I am expected to see about 21 patients a day. Let’s round down to 20. That’s do-able in an eight-hour day, with 15-minute appointments, even with some new patients thrown in for 30-minute appointments. But let’s say that some days it’s 30 patients. 20-30 patients per day, with 3 clinic days per week. Every week, that adds up to between 60 and 90 clinic patients per week, excluding all hospital-based women I work with.
Why is this important? Because an estimated 1 in 6 women in the United States have been sexually assaulted. In specific groups like Native American women or Black women, the number can be as high as 1 in 3. Those are powerful numbers. Even if we average it to one in five: think of 5 women you know, yourself included, and the stats say that one of them might have a history of sexual assault. Women aged 16-21 are in the highest risk category. However, if around 50% of women are not reporting the act to authorities, those numbers may be grossly below the actual rate. On any given day, that could add up to 5 patients whom I’m seeing for their gynecological or reproductive healthcare, who may or may not share this information, about a part of their body which we might discuss or assess during their visit. On any given week, that could add up to 15 women. That’s a big number.
In Midwifery school, we were taught to ensure that women know they are in control of their body, that any exam we do, the woman has control over. She can say “No” at any time, if it hurts or if she’s nervous or scared. Or she can say “No” if she just plain wants to say no. It’s her body, and she is in control of it. We tell her everything that we are doing before we do it, where we are going to touch, what the instruments are, and what we are assessing during the internal exam. This is not only appropriate care, but it also provides the woman with the knowledge of what is happening during her exam, on her body, and gives additional opportunities for her to ask questions, consent, or say no. Knowing that she can say “No,” and having those tools, is vital. The University of Michigan’s Sexual Assault Prevention and Awareness Center has a great graphic showing powerful words and their impact.
One of my midwifery professors was adamant about speculum exams being in the woman’s control. She has the power to say “No” at any time, and the speculum exam stops. If the woman is tense, uncomfortable, muscles completely contracted, or not willing or able to fully consent to the speculum exam, it should not proceed. The midwife should stop the exam, move around to the woman’s side and have her sit up, and really try to elucidate what is going on that caused the woman’s body or mind to react that way. For my professor, it is a form of sexual assault to force a speculum inside, when a woman’s body, her vagina, is saying no. I vehemently agree with her. As providers, when we recognize that initial tension when the woman first feels the speculum, we ask if she is okay, and if she is, tell her to try to relax her muscles right where the speculum is, most times she can. But sometimes she can’t, and we should really consider how we are proceeding with our exam at that point.
This seems like an obvious fact to some, but as a student, I found that not all preceptors agreed with this “pap smear be damned” philosophy. Especially in pregnancy, I remember that one midwife preceptor really pushed the fact that (and I paraphrase here) the woman ‘needed to get used to vaginal exams, because they would be happening often in labor, and it’s better if they get used to someone they know, because it could be anyone at the hospital who is doing them.’ I disagree with many, many parts of that philosophy. Pap smears can wait, especially during pregnancy, where management would likely be deferred until postpartum if they are abnormal. If the pap smear is the opportunity for the provider to determine that there is assault history, and perhaps alter a management plan for that patient during her labor and birth experience, that is an opportunity lost if we are ignoring the woman and focusing on the pap smear. True, that in many places vaginal exams are required for labor assessment, but never should it be discussed in a way that a “woman should get used to it,” or “it could be anyone.” Language and approach like that shows women that the power is not theirs, during a point in time when their body may not feel like theirs, and that is the opposite of midwifery care.
Then, there are women who are in labor in hospitals, where it is often required to perform vaginal exams to determine their cervical dilation and thus assess the course of their labor. Midwifery students learn about cues of prior sexual assault, that if during a cervical check the woman looks away, or her knees clamp around your arm, or if appears that she dissociates, those are signs of which to take important note. Ideally, providers would know of her history beforehand, but that is rarely the case in busy hospital settings. Especially in a large midwife practice where it is uncommon that the midwife whom one saw for prenatal care is also the midwife attending the birth.
Does knowing a past sexual assault history change how we work with patients? If the woman shares her history, and she names it as important for her provider to know, perhaps she will share what that means to her and her gynecological or obstetrical care during the visit. In cases where prior assault is unknown, we seek to provide the same sensitive, compassionate care for all women. In cases where prior assault is known, during pregnancy and birth, continuity of care should be the main consideration. Finding a way to maintain the same provider throughout one’s pregnancy and birth can provide the woman with the knowledge that her provider knows her, there is a trusting relationship, and consent for exams and procedures can be more fully obtained with that level of trust. Continuity of care is always the ideal, that standard all providers strive for, but is often unattainable. In cases of known sexual assault, especially upon the woman’s request, it should be fought for and won, for the patient’s well-being.
What is possibly more likely, unfortunately, is the provider may sense tension, dissociation, or an involuntary reaction during an assessment that might facilitate a moment of conversation. Those moments when the woman’s body speaks for her, indicating past history. And a bodily response like that should be as audible as the spoken word, and we should respond similarly.
Last week, if I saw 8 patients in one day for their annual exams, at lest 7 of them told me that they were really nervous or scared. I don’t think it’s inappropriate for women to feel nervous, especially if they’ve had a bad experience with their annual exam before, or just that they feel naked and vulnerable. If you are a provider, find a way, in English, in Spanish, in French, to tell the woman that she is in control, that she can stop the exam at any time. And we, as providers, will stop. One phrase like this, at every visit, with words highlighting her power, her control, is so incredibly important. This naming really sets the tone as a safe space, reminding her of her ownership over her body, and demonstrating our recognition of that fact. My phrase goes something like, “You are completely in control of this exam, and if at any time you want me to stop or it hurts, let me know, and I’ll stop.” For some, this is an extra opportunity to share that they have had a bad exam in the past, or that they’re always a little nervous but they’re okay, or that they have a history of not being in a situation where their body was their own and in their control. And that’s an extra opportunity worth providing every time. This is only the initial part of knowing, how to open the door between yourself and the woman, to know her and let her know you.
Then there is the woman who is on your schedule for a pap smear, you walk into the room, and they start crying and tell you they were assaulted recently and are scared. Didn’t report it to the police, didn’t go to the hospital, wasn’t on birth control at the time. And this was the only free visit they could find. Would you know what to do? As a friend, as a family member, as a provider?
Know that one in six women have been sexually assaulted. Know the resources in your area. Know them for yourself, your friends, your family, and your patients. Know ways to communicate to women that they are in control of their bodies. Know at least this much today. Know now.
National Sexual Assault Hotline: 1-888-656-HOPE (4673)
How does the National Sexual Assault Hotline work?
The concept behind the hotline is simple. When a caller dials 1.800.656.HOPE, a computer notes the area code and first three digits of the caller’s phone number. The call is then instantaneously connected to the nearest RAINN member center. If all counselors at that center are busy, the call is sent to the next closest center. The caller’s phone number is not retained, so the call is anonymous and confidential unless the caller chooses to share personally-identifying information.