time to hear them, to earn their trust, to help.
There is no replacement for enthusiastic consent. There is no end to the value of explaining thoroughly the what, the how, the why of the exam and treatment process. Providers need to answer questions and validate concerns. Knowledge and control are power and we should be enhancing the power of our patients. Consent is fluid and patients should have the power to change their mind and stop an exam at any time. Period.
Sometimes, I can tell a patient isn’t ready. They are verbally saying yes, but their body is tense, their shoulders are high, their arms or legs tightly crossed, their whole visual message is a NO. If, as a patient, you are saying “Do what you need to” or “Let’s get it over with” to me, then you probably aren’t ready for an exam! In these cases, I tell the patient the exam can wait until another time, or it can be modified to something less invasive. Often I then see them exhale and watch the tension drop from their body. I see the apprehension leave their eyes and know I made the right choice.
Giving my patients the power in the room can be a revelation for them. I let my patients know that they are in control at every visit, during every exam. I tell them they can and should let me know if they change their mind, if something is hurting, if mental images or intense feelings are stirred up. But I don’t wait for that either. I don’t put all the onus on them. If I notice a change, if someone is no longer meeting my eyes, if they have retreated into themselves, if they’re tensing, guarding, or pulling away, I stop. I check in. I back off. It doesn’t matter if we accomplished more at a previous visit; every treatment is a blank slate and there can’t be pressure to always push forward. A person’s present experience of their symptoms or trauma may hinge heavily on their current stress level, sleep, triggering events, or many other conflicting factors that interact to form a unique picture every session. That is ok! Accepting this and removing expectations for continuous forward progress leaves space for safety and allows the room for each person to recover at their own pace.
There is nothing gained by continuing a painful, traumatizing exam. Unless the patient is emotionally present and fully participating, providers should stop. Otherwise, they have left behind the most basic tenet of medical care: do no harm.
We can further damage a patient’s physical, emotional, and mental wellbeing by rushing through, by forgetting about the power gradient, by pushing forward when it’s inappropriate or unnecessary. This is not about blaming providers. Most likely, they chose this career to help and to heal. Their hearts are in the right place and there are many pressing, ugly sides of our healthcare system that limit providers’ time, support, and their own emotional and mental bandwidth.
Truly integrating consent into daily practice is one way for providers to embody the word care. Providers must slow down and explain. They must give patients real space to say no and have other options to complete an exam. Providers should weigh carefully whether an invasive exam is really appropriate and necessary.
I honor the bravery, strength, and resilience it takes for my patients to reach out, come in, and try to heal.
Patients, I know how difficult it can be to advocate for yourself with providers. I have had this experience myself. Please know though, your needs matter. If you need something different, please tell your providers.
For some folks, this concept is so foreign, they don’t even know what they could ask for!
Here’s some ideas:
As a patient, once you find a provider you trust, stick to them like glue! I recommend that patients with a history of any type of trauma avoid bouncing around to different providers. The more a provider knows and understands your individual needs, and the more you trust your provider, the better things will go.
I am sending you compassion, strength, and courage to discuss and advocate for your individual needs with your providers. Please feel free to share this post and my contact information with your providers if it’s tough to put it into words yourself!
Jessica Abele, PT
Therapy Roo Physical Therapy
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