Sensitive Practice

Handbook on Sensitive
Practice for Health Care

Practitioners:
Lessons from Adult Survivors of
Childhood Sexual Abuse
Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Child-
hood Sexual Abuse was researched and written by Candice L. Schachter, Carol A. Stalker, Eli Teram,
Gerri C. Lasiuk and Alanna Danilkewich
Également en français sous le titre Manuel de pratique sensible à l’intention des professionnels
de la santé – Leçons tirées des personnes qui ont été victimes de violence sexuelle durant l’enfance
The opinions expressed in this report are those of the authors and do not necessarily reflect
the views of the Public Health Agency of Canada.
Contents may not be reproduced for commercial purposes, but any other reproduction,
with acknowledgements, is encouraged.
Recommended citation:
Schachter, C.L., Stalker, C.A., Teram, E., Lasiuk, G.C., Danilkewich, A. (2008). Handbook on
sensitive practice for health care practitioner: Lessons from adult survivors of childhood
sexual abuse. Ottawa: Public Health Agency of Canada.
This publication may be provided in alternate formats upon request.
For further information on family violence issues please contact:

National Clearinghouse on Family Violence
Family Violence Prevention Unit
Public Health Agency of Canada
200 Eglantine Driveway
Jeanne Mance Building, 1909D, Tunney’s Pasture
Ottawa, Ontario K1A 0K9
Telephone: 1-800-267-1291 or (613) 957-2938

Fax: (613) 941-8930
TTY: 1-800-561-5643 or (613) 952-6396
Web site: www.phac-aspc.gc.ca/nc-cn
E-mail: [email protected]
© 2009 Candice L. Schachter, Carol A. Stalker, Eli Teram, Gerri C. Lasiuk, Alanna Danilkewich
Cat.: HP20-11\2009E HP20-11\2009E-PDF
ISBN 978-0-662-48577-3 978-0-662-48578-0
Handbook on Sensitive
Practice for Health Care
Practitioners:
Lessons from Adult Survivors of
Researched and Written by...
Candice L. Schachter, DPT, PhD

Adjunct Professor, School of Physical Therapy
University of Saskatchewan, Saskatoon, SK
Carol A. Stalker, PhD, RSW

Professor, Faculty of Social Work
Wilfrid Laurier University, Waterloo, ON
Eli Teram, PhD

Professor, Faculty of Social Work
Wilfrid Laurier University, Waterloo, ON
Gerri C. Lasiuk, RN, PhD

Assistant Professor, Faculty of Nursing
University of Alberta, Edmonton AB
Alanna Danilkewich, MD, FCFP

Associate Professor, College of Medicine
University of Saskatchewan, Saskatoon, SK
Table of Contents
Acknowledgments ................................................................................................................ vii

Epigraph .............................................................................................................................. ix
1 The Handbook as a Tool for Clinical Practice ................................................................... 1
1.1 Audience and focus ........................................................................................... 1
1.2 An issue for all heath care practitioners ............................................................ 1
1.3 Organization ...................................................................................................... 2
1.4 Suggested uses of this Handbook ...................................................................... 2
1.5 Terminology ...................................................................................................... 3
1.6 Limitations ........................................................................................................ 4
2 Background Information about Childhood Sexual Abuse ................................................ 5
2.1 Definitions ......................................................................................................... 5
2.2 Childhood sexual abuse survivors...................................................................... 5
2.3 Perpetrators of childhood sexual abuse ............................................................ 6
2.4 The dynamics of childhood sexual abuse .......................................................... 6
2.5 Childhood sexual abuse and health .................................................................. 6
3 What Childhood Sexual Abuse Survivors Bring to Health Care Encounters....................... 9
3.1 Gender socialization: Women’s experiences ...................................................... 9
3.2 Gender socialization: Men’s experiences ........................................................... 10
3.3 Societal myths about the cycle of violence ........................................................ 11
3.4 Transference and counter-transference ............................................................. 12
3.5 Specific behaviours and feelings arising during health care encounters ........... 12
3.6 Questions about sexuality and sexual orientation ............................................. 15
4 Principles of Sensitive Practice......................................................................................... 17
4.1 Overarching consideration: Fostering feelings of safety for the survivor ........... 17
4.2 The nine principles of Sensitive Practice ........................................................... 17
4.3 Using the principles to avoid retraumatization ................................................. 23
4.4 Questions for reflection ..................................................................................... 24
5 Guidelines for Sensitive Practice: Context of Encounters ................................................. 25
5.1 Administrative staff and assistants .................................................................... 25
5.2 Waiting and waiting areas ................................................................................. 25
5.3 Privacy ............................................................................................................... 26
5.4 Other issues related to physical environment.................................................... 26
5.5 Patient preparation ........................................................................................... 26
5.6 Encouraging the presence of a support person or “chaperone” ........................ 27
5.7 Working with survivors from diverse cultural groups ........................................ 28
5.8 Collaborative service delivery ............................................................................ 29
5.9 Practitioners’ self-care ....................................................................................... 30
5.10 Community resources for survivors and health care practitioners .................... 31
6 Guidelines for Sensitive Practice: Encounters with Patients ............................................. 32
6.1 Introductions and negotiating roles .................................................................. 32
6.2 Clothing ............................................................................................................. 32
6.3 Task-specific inquiry .......................................................................................... 33
6.4 General suggestions for examinations ............................................................... 36
6.5 Time .................................................................................................................. 37
6.6 Informed consent .............................................................................................. 38
6.7 Touch................................................................................................................. 39
6.8 Pelvic, breast, genital, and rectal examinations and procedures....................... 40
6.9 Body position and proximity ............................................................................. 41
6.10 Pregnancy, labour and delivery, postpartum..................................................... 42
6.11 Oral and facial health care ................................................................................ 43
6.12 Care within the correctional system .................................................................. 46
6.13 After any physical examination ......................................................................... 46
7 Guidelines for Sensitive Practice: Problems in Encounters............................................... 48
7.1 Pain ................................................................................................................... 48
7.2 Disconnection from the body ............................................................................ 48
7.3 Non-adherence to treatment ............................................................................. 49
7.4 Appointment cancellations................................................................................ 50
v
Table of Contents
7.5 “SAVE the Situation”: A general approach for responding to difficult
interactions with patients .................................................................................. 51
7.6 Triggers and dissociation ................................................................................... 52
7.7 Anger or agitation.............................................................................................. 56
8 Guidelines for Sensitive Practice: Disclosure .................................................................... 57
8.1 The challenge of disclosure for survivors .......................................................... 57
8.2 Possible indicators of past abuse....................................................................... 59
8.3 Inquiring about past abuse ............................................................................... 59
8.4 Responding effectively to disclosure ................................................................. 63
8.5 Additional actions required at the time of disclosure or over time ................... 65
8.6 Responses to avoid following a disclosure ......................................................... 68
8.7 Legal and record-keeping issues ........................................................................ 68
9 Summary and Concluding Comments .............................................................................. 71
9.1 Clinicians’ contributions to survivor’s healing from childhood sexual abuse .... 71
9.2 Sensitive Practice and patient-centred care ....................................................... 71
Appendix A: Empirical Basis of the Handbook .................................................................... 72
Appendix B: Prevalence of Childhood Sexual Abuse ........................................................... 74
Appendix C: Traumagenic Dynamics of Childhood Sexual Abuse ........................................ 75
Appendix D: Diagnostic Criteria for Stress Disorders ........................................................... 77
Appendix E: Sample Introduction to a Facility .................................................................... 80
Appendix F: Using Plain Language in Consent Forms ......................................................... 81
Appendix G: Working with Aboriginal Individuals ............................................................... 82
Appendix H: A Note about Dissociative Identity Disorder ................................................... 86
Appendix I: The Evidence Debate Pertaining to Inquiry about Interpersonal Violence ...... 87
Bibliography ........................................................................................................................ 89
Works Cited................................................................................................................ 89
Recommended Reading and Resources ..................................................................... 100
Index .................................................................................................................................... 105
Sensitive Practice At-a-Glance .............................................................................................. 107
vi
Handbook on Sensitive Practice for Health Care Practitioners
Acknowledgements
The authors are deeply grateful to all of the Ginny Freeman MacOwan, for their work on the
survivors, health care practitioners, students, and Handbook.
mental health practitioners who participated
in this research project. These individuals gave The authors are grateful for permission to reprint
generously of their time and energy; without previously published material:
them, this Handbook would not have been Table 6, Traumagenic Dynamics of Childhood
possible. Sexual Abuses has been adapted from
We are indebted to the many individuals Finkelhor, D., & Browne, A. (1985). The
who assisted with recruitment of participants traumatic impact of child sexual abuse:
throughout this project. We wish to acknowledge a conceptualization. American Journal
and thank those whose assistance made this of Orthopsychiatry, 55(4), 530-41, with
second edition of the Handbook possible. Don permission of author David Finkelhor.
Wright and the staff of the British Columbia Appendix D, Diagnostic criteria for Acute
Society for Male Survivors of Sexual Abuse, Rick Stress Disorder and Post Traumatic Stress
Goodwin and the staff of the Men’s Project, Disorder has been reprinted from American
Duane Lesperance and the staff at the Men’s Psychiatric Association. (2000). Diagnostic
Resource Centre, and Joy Howatt and Elsie Blake, and statistical manual of mental disorders
of the Stratton project, Family Service Association (4th ed., Text Revision), pp. 471-72 and 67-68.
assisted with recruitment, allowed us to conduct Washington, DC: Author, with permission of
interviews and working groups in their offices the American Psychiatric Association.
and offered much encouragement for the project.
Fran Richardson, College of Dental Hygienists of The authors gratefully acknowledge the assistance
Ontario, Shari Hughes and Ariadne Lemire, College of the National Clearinghouse on Family Violence,
of Physiotherapists of Ontario, Donna Beer, School Public Health Agency of Canada in translating,
of Physical Therapy, University of Western Ontario designing and printing the second edition of the
helped to organize and host focus groups in the Handbook. We would also like to thank Stacey
final phase of this project. Angela Hovey, Liz Scott, Croft and Salena Brickey, Policy Analysts at the
Julia Bidonde, Leane King and Jennifer Ewen Family Violence Prevention Unit, for their work on
contributed valuable research assistance. the publication of this Handbook.
We would like to thank Rose Roberts, Faculty of The authors gratefully acknowledge the financial
Nursing, University of Saskatchewan for writing support received over the duration of this project
the sections titled Working with Aboriginal from the following:
Individuals. We would like to express our
Health Canada
appreciation to Sanda Rodgers, Faculty of Law,
University of Ottawa, for taking time to review Physiotherapy Foundation of Canada
the information on legal and record keeping University of Saskatchewan College of
issues, to Diana Gustafson, Faculty of Medicine, Medicine Scientific Teaching and Research
Memorial University, and Shoshana Pollack, Fund
Faculty of Social Work, Wilfrid Laurier University University of Saskatchewan Internal Grants
for their thoughtful and important comments. Program (New Faculty Start-up, President’s
We are indebted to our editors, Bob Chodos and SSHRC and Publication Fund Grants)
vii
Acknowledgements
Wilfrid Laurier University Internal Research photocopying, mailing costs, and ongoing support
Grants Program throughout the project and the faculty and staff
of the School of Physical Therapy, University of
Lastly, we wish to thank the Lyle S. Hallman
Saskatchewan for their ongoing support and
Faculty of Social Work at Wilfrid Laurier
University for assistance with research assistants, encouragement.
viii
This may be a person who’s gone through something very traumatic ...[who needs] some
really safe technique ... Because otherwise you’re going to have a certain segment of
patients that are going to walk away feeling as though they’ve been abused all over again,
quietly abused, just walking away and seeking another health care practitioner, just going
through the cycle, again and again and again, and maybe not understanding why, maybe
not knowing how to say it, how to voice that, just keep going through that whole cycle
over and over again. There’s a huge populace out there that just needs that extra gentle
care. It’s because of that, maybe the whole populace needs to be treated the same way.
– A male survivor of childhood sexual abuse –

1 The Handbook as a Tool for Clinical Practice
1.1 Audience and focus 1.2 An issue for all heath care
This handbook presents information that will help
practitioners
health care practitioners practise in a manner As many as one third of women and 14% of men
that is sensitive to the needs of adult survivors are survivors of childhood sexual abuse.31,62,25
of childhood sexual abuse and other types of Childhood adversity – including sexual, physical,
interpersonal violence. It is intended for health care and emotional abuse – is associated with a greater
practitioners and students of all health disciplines risk of a wide variety of health problems. This
who have no specialized training in mental health, means that all health care practitioners – whether
psychiatry, or psychotherapy and have limited they know it or not – encounter adult survivors
experience working with of interpersonal violence in
adult survivors of childhood
All health care practitioners - whether their practices. Survivors are
sexual abuse. This second health care consumers of
they know it or not - encounter
edition includes experiences every age who seek all types
survivors of interpersonal violence in
and ideas of both women of health services, and our
their practices.
and men survivors as well hope is that the principles
as of practitioners from and guidelines of Sensitive
more than ten health disciplines. The Handbook Practice will become “universal/routine procedures”
is not meant to encourage health care providers in all health care encounters and that all health
to step outside their scope of practice, nor is it a care consumers136 will benefit from them.
substitute for the specialized training required to
provide intensive psychotherapy or counselling for
Section 2.5 – Childhood sexual abuse and health
survivors.
The Handbook is based on extensive interviews, Examinations and procedures that health
group discussions, and a national consultation care providers might consider innocuous or
process involving adult routine can be distressing
survivors, clinicians, and The principles and guidelines of for survivors, because they
mental health practitioners. Sensitive Practice can be adapted may be reminiscent of the
Direct quotes from to all health care venues. original trauma. Exclusive
participants are included focus on the body, lack of
to illustrate selected issues and to connect control, invasion of personal
health care providers in a more personal way boundaries, exposure, vulnerability, pain, and
to survivors’ thoughts and feelings. To our sense of powerlessness are common experiences
knowledge, the Handbook is the only work in print in the health care environment and may be
that has employed a process of bringing adult extremely difficult for survivors because they can
survivors and health care practitioners together mirror aspects of past abuse. An appreciation
to develop an empirically grounded account of of the dynamics and long-term effects of
the issues and problems that adult survivors of childhood abuse is the first step toward a better
childhood sexual abuse encounter in health care understanding of survivors’ needs and responses
settings. The empirical basis of the Handbook is to care. Sensitive Practice builds on core
competencies to help health care practitioners
found in Appendix A.
be more understanding of and responsive to the
specific needs of adult survivors of violence and Chapters 5, 6, 7, and 8 outline the
abuse. guidelines for Sensitive Practice. These
guidelines operationalize the principles
of Sensitive Practice and are meant as
Chapter 2 – Background Information about
Childhood Sexual Abuse practical suggestions that health care
practitioners can incorporate into their
Chapter 3 – What Childhood Sexual Abuse Survivors
clinical practice.
Bring to Health Care Encounters
Chapter 5 presents those guidelines
Although our research focuses primarily on related specifically to the context of
Sensitive Practice in traditional health care health care encounters.
settings, health care providers work in widely
diverse areas including client homes, rural and Chapter 6 details guidelines applicable
remote areas, and school systems. We believe the to all interactions between health
principles and guidelines of Sensitive Practice can practitioners and their clients.
be adapted to all health care venues. Chapter 7 offers health care
practitioners guidelines for coping
Chapter 3 – What Childhood Sexual Abuse Survivors with the problems that can occur in
Bring to Health Care Encounters encounters with child sexual abuse
survivors.
1.3 Organization Chapter 8 highlights guidelines focused
on disclosure of past abuse, especially
The Handbook is divided into nine chapters. as it is related to survivor-clinician
Readers are alerted (watch for a blue “i” in a blue interactions.
circle) when the topic addressed in one section is
clarified or expanded upon in another section. Chapter 9 explores the contributions which
health care practitioners can make to an
Chapter 1 offers an introduction to adult survivor’s healing and recovery, and
terminology and suggestions for using the elaborates on the relationship between
Handbook. Sensitive Practice and patient-centred care.
Chapter 2 provides basic information about Chapters 4, 6, and 8 conclude with
the nature and scope of childhood sexual questions intended to stimulate reflection
abuse and health problems associated about the application of the principles and
with a history of childhood sexual abuse guidelines to health care practices.
to assist health care practitioners to
understand the significance of Sensitive Nine appendices augmenting the text and
Practice. a bibliography detailing both works cited
and recommended readings and resources
Chapter 3 presents information about how finish off the Handbook.
experiences associated with a history of
childhood sexual abuse may be manifested
in health care settings. 1.4 Suggested uses of this
Handbook
Chapter 4 describes the principles of
Sensitive Practice derived from our Students, practitioners, and administrators are
research; we consider these principles urged to think about the information on violence
foundational to ethical health care. and abuse and Sensitive Practice provided in
this Handbook, and to reflect on its potential
2
for informing their own practice and workplace Teach administrative personnel and
policies. Specifically, health care providers should assistants about childhood abuse and its
consider: implications for their work;
How the information applies to them; Disseminate ideas from the Handbook to
colleagues with the intent of creating an
How to implement the principles and integrated and responsive network of care;
guidelines into their practices;
Influence policies and practices within
How they might best respond to the public agencies to be more sensitive to
various situations described in the survivors;
Handbook.
Coach students and colleagues to critically
We believe the information in the Handbook applies analyze professional practices;
to everyone in health care environments. Many
of the difficulties that adult survivors experience Reflect on their philosophies of care and how
in these environments arise they are expressed in day-to-
because practitioners who The information in the Handbook day practice, with the intent
work in them are unaware applies to everyone in health care of becoming more ethical,
of the effects of violence on environments. congruent, and sensitive in their
health and health care or work;
because organizational policies and attitudes have
Develop clear guidelines to address their
not taken this information into consideration.
concerns about best practice with a specific
Before dismissing a suggestion as inapplicable to
patient or treatment procedure.
their practices, clinicians are encouraged to reflect
upon the following questions:
1.5 Terminology
What aspects of this suggestion do not
apply? The following is a clarification of terms the reader
will encounter in this Handbook. Many health care
If a suggestion is not completely applicable,
providers have various preferences for the words
what element(s) of it could be relevant?
patient and client, clinician, and practitioner,
The Handbook can be used to help health care and for the terms they use to describe their work
practitioners: (examination, treatment, etc.). However, all
readers are encouraged to look
Learn more about the All readers are encouraged to beyond the terminology we
effects of interpersonal look beyond the terminology to use in the Handbook and to see
violence on health; fully consider how the information that the information applies to
applies to their own practices. all health care providers.
Work more effectively
and compassionately Survivor or adult survivor is used instead
with affected individuals; of victim when referring to adults who
Identify and respond sensitively to have experienced childhood sexual
individuals who are triggered or dissociate abuse to acknowledge the strength and
in a health care encounter; resourcefulness of individuals who have
lived through the experience.23 Attitudes
Feel better prepared to work with patients about the words survivor and victim vary
who disclose past abuse; among those who have experienced
childhood abuse, as well as among those
who work with these individuals.
3
The Handbook as a Tool for Clinical Practice
Victim is used when referring to the abused range from eating well and exercising
child. regularly to adhering to clinicians’ specific
recommendations.
The person seeking care is referred to
interchangeably as survivor, patient, client, Participants’ words appear in italics.
or individual.
When referring to violence and abuse 1.6 Limitations
we use the terms child sexual abuse,
childhood sexual abuse, child abuse, abuse, The experience and long-term effects of childhood
interpersonal violence, violence, and sexual abuse are affected by a complex interaction
trauma. In the Handbook, the word trauma of factors including: (a) those related to the
is used only with this connotation. individual (e.g., genetics, stage of development
at which the abuse occurred, personal coping
Recovery and healing are both used to resources); (b) the abuse itself (e.g., frequency,
refer to survivors’ efforts to address issues duration, relationship between perpetrator
related to childhood sexual abuse. and victim); (c) the presence and quality of
social support at the time of the abuse and into
Clinician, practitioner, health care
adulthood; and (d) those related to the larger
practitioner, health care provider,
environment, including culture, ethnicity, and
and health care professional are used
other social determinants of health. Adult survivors
interchangeably.
who participated in our studies were recruited
Survivor participant refers to survivors who from agencies, groups, and individuals offering
participated in the interviews, working counselling and support. Thus, they are individuals
groups, and consultations that were part of who have worked or are working towards recovery
this research project. with the assistance of external support.
Health care practitioner participants and Notwithstanding the diversity and uniqueness of
health care provider participants are the these participants, the Handbook cannot claim to
health care practitioners who participated address Sensitive Practice for adult survivors with
in the working groups. every abuse experience, of every ethnicity and
culture, of every sexual orientation, or at every
Assessment and examination reflect initial stage of recovery. Similarly, although we have tried
and ongoing collection and evaluation of to address a wide range of health practitioners
subjective and objective information about working in various settings by incorporating a broad
an individual’s health. consultation in the research method, we cannot
Protocol, procedure, treatment, and claim to address every aspect of Sensitive Practice
intervention describe types of care that for every type of health care practitioner.
health care practitioners offer. While acknowledging these limitations, we believe
Appointment, encounter, and interaction that this second edition of the Handbook presents
are used to reflect ways that health care a framework for working with adult survivors of
providers see patients/clients in various interpersonal violence in all types of practice that
health care settings. is both accessible and empirically derived. We
hope that health care practitioners will adapt and
Self care represents the array of actions refine the guidelines as they work with survivors
that a person can take to promote general whose unique needs and reactions were not
health and/or as a component in the represented by the research participants.
management of health problems. They
4
2 Background Information about Childhood
Sexual Abuse
2.1 Definitions on an unwilling human victim, committed by

one or more individuals, as part of a prescribed
While the sexual exploitation of children and ritual that achieves a specific goal or satisfies the
adolescents is a criminal act, legal definitions of perceived needs of their deity.27,140
childhood sexual abuse vary across jurisdictions.
There is, however, wide agreement that childhood
2.2 Childhood sexual abuse
sexual abuse involves: (a) sexual acts with children
and youth who lack the maturity and emotional survivors
and cognitive development to understand or to
The great paradox of childhood sexual abuse is
consent; and (b) “an ‘abusive condition’ such as
that, while it has become more prominent in
coercion or a large age gap between participants,
the public consciousness, it remains shrouded in
indicating lack of consensuality.”62p.32 In general,
secrecy. Media coverage of high-profile disclosures
children and younger adolescents are unable to
and investigations provide evidence that childhood
consent to sexual acts with adults because of their
sexual abuse does exist – in “good” families and
lack of maturity and relative lack of power.* An
“trusted” institutions, at all socioeconomic levels,
abusive condition implies a difference in power
and among all racial and ethnic groups. Frequently
between the perpetrator and the victim. Children
we hear and read stories about
can also be abused by other
survivors who are men and
children or adolescents who have An abusive condition implies a
women from all walks of life –
more power by virtue of age, difference in power between the
students, sports figures, clergy,
physical strength, life experience, perpetrator and the victim.
entertainers, educators, police
intelligence, authority, or
officers, judges, politicians, and
social location. The Canadian Incidence Study of
health care practitioners. They are our friends and
Reported Child Abuse and Neglect tracked eight
neighbours, our colleagues, and sometimes even
forms of child sexual abuse: penetration (penile,
ourselves or members of our own families. Despite
digital or object penetration of vagina or anus),
this prevalence, most childhood sexual abuse
attempted penetration, oral sex, fondling of the
survivors are invisible to us, particularly given that
genitals, adult exposure of genitals to child, sexual
it is estimated that fewer than half disclose their
exploitation (e.g., involving child in prostitution or
abuse to anyone.62,105 Some are silent because they
pornography), sex talk (including proposition of a
fear reprisal from their abusers; others worry they
sexual nature and exposing a child to pornographic
will not be believed or that they will be blamed or
material), and voyeurism.168p.38-39 even punished.56,113 Still others say nothing because
An extreme and controversial type of abuse they harbour the erroneous belief that they are
is ritual abuse, which has been defined as responsible for their abuse.
psychological, sexual, and/or physical assault
* According to the Criminal Code of Canada, when sexual activity is exploitive (such as sexual activity involving prostitution, pornography, or a
relationship of trust, authority or dependency) the age of consent is 18. For sexual activity which is not exploitive, the age of consent is 16 years. The
exceptions are that a 12 or 13 year old can consent to engage in non-exploitive sexual activity with another person who is less than 2 years older; and
a 14 or 15 year old can consent to engage in non-exploitative sexual activity with another person who is less than 5 years older. A 14 or 15 year old
can also consent to engage in sexual activity with a person to whom they are married. These laws governing the age of consent for non-exploitative
sexual activity came into force on May 1, 2008. Transitional provisions allow 14 and 15 years old who were in common-law relationships on May 1,
2008, to continue engaging in non-exploitative sexual activity.
Appendix B: The Prevalence of Childhood Sexual little consideration for their effect on the child.
Abuse Some child abusers use physical force or explicit
threats of harm to coerce their young victims
If you are both a health care practitioner and a
survivor of childhood abuse, before reading further into compliance, while others develop long-term
please refer to Section 5.9 Practitioners’ self-care relationships with their victims and carefully
groom them with special attention or gifts. While
The most current and reliable childhood sexual abuse does not always involve
lifetime prevalence estimates physical injury, it is a violation
Childhood sexual abuse survivors of body, boundaries, and trust23
are that as many as one third are our friends and neighbours,
of women and 14% of men are our colleagues, and sometimes and is typically experienced as
survivors of childhood sexual traumatic.81
even ourselves or members of
abuse.25,31,62 our own families. While people who report a
history of childhood sexual
2.3 Perpetrators of childhood abuse are at increased risk for a wide range of
sexual abuse diffi culties in adulthood, studies suggest that
“in the region of 20% to 40% of those describing
Individuals who are sexually abused as children CSA [childhood sexual abuse] do not have
are, in adulthood, men and women of diverse ages, measurable adult dysfunction that could be
ethnicity, occupation, education, income level, and plausibly be related to abuse.”60p.89,61 A number
marital status.16,31,48,73,114,139 Most studies of sexual of factors affect how a particular individual
offending have focused on males as perpetrators. may respond to childhood sexual abuse. Some
Although the majority of perpetrators of childhood of these include the gender of the perpetrator,
sexual abuse are male,31,48,49,60 recent research the number of perpetrators, the nature and
suggests that females engage in sexually abusive closeness of the relationship between victim and
behaviour with children more often than has perpetrator, the duration and frequency of the
been previously recognized. 31,48,60 abuse, characteristics of the
Common to all perpetrators is that As many as one third of women abuse itself (e.g., contact vs.
they have more physical strength, and 14% of men are survivors of noncontact, penetration, etc.),
social power, and/or authority childhood sexual abuse. the use of threats or force, and
than their victims. the age of the victim at the
18,29,31
time of the abuse.
The most recent report of the Canadian Incidence
Study of Reported Child Abuse and Neglect –
2003168p.53 found that, in contrast to physical abuse Appendix C – Traumagenic Dynamics of Childhood
Sexual Abuse
of children, non-parental relatives constituted
the largest group of perpetrators (35%) of child
sexual abuse. Other groups of perpetrators include 2.5 Childhood sexual abuse and
the child’s friend/peer (15%), stepfather (13%), health
biological father (9%), other acquaintances (9%),
parent’s boyfriend/girlfriend (5%), and biological While not everyone who reports a history of
mother (5%). childhood sexual abuse develops health problems,
many live with a variety of chronic physical,
behavioural, and psychological problems that
2.4 The dynamics of childhood bring them into frequent contact with health care
sexual abuse practitioners. Because health care practitioners
do not routinely inquire about childhood sexual
All sexual encounters with children are intended
abuse, its long-term effects are under recognized,
to meet the needs of the perpetrator, with
its related health problems are misdiagnosed,
6
and it is often not met with a sensitive, integrated endocrinology, and psychosomatic medicine has
treatment response. demonstrated clear physiological relationships
among stress, illness, and disease (e.g.,71,95,101,104).
Childhood sexual abuse often co-occurs with
other types of childhood adversity, including
physical abuse, marital discord, separation from Chapter 3 – What Childhood Sexual Abuse Survivors
or loss of parents, parental psychopathology Bring to Health Care Encounters
and/or substance abuse, and other types of Chapter 8 – Guidelines for Sensitive Practice:
abuse/neglect.31,60,108 Even when these other Disclosure
types of adversity are
controlled for, childhood Because most health care practitioners Table 1 lists the findings
sexual abuse remains do not routinely inquire about childhood of a number of studies
a powerful predictor sexual abuse, its long-term effects are that have examined the
of health problems in under recognized, its related health correlation between
adulthood.30,33,145,183 It problems are misdiagnosed, and it is histories of childhood sexual
is suggested that the not met with a sensitive, integrated abuse and later health and
underlying mechanism treatment response. function. Considerably more
for these difficulties is studies have examined
“that childhood sexual abuse causes disruptions these relationships in women, and when male
in the child’s sense of self, leading to difficulty in survivors have been studied, the relationship
relating to others, inability to regulate reactions between past abuse and the mental health of
to stressful events, and other interpersonal and male survivors has been the primary focus. Guy
emotional challenges”. 108p.753
Kathleen Kendall- Holmes, Liz Offen, and Glenn Waller85 argue that
Tackett93p.716 describes two pervasive myths – that
behavioural, emotional, Two pervasive myths - that males are males are rarely sexually
social, and cognitive rarely sexually abused and that childhood abused and that childhood
pathways by which sexual abuse has little effect on males - sexual abuse has little effect
childhood abuse affects deter boys and men from disclosing their on males – deter boys and
health, pointing out that abuse and, in turn, prevent society from men from disclosing their
“adult survivors can be legitimizing it as a problem. abuse and, in turn, prevent
affected by any or all of society from legitimizing it
these, and the four types influence each other. as a problem. The increasing societal recognition
Indeed, they form a complex matrix of inter- of the prevalence and seriousness of sexual abuse
relationships, all of which influence health.” In of boys is likely to lead to further investigation of
addition, research in the fields of immunology, physical health correlates.
7
Background Information about Childhood Sexual Abuse
TABLE 1
Correlates of childhood sexual abuse and measures of health and function:
A selected list of findings from research studies
In females, a history of childhood sexual abuse or a range of childhood traumas including

sexual abuse is correlated with:
poorer physical and mental health and a lower health-related quality of life than non-traumatized
individuals59,145,176
chronic pelvic pain129
gastrointestinal disorders53,141
intractable low back pain146
chronic headache58
greater functional disability, more physical symptoms, more physician-coded diagnoses, and more
health risk behaviours, including driving while intoxicated, unsafe sex, and obesity176
ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease59
high levels of dental fear177,185
greater use of medical services35,87,102,116,150,178
drug and alcohol use, self-mutilation, suicide, and disordered eating156
adult onset of 14 mood, anxiety, and substance use disorders108
higher rates of childhood mental disorders, personality disorders, anxiety disorders, and major
affective disorders, but not schizophrenia154
diagnosis of Borderline Personality Disorder79,82,100
In males, a history of childhood sexual abuse is correlated with:
anxiety, low self-esteem, guilt and shame, depression, post-traumatic stress disorder, withdrawal and
isolation, flashbacks, dissociative identity disorder, emotional numbing, anger and aggressiveness,
hypervigilance, passivity and an anxious need to please others22,28,32,45,147
adult onset of five mood, anxiety, and substance use disorders108
substance abuse, self-injury, suicide, depression, rage, strained relationships, problems with self-
concept and identity, and a discomfort with sex49,54,133,161
increased risk of HIV5
anxiety and confusion about sexual identity and sexual orientation85,133
increased risk of “acting out” aggressively85
contact with criminal justice system85,96
8
3 What Childhood Sexual Abuse Survivors
Bring to Health Care Encounters
3.1 Gender socialization: A female abuse survivor may also be mistrustful

of authority figures, which stems from having
Women’s experiences
been betrayed by the trusted adult who abused
Gender socialization affects both children’s her. This helps to explain the difficulty that some
responses to sexual abuse and how the experience survivors have trusting health care practitioners
affects them in adulthood. Throughout the and why they experience health care encounters
research for this handbook, survivor participants as distressing. It also helps explain why so many
described ways in which gender socialization female survivors report symptoms of depression
shaped their interactions with health care and anxiety:
practitioners. I didn’t want to state what my needs were
Although many would argue that gender because ... [with] the abuse ... you don’t get to
socialization has changed choose what happens to you. What happens to
considerably in the past century, you happens to you, you just
Socialization to be submissive accept it and that’s the way I
many female children continue
coupled with children’s thought for a long time. I still
to be encouraged to be non-
normative tendency to blame probably think that way but
aggressive, submissive, and “nice.”
themselves for negative I’m trying to change the way I
They receive multiple messages
experiences involving adults think because I do have choice
that to be female is to be less
leaves many female survivors now. (Woman survivor)
valued and less powerful than
believing that they are “bad”
males, and that the appropriate
people who are responsible Girls learn that it is important
role for females is to please
for the abuse. for females to be objects
others, especially males. Rebecca of male sexual desire and
Bolen states, that appearing young and innocent is sexually
Females develop a sense of their lack of appealing. “We dress fashion models up to look
entitlement and vulnerability to the more child-like and sexually provocative and set this
powerful members of society. Females standard for all women,” writes Calgary social
internalize this message ... they are socialized worker Lois Sapsford.138p.76 Girls may also learn
to be less powerful than, and to defer to, the that, to be valued, they must be sexually “pure”;
more powerful and more entitled males.26 p.146 at the same time, they receive the contradictory
message that they should be not only beautiful
These aspects of normative female socialization but also “sexy.” Sexual abuse objectifies a girl’s
may exacerbate girls’ tendency to be submissive body to serve the needs of her abuser and may
and to blame themselves for negative experiences leave her believing that her sole value is as a
involving adults, which can leave many female sexual object. The message that females should
survivors believing that they are “bad” people be sexually “pure” along with the stigma attached
who are responsible for the abuse and that their to sexual abuse contributes to some female
bodies, which they have come to hate, somehow survivors’ perceptions of themselves as “damaged
caused the abuse: goods” and to the shame and guilt that many
describe. This may be manifested in a survivor’s
Most survivors I know hate their body, disown
ambivalence about her body and reticence to seek
their body ... become disconnected from it.
care for health problems:
(Woman survivor)
The other thing is the big shame and the society’s notions of masculinity and victimhood;
secret ... We may have an ailment that could and (c) the fact that services for childhood sexual
be addressed ... [early] but let it go and let it abuse survivors, which grew out of the second
go until ... it takes longer to mend or to heal. wave of feminism, were historically designed for
(Woman survivor) women and not for men.
The historical and current societal factors that For a man to acknowledge that he has been
encourage people in our society to deny or sexually abused is an admission of vulnerability in
minimize the significance of child sexual abuse a society that has few models for the expression
also affect female survivors’ perceptions about of masculine vulnerability. Indeed, applying
the wisdom of disclosing the label victim of
their experience. Many The stigma attached to sexual abuse sexual abuse to a man
women participants talked contributes to some female survivors’ juxtaposes vulnerability
about their fear of not perceptions of them-selves as “damaged with masculinity, an
being believed; some gave goods,” as well as their ambivalence uneasy pairing that
examples of being told about their bodies and reticence to seek further contributes to
directly that they must be care for health problems. the under recognition
lying or imagining things. and underreporting
Another aspect of female gender socialization of childhood sexual abuse among boys and
is the message that it is the female who is men.3,43,52,86,105
responsible for setting limits on sexual behaviour,
which contributes to women survivors fearing The socialization of men to be strong and
that they will be blamed for what happened, independent15,85 complicates the situation for
even though the sexual behaviour occurred male survivors who consider sharing their history
when they were children and the perpetrator of abuse with a health care practitioner.165 As
was older and more powerful. One health care Michel Dorais puts it in his book Don’t Tell: The
practitioner responded to Sexual Abuse of Boys, the “masculine conception
a woman’s disclosure of of virility is incompatible
For a man to acknowledge that he has with the factual experience
past abuse by asking, “How
been sexually abused is an admission of having been a victim of
did you let it happen?”
of vulnerability in a society that has sexual abuse, or needing
These societal messages
few models for the expression of help following such a
strongly discourage women
masculine vulnerability. trauma”52p.17 (see also
survivors from sharing their
experience with health care O’Leary117). Men in our study
practitioners, which in turn impedes the clinician’s spoke about their need to appear “tough” and “in
ability to assess all factors that may contribute to control” despite feeling anxious and fearful during
health problems. encounters with health care practitioners:
Men are tough. Men are macho. Men don’t
3.2 Gender socialization: Men’s need [help]. All we have to do is to “get over it!
Get over it – be a man!” You know, men don’t
experiences cry. (Man survivor)167p.509
The men in our studies repeatedly reported Some participants also spoke about their difficulty
feeling invisible as survivors of childhood sexual in identifying and expressing their feelings:
abuse. Among the major factors contributing
to the invisibility of male childhood sexual Women appear to me more aware of the
abuse survivors are: (a) the widespread lack of names of things. Such as “I’m feeling
knowledge about the prevalence of childhood depressed” or “I’ve been having a real struggle
sexual abuse of boys; (b) incongruence between for the past couple of weeks and these are the
10
circumstances.” I don’t know what half of that of the men in our study talked about their fear
stuff is called. (Man survivor)167p.510 that health care practitioners would think they
were homosexual if they revealed their history
There is a pervasive belief that boys and men of childhood sexual abuse. Others talked about
are rarely victimized and that a central feature how their abuse experiences had led them to
of masculinity is the ability to protect oneself develop strong negative feelings about individuals
(Mendel as cited in Lab, Feigenbaum, & De Silva96); (including health care practitioners) whom
failure to do so is seen they perceived to be
as evidence of weakness The participants suggested that health care homosexual:
and can be a source of practitioners are sceptical about men who
great male shame. Thus, disclose sexual abuse and tend to take their I had to go into the
the “dissonance between experiences less seriously than those of hospital where I had
the male role expectation their female counterparts. a problem with some
and the experience of medication I had
victimisation”117p.83 may seriously compromise the [taken] and there was a male nurse there and
health care of male survivors, often because their he was obviously very effeminate, and he had
feelings of shame and unworthiness affect their to give me an IV, I refused him because I didn’t
ability to seek care: want him touching me. (Man survivor)167p.506
One of the reasons why for a long time I Such reactions can be seen as internalized
didn’t go [to a health care practitioner was homophobia. These fears may also reflect the
that] ... quite frankly, I just didn’t feel worthy pervasiveness of the myth in our society that
... Worthy of the care, the attention. I mean childhood sexual abuse causes boys and girls to
doctors are busy. (Man survivor) become gay or lesbian.132
Most of the men in our studies expressed the
belief that different reactions to male and female Section 3.6 – Questions about sexuality and sexual
childhood sexual abuse survivors shape their orientation
help-seeking behaviours and, in turn, influence
how health care practitioners treat them. In 3.3 Societal myths about the
general, the participants suggested that health
cycle of violence
care providers are sceptical about men who
disclose sexual abuse and tend to take their The emotional cost of childhood victimization is
experiences less seriously than those of their intensified especially for male survivors by the
female counterparts. In addition, some regard societal belief that it is only a matter of time
sexual abuse by a woman as something that the before they become abusers themselves, if they
“fortunate” male survivor should have enjoyed. have not already done so. The media typically give
Ramona Alaggia3 and Guy Holmes and colleagues85 more attention to the erroneous belief that male
reiterate that such perceptions are common. The survivors will likely become perpetrators43 than
media also contribute to these views by framing to information that disputes this belief.117 Despite
the sexual abuse of boys by adult women as a the lack of conclusive evidence regarding this
“sexual relationship” (e.g.,36,149). The fact that boys causal link (e.g.,68,137) and the fact that many male
are more often sexually abused by a female than perpetrators do not report a history of childhood
girls31 may fuel the myth that sex between boys sexual abuse,99 the public and even some male
and women is normative rather than abusive and survivors themselves continue to fear that they
perpetuates the “male gender role of seeking early are destined to become perpetrators.85,117,133 Some
sexual experiences with women.”15p.225 female survivors may also fear that they will
sexually abuse children or that others will see
Notwithstanding the general progress made in
them as potential offenders.
addressing homophobia in our society, some
11
What Childhood Sexual Abuse Survivors Bring to Health Care Encounters
3.4 Transference and by behaving in a hostile manner towards a
practitioner whom he incorrectly believes does not
counter-transference
care about him just as his parents did not seem to
The concepts of transference and counter- care about his wellbeing. A health care practitioner
transference were originally identified by Freud who responds with anger and defensiveness can be
in the context of psychoanalysis, and refer to said to be allowing counter-transference feelings to
common human experiences that are important be expressed.
for everyone working in human service to While it is understandable that health care
understand. Transference is said to occur when providers have negative feelings in response
an individual displaces thoughts, feelings, and/ to a patient’s negative transference, they must
or beliefs about past situations onto a present strive to contain these feelings and respond
experience. It is widely agreed that we all engage professionally. Inquiring about the reasons for
in transference to some extent. While transference the patient’s hostility, for example, is likely to
can be positive or neutral, it can also be negative be more productive than responding with anger.
and may interfere with healthy and adaptive Health care providers have an ethical obligation
functioning. For example, an adult who was to work continuously at being self-aware and
constantly criticized by an authority figure may to reflect critically on their practice in order to
grow up expecting all authority figures to be recognize when they may be responding harmfully
critical and may hear criticism where none is to a patient’s transference
intended. Similarly, or experiencing counter-
survivors of childhood The media typically give more
transference. Further, health
sexual abuse may react attention to the erroneous belief that
care providers need to remind
negatively towards a male survivors will likely become
themselves repeatedly of their
health care practitioner perpetrators than to information that
obligation to respond to a patient
whose appearance, disputes this belief.
professionally, even when they
gender, or mannerisms believe they have been judged
are reminiscent of someone who abused them. harshly, have been provoked, experience negative
The dynamics of transference help explain why feelings about the patient or are personally upset.
a survivor may respond to an interaction with a When practitioners have difficulty meeting these
health care practitioner in ways that are unrelated ethical requirements, they need to reflect on the
to the encounter or to the specific health care situation and the reasons for their responses and
practitioner. Understanding transference may take appropriate steps to prevent harming their
also help health care practitioners to avoid taking patients directly or indirectly. If a health care
patients’ negative responses personally. practitioner notices a recurring strong reaction to
Counter-transference involves the same dynamics a particular individual or to certain behaviours,
as transference, but occurs when a health care personal characteristics, or events, it may be
practitioner responds to a patient with thoughts, useful to talk to a supervisor or trusted colleague
feelings, and/or beliefs associated with his or her about it.
own past. For example, a patient who reminds a
practitioner of an angry and demanding teacher 3.5 Specific behaviours and
may evoke feelings of anxiety that seem out of
feelings arising during
proportion to the current situation.
health care encounters
Counter-transference can also refer to the health
care practitioner’s expectable emotional reaction Distrust of authority figures. Throughout this
to a patient’s behaviour – in particular, when the project, survivors told us how, as children,
patient is transferring experiences from the past. they experienced violation at the hands of an
For example, a survivor may engage in transference authority figure and how the distrust from these
12
past experiences affects their interactions with happened, but I just didn’t like the fact that
health care practitioners. Although this distrust I was in a room by myself with my pants off,
originates in the past and should not be taken as with two men. That was really eerie. (Woman
a personal affront, survivors constantly scrutinize survivor)
health care providers for evidence that they are
taking active and ongoing steps to demonstrate My abuser was my mother. I don’t like to be
their trustworthiness. It is crucial to recognize that touched by women, especially strange women.
some survivors may (Man survivor)
associate a health care Triggers. Examinations or
While it is understandable that health care
practitioner’s attempts practi-tioners have negative feelings in treatments may “trigger”
to verbally assure them response to a patient’s negative transference, or precipitate flashbacks,
that they are safe with they must strive to contain these feelings and a specific memory or
the perpetrator’s empty respond professionally. overwhelming emotions
assurance of safety such as fear, anxiety, terror,
during their abuse. grief, or anger. A flashback is the experience of
reliving something that happened in the past and
Section 4.1 – Overarching consideration: Fostering usually involves intense emotion. Some survivors
feelings of safety for the survivor are particularly susceptible to flashbacks and
some are overwhelmed by them:
Fear and anxiety. Many survivors spoke at
length about their tremendous fear and anxiety And the goop that they put on me for the
during health care encounters. The experiences ultrasound gave me flashbacks, nightmares,
of waiting, being in close contact with authority insomnia; I just couldn’t deal with it. (Woman
figures, and not knowing what is to come all survivor)143p.257
resonated with past abuse. Some survivor
participants said that they were even afraid of Section 7.6 – Triggers and dissociation
being abused by the health care practitioner:
Dissociation. Survivor participants also spoke
[In the clinic waiting room, I felt] nervous, about dissociating during interactions with health
apprehensive, not exactly knowing what was care providers. The Diagnostic and Statistical
going to happen ... as far as clothing was Manual of Mental Disorders, Fourth Edition (Text
concerned or ... touch, just not knowing. Revised) (DSM-IV-TR)11p.519 explains dissociation as
(Woman survivor)143p.252 “a disruption in the usually integrated functions of
Discomfort with persons who are the same gender consciousness, memory, identity, or perception of
as their abuser(s). For some survivors, the gender the environment” that may be sudden or gradual,
of a person in a position transient or chronic. Some
of authority is a powerful For some survivors, the gender of a authors (e.g.,120,155) liken it to a
“trigger” that can leave person in a position of authority is a state of divided consciousness
them feeling vulnerable powerful trigger that can leave them in which aspects of the self that
and unsafe. This strong feeling vulnerable and unsafe. are normally integrated become
reaction prevents some fragmented. Dissociation is
survivors from seeking care from practitioners who also understood to be a process that exists on
are the same gender as their abuser: a continuum,120 with one end being “common
experiences such as daydreaming and lapses in
[A male health care provider and assistant attention, through déjà vu phenomena ... [and
were] in the room with me, and I had my pants the other end of the continuum involving] a
off, and this guy’s putting [ultrasound] gel pathological failure to integrate thoughts, feelings,
on my leg. And I felt really uncomfortable ... and actions.”111p.806
even though ... probably nothing could have
13
DSM-IV-TR states that “dissociative states Physical pain. For some survivors, the experience
are a common and accepted expression of of acute and/or chronic physical pain may be
cultural activities or religious experience in associated with past abuse. This association
many societies”11p.519 and in these cases they can manifest itself in various ways (e.g., some
do not usually lead to the “significant distress, individual have learned to ignore or dissociate
impairment, or help-seeking behaviour”11p.519 that from pain, while others are hypersensitive to it):
is required for them to be diagnosed as a disorder.
A common experience of dissociation that most of I think sometimes when survivors are in pain,
us can relate to is highway hypnosis, in which an and coming for physical therapy, it hooks us
individual driving a car suddenly realizes that he back into…our childhood where we were in
or she cannot remember all or part of the trip.121 pain and ... no one responded. And if you
did indicate you were in pain ... the pain was
The International Society for the Study of trivialized or you were threatened [so that you
Trauma and Dissociation89 takes the position did not tell] anyone. (Woman survivor)143p.256
that traumatic experiences play an important
role in the development of various pathological
dissociative disorders. Many believe that
dissociation is an effective strategy for coping Section 7.1 – Pain
(in the immediate situation) with extreme stress Recommended Readings and Resources –
Childhood sexual abuse and trauma (especially van
such as childhood sexual abuse. However, if
der Kolk & McFarlane172 and van der Kolk170)
it becomes a long-term
coping mechanism, it may
contribute to a variety of Examination or treatment may Ambivalence about the
mental health problems and “trigger” or precipitate flashbacks or body. Many survivors feel
overwhelming emotions such as fear, hate, shame, and guilt
interfere with relationships,
anxiety, terror, grief, or anger. about their bodies. As
self-concept, identity
children, many believed that
development, and adaptive
something about them or their bodies invited or
functioning.4,77
caused the abuse. This belief is reinforced if the
A number of the survivor participants told us survivor enjoyed some aspects of the abuse (e.g.,
that they do not have consistent control over this special attention, physiological arousal).85,133 This
mechanism through which they “escape” from a shame and guilt may lead some survivors to feel
current (usually stressful) situation; some even ambivalent about and disconnected from their
report that for many years they were unaware of bodies:
their tendency to dissociate. When they are in a
And [the amount of attention that I give to
dissociative state, some individuals experience
my body] ebbs and flows too, depending on
themselves as being outside their bodies, watching
where I’m at and how well I’m choosing to take
the present situation from a distance. Others
care of my body. Which is a very difficult thing
simply go silent, stare blankly into the distance,
for me physically to do, because when you
or seem unaware of their surroundings. When
don’t live there, it’s just sort of a vehicle to get
the dissociative episode is over, individuals may
around. (Woman survivor)143p.255
have no memory of what occurred and may
have difficulty orienting themselves back to the The conflict between the need to seek health care
present: for a physical problem and the ambivalence or
dislike of one’s body can affect treatment. For
[In a physical therapy session] I would just get
example, an individual may ignore symptoms
that same dread feeling inside, and I would do
that might contribute to an accurate diagnosis,
the same coping that I would have done when
explain an individual’s response to treatment, or
I was abused ... just trying to not feel my arms
and not really be there. (Woman survivor)158p.182
14
interfere with the ability to self-monitor effects of 3.6 Questions about sexuality
an intervention or medication.
and sexual orientation
Conditioning to be passive. Abuse can teach
Survivors of child sexual abuse, like many other
children to avoid speaking up or questioning
people in our society, may have questions about
authority figures. In adulthood, survivors may
their sexuality or sexual orientation. Some male
then have difficulty expressing their needs to a
participants who had been abused by men said
health care practitioner who is perceived as an
they had struggled with uncertainty about their
authority figure.
own sexual orientation:
[The health care practitioner did something
I just realized in sexual abuse, it seems very,
and] I really freaked but ... I didn’t show her
very common that the issue of homosexuality
I was freaking, because our history is that
when dealing with a male [survivor] of
you don’t let on if things are a problem for
sexual abuse comes up. It’s an issue: “Am I a
you. You just deal with it however you can
homosexual?” (Man survivor)
... by dissociating or what have you. (Woman
survivor)143p.254 Some women survivors report similar struggles:
Self-harm. Self-harm Female survivors of female-
(e.g., scratching, Abuse can teach children to avoid
perpetrated abuse also
cutting, or burning speaking up or questioning authority
experience this confusion
the skin) is a way figures. In adulthood, survivors may then
around their sexual identity
that some survivors have difficulty expressing their needs to a
and orientation. (Woman
attempt to cope with health care practitioner who is perceived survivor)
long-term feelings as an authority figure.
of distress. Health For participants who self-
care practitioners may see evidence of self-harm identified as gay, public assumptions about the
in the form of injuries or scars on the arms, legs, “cause” of their sexual orientation and about their
or abdomen. Self-harm may take more subtle potential to be abusers were also problematic:
forms as well, such as ignoring health teachings They assume that because it was your mother
or recommendations for treatment or symptom [who abused you] that’s why you’re gay.
management (e.g., refusing to pace one’s activity Because it was a woman doesn’t make much
in response to pain or fatigue, or failing to adhere sense. Or that then because you’re gay, you
to a diabetic treatment regime). were abused, you’re going to be a pedophile
There are many reasons why survivors harm yourself. These attitudes come out from others
themselves. It may serve to distract them from that I’ve disclosed to. Lots of layers there;
emotional pain, focus the pain to one area of the biases would be one of the big problems there
body, or interrupt an episode of dissociation or with health practitioners. They’re going to
numbness. Some survivors may harm themselves make assumptions. (Man survivor)
to regain a sense of control or ownership of their Relatively few survivor participants raised the
bodies. For others, it may be a punishment or issue of sexual orientation in the context of
an effort to atone for wrongs they believe they their interactions with health care practitioners.
have committed.47 Dusty Miller107 argues that However, a number of health care practitioner
self-harm is one example of a range of self- participants who commented on drafts of the
destructive behaviours that can be thought of as Handbook pointed out that the phenomena of
an unconscious effort to reenact past trauma. sexual identity and sexual orientation are often
overlooked or ignored by health care practitioners.
Certainly, it is important to recognize that
15
women and men who have Participants who were abused
been sexually abused in The conflict between the need as children and who are (or
childhood may experience to seek health care for a physical have been) involved in same-
challenges around sexuality problem and difficulty in caring for sex relationships often have to
and intimacy in general. one’s body often affects treatment. deal with negative thoughts
This is true of a proportion about themselves based on
of survivors in heterosexual relationships as well negative societal stereotypes. For example, some
as for some in same-sex relationships and for some may think, “I’m bad because I was abused,” or “I
survivors who identify as gay, lesbian, bisexual or am really bad because I was abused and it made
transgendered. me be attracted to the same sex.” These thoughts
should be recognized as internalized heterosexist
Because of the general societal perception that and homophobic social attitudes that need to
being gay, lesbian, bisexual, or transgendered be challenged and worked through. (Shoshana
(GLBT) is “abnormal” or “wrong,” abuse survivors Pollack, 2007, personal communication)
(and health care practitioners) may sometimes
attribute their same-sex attraction to past sexual No research studies have supported the claim
abuse. Shoshana Pollack, professor of social that childhood sexual abuse is associated with
work at Wilfrid Laurier University, notes that the development of GLBT identity.132 In an online
“fostering this assumption in patients misses the questionnaire study of lesbian and bisexual
important point that childhood sexual abuse women between 18 and 23 years old, fewer than
involves traumatic sexualization and often leaves half of those who had experienced childhood
survivors confused about how to engage sexually sexual abuse thought that the childhood sexual
in general, what their sexual abuse had affected their feelings
preferences are (not only No research has supported about their sexuality or how
gender, but practices), what it the idea that childhood sexual they “came out.” Among those
means if they experience same abuse is associated with the who did identify effects on their
sex attraction, what it means if development of GLBT identity. feelings about their sexuality
they don’t experience it but as and coming out process, some
a child their abuser was the same sex etc.” (2007, said that the abuse had not affected their feelings
personal communication). about their sexual orientation, which they
believed was unconnected to the childhood sexual
abuse experience.
16
4 Principles of Sensitive Practice
4.1 Overarching consideration: are safe can trigger fear and anxiety. Thus it is
Fostering feelings of safety clearly not enough for health care practitioners
to simply assure their patients that they are
for the survivor safe. To facilitate survivors’ feelings of safety,
practitioners need to make every effort to follow
I now am beginning to understand that my
the principles of Sensitive Practice. To paraphrase
physical wellness is really very connected to my
one of the health care practitioner participants,
emotional state, and if I’m not comfortable,
the principles of Sensitive Practice articulate a
if I’m feeling unsafe, then I’m not going
standard of practice and provide a concrete and
to progress as quickly as [the health care
specific “how to” guide for doing this.
practitioner] would want me to. (Woman
survivor) Since all health care practitioners – knowingly
and unknowingly – work with individuals with
The primary goal of Sensitive Practice is to
histories of sexual, physical, and emotional
facilitate feelings of safety for the client. The nine
abuse and other forms of
themes below were identified
The primary goal of Sensitive violence, these principles
by virtually all participants
as important to facilitating Practice is to facilitate feelings represent a basic approach to
of safety for the client. care that should be extended
their sense of safety during
to all clients. The principles of
interactions with health care
Sensitive Practice are analogous
practitioners. These themes are so critical to
to the infection control guidelines (commonly
survivors’ feelings of safety that we term them the
termed “routine practice” or “universal
principles of Sensitive Practice. Through the course
procedures”) that have become part of everyday
of our research, we have come to conceptualize
practice in all health care settings. Just as
safety as a protective umbrella, with the principles
clinicians may not know an individual’s history of
of Sensitive Practice being the spokes that hold
past infection, they may not know an individual’s
the umbrella open. When the umbrella is open,
abuse history. By adopting
an individual feels safe,
Since all health care practitioners the principles of Sensitive
and can participate in the
examination or treatment work with individuals with histories Practice as the standard of
of violence, the principles of care, health care practitioners
at hand. While most of the
principles are components Sensitive Practice represent a basic make it less likely that they
approach to care that should be will inadvertently harm their
of patient-centred care (see
extended to all clients. patients or clients.
Stewart163), they take on even
greater significance within
the context of childhood sexual abuse and other 4.2 The nine principles of
interpersonal violence.
Sensitive Practice
Child sexual abuse is a betrayal of trust and
the antithesis of safety. Survivor participants First Principle: Respect
frequently described to us how perpetrators, while
abusing them, assured them that they were safe [Feeling respected], to the person who has been
when just the opposite was true. For some adult abused, it certainly means a great deal. (Man
survivors, the experience of being told that they survivor)
FIGURE 1
The umbrella of safety
The Oxford English Dictionary118 defines respect ... that I feel like I’m being respected ... [and]
as to give heed, attention, or consideration that I have information about myself that’s
to something; to have regard to; to take into valuable for them to have … [I need to know
account. Conveying respect for another involves that I will] be allowed to be confused in their
seeing the “other” as a particular and situated office, that’s it okay for me to be upset and
individual, with unique beliefs, values, needs, afraid in front of them. Not that I want to be
and history. It means ... but sometimes that happens
acknowledging the Conveying respect for another involves when you’re dealing with illness.
inherent value of each seeing the “other” as a particular And [I need] not to be put
individual, upholding and situated individual, with unique down for it or ... judged for it.
basic human rights beliefs, values, needs, and history. (Woman survivor)
with conviction and
compassion, and suspending critical judgement.46 Second Principle: Taking time
Because abuse undermines an individual’s Time pressures – a reality in today’s health care
personal boundaries and autonomy, survivors system – constantly challenge clinicians to balance
often feel diminished as human beings and efficiency with good care. Sadly, this often leaves
may be sensitive to any hint of disrespect. Many individuals feeling like one of many objects in
survivors said that being accepted and heard by a never-ending assembly line, and compounds
a health care practitioner helped them to feel survivors’ feelings of being depersonalized and
respected: devalued. For some, being rushed or treated like
an object diminishes their sense of safety and
I need to have ... the ability to connect with the undermines any care that follows.
practitioner ... so [that] I’m not ... a number
18
Escalating patient-clinician ratios may lead many participants agreed that rapport is strengthened
practitioners to become exclusively task-oriented, when clinicians are fully present and patient-centred.
questioning whether they can afford the time to
really listen to their patients. It is important to The balance of professionalism and friendliness
remember that feeling that contributes to positive rapport is partly a
genuinely heard and function of interpersonal
Feeling genuinely heard and therefore style, but it can be developed
therefore valued is healing valued is healing in itself, and in some
in itself, and in some cases with practice. Clinicians
cases may be the most effective who are distant and cold
may be the most effective intervention a clinician has to offer.
intervention a clinician has in their professionalism
to offer: are unlikely to facilitate a
positive connection with clients. Conversely, an
It’s the health care practitioners that ... stop overly familiar style may be perceived as invasive
and give you a moment, and that’s one of and even disrespectful. Developing a tone that
the biggest healing things right there, that is professional and yet conveys genuine caring
moment. (Man survivor)159 promotes a sense of safety and helps to establish
and maintain appropriate boundaries.
Sixth Principle – Respecting boundaries
Fourth Principle: Sharing Information
Section 6.5: Time
Section 8.4 – Responding effectively to disclosure [He always gave] a reason why he was doing
something, which was great ... It wasn’t just
Third Principle: Rapport doing things and then leaving you in the dark.
Or if he was asking questions, you don’t have to
Showing some empathy, some second guess, “Why did he ask that
caring, some concern ... make Developing a tone that is question?” Because my favourite
me feel that I’m a person as professional and yet conveys sport is jumping to conclusions,
opposed to another client file genuine caring promote a right? ... If the person took ten
going through. (Man survivor) sense of safety and helps seconds to tell me, “This is why
to establish and maintain I’m going to do it,” it will stop
While rapport is essential to the mind from running. (Man
appropriate boundaries.
every therapeutic relationship, survivor)
it is an absolute necessity to
facilitate safety for survivors. Practitioners who are While knowing what to expect decreases anxiety
warm and compassionate facilitate good rapport for most people, it is particularly important for
and subsequent feelings of safety: survivors. Survivor participants emphasized
that they do not know what many health care
[For the health care practitioner I saw, this practitioners do and therefore do not know what
was] just a job like any other job. She could to expect. Being told what to expect on an ongoing
be answering phones. And I was just another basis helped to allay their fear and anxiety and
name on a [referral] ... She wasn’t interested. often prevented them from being triggered by
She had no warmth ... I didn’t experience being unanticipated events:
safe with her because I didn’t think that this
was somebody I could talk to at all, about I think they should spend the five minutes at
anything! She just was not interested. (Woman the beginning saying, “This is what [I] need
survivor)143p.252 to do to figure out what will best work for
you,” so that we’re prepared, you know. The
Good rapport not only increases individuals’ sense element of surprise is just really, really difficult
of safety, but also facilitates clear communication to deal with ... and if there’s a preparation
and engenders cooperation. Survivor and clinician and there’s not that fear of the unknown, and
19
Principles of Sensitive Practice
not the likelihood then that I will be triggered for many successive nights after getting braces put
by something that is done, you know, into on his teeth).
remembering something that is abusive for me.
(Woman survivor)143p.255 Fifth Principle: Sharing control
The surprises are the worst thing. (Man survivor) A central aspect of sexual victimization is the loss
of control over one’s body. It is understandable,
In many cases, clinicians can begin the then, that having a sense of personal control
information sharing process before seeing the in interactions with health care providers who
new patient by providing written information are more powerful is crucial to establishing and
about what is involved in a patient appointment. maintaining safety.
Some clinicians share information by offering a
running commentary on what they are doing as I’m learning that if I don’t have a sense of
they are doing it. This does not require additional control ... I will walk away from [the situation].
time, can be a tool for patient education, and is (Woman survivor)143p.255
tremendously reassuring.
Although both parties contribute to the dynamics
of the helping relationship, the health care
Appendix E – Sample Introduction to a Facility practitioner, by virtue of having greater social
power and specialized training, has a greater
As the term sharing information implies, it is a
responsibility in this area. Contracts for care,
mutual process of information exchange in which
practitioner services contracts, and therapeutic
both parties feel heard and understood. A place
contracts (either written
to begin is to ask patients
what information they As the term sharing information implies, or verbal) are all tools for
articulating goals, clarifying
want or need and to invite it is a mutual process of information
exchange in which both parties feel roles and responsibilities,
questions:
heard and understood. and defining the parameters
[The clinician] brings of the helping relationship.
definite knowledge and A frank, matter-of-fact
expertise [into treatment] ... So together with discussion of these issues should be part of
what I know and what I can tell her, I would the treatment plan, as it serves to minimize
hope that she would be able to ... assess the miscommunication and misunderstanding and
situation and offer alternatives ... So instead of contributes to increased trust on the part of
her being the expert and me being the patient, patient and health care practitioner alike. To
us being co-communicators about my body. proceed without such discussion assumes that
That’s what I’d like to see. clients and clinicians are all
(Woman survivor)144p.82 Sharing control of what happens mind readers who, without
in the clinician-patient interaction deliberate effort, can clearly
Health care practitioners must enables individuals to be active understand others’ words,
also seek ongoing feedback participants in their own care, rather motives, and intents.
about the patient’s reactions than passive recipients of treatment.
to the exam, treatment, or Sharing control of what
intervention throughout every encounter and happens in the clinician-patient interaction
prior to the next encounter. This invitation to enables individuals to be active participants in
articulate one’s reactions is particularly important their own care, rather than passive recipients of
for individuals who may indeed experience adverse treatment. In this way, the clinician works with,
reactions – such as flashbacks or nightmares – after rather than on, the client:
an encounter (one man who had experienced oral
[A health care practitioner should say,] “If you
abuse, for example, spoke about having nightmares
are not comfortable with doing it that way,
maybe we can make adjustments and do it
20
some other way that you feel more comfortable information of an intimate nature. Survivors
– help us, help us so that we can help you out. said that health care practitioners’ questions and
Let’s communicate here, let’s talk about things. actions when initiated either without explanation
I can’t read your mind ... I care enough about or without permission left them feeling violated.
you to consult with you. To make you part of
the healing process rather than a recipient.” Violation of a client’s personal boundaries may
You know? You need to be part of it. (Man occur unintentionally. For example, a practitioner,
survivor) when rushed for time, may neglect to ask for
consent before beginning a procedure. Although
The process of ascertaining informed consent is this action may meet the health care practitioner’s
a vital part of sharing control, as well as a legal need for expedience, it does so at the expense
responsibility. Informing, consulting, and offering of the client’s need for control and autonomy.
choices are all part of seeking consent: Similarly, asking a very personal question before
establishing rapport can be perceived as a
It’s the approach for me. That immediate psychological breach:
taking over, taking over for me without
consulting me or giving me a choice ... For me [My concerns when seeing a health care
that’s the first thing that raises my anxiety level practitioner] are related to the problems that
... for instance if you lay on a table, [the health I experienced as a child, and I’m still affected
care practitioner could say], “Are you okay to by them, and when somebody’s going to cross
lay sideways or are you okay to lay on your my – what I call my personal boundaries, the
back?”, instead of telling me, “You lay on your space that’s around me, that I call my own ...
back.” ... It goes back to education in a sense: and if anyone else is coming into that space, I
“This is the procedure prefer that they tell me exactly
that we’ll be doing and By demonstrating respect for and what they’re doing there.
this is what is expected of sensitivity to personal boundaries, When it comes to doctors,
you.” ... So information clinicians model healthy boundaries more so than anybody else,
and then choice. (Woman and reinforce patients’ worth and because they have a tendency
survivor) 159 right to personal autonomy. to approach you ... with their
hands out to go to work. I just
can’t accept that because of
Section 6.6 – Informed consent
the feelings and the stress and the emotions
The health care practitioner must directly address that are created in me are just too hard on me.
all clients – even those who are minors, speaking (Man survivor)
through an interpreter, or cognitively impaired –
Learning about boundaries and boundary
and negotiate care with them.
maintenance is a lifelong process. The blatant
Sixth Principle: Respecting boundaries disregard of personal boundaries during abuse
teaches children that their wants and needs are
As a survivor, I need to know that that person of little consequence. For many survivors, healing
is not going to invade my space. Or do harm to from abuse involves establishing or reestablishing
me. Not necessarily physically, but emotionally. personal boundaries and learning healthy and
(Woman survivor) 164p.95
effective boundary maintenance strategies. By
demonstrating respect for and sensitivity to
Because respect for boundaries is crucial to a personal boundaries, clinicians model healthy
sense of safety for most survivors, it is a principle boundaries and reinforce patients’ worth and right
in its own right, separate from the first principle to personal autonomy.
of Sensitive Practice, “respect.” The provision of
health care often requires clinicians to work in It is also possible that a clinician’s boundaries
close physical proximity to patients and to seek may be violated. For example, the patient who
21
persistently asks for longer appointments or they may need encouragement to become full,
attempts to contact the health care practitioner active participants in their own health care. Many
outside of work hours may be testing the of the survivors in our studies talked about the
firmness of the clinician’s importance of even small
professional boundaries. As health care practitioners learn about encouragements from
Talking calmly with the the health effects of interpersonal health care practitioners
patient about the need violence and about working effectively and of how they carry these
to respect the health care with survivors, their best teachers will encouragements into other
practitioner’s need for be survivors themselves. life situations:
time limits and personal
privacy can provide That assertiveness of
useful modelling for patients who have difficulties [saying] no takes a long time to get ... it was
maintaining their own boundaries with others. somebody else giving me permission that
Boundaries may also be violated by survivors who allowed me to say no until I could learn to
sexualize their relationship with a health care give myself permission [to do so]. (Woman
practitioner, having learned as children to relate survivor)143p.254
to their more powerful abusers in a sexual way. I often need the “permission” later in the
This can be a difficult situation for any health care examination, when my trust has built, to be
practitioner, but a calm stance that avoids blame able to speak or ask about those things as well.
is likely to be most helpful. (Man survivor)
As health care practitioners learn about the
Second Principle – Taking time
health effects of interpersonal violence and
Boundary maintenance is about working effectively
a fiduciary responsibility The degree to which a survivor is able with survivors, their best
clearly spelled out in to tolerate or participate in treatment teachers will be survivors
professional codes of may vary from one health care themselves. Most survivors are
ethics, and violations encounter to the next. interested in helping clinicians
carry serious sanctions. who demonstrate genuine
Addressing boundary problems in a direct, compassion and interest to learn about the
matter-of-fact way helps ensure patient safety and health effects of interpersonal violence and about
helps health care practitioners avoid potentially their particular needs. In the context of a caring
dangerous or compromising situations. While relationship, most survivors are even willing to
effective boundary maintenance may seem simple tolerate missteps and the inevitable discomfort
at first glance, it can be just the opposite and so that comes with addressing a difficult topic.
requires the ongoing, lifelong attention of every
health care provider. Practitioners who encounter Eighth Principle: Understanding non-
specific difficulties are encouraged to consult with linear healing
a respected peer or supervisor or seek advice from
Survivor participants reminded us repeatedly that
their professional body.
healing/recovery from childhood sexual abuse
Seventh Principle: Fostering mutual is not a linear process. As a result, the degree to
which a survivor is able to tolerate or participate
learning
in treatment may vary from one health care
The principles of Sensitive Practice are intended encounter to the next. This variability may occur
to increase clients’ sense of interpersonal safety. over the short term (day to day) or over longer
Because many of them have not experienced that periods of time. In recognition of this reality,
sense of safety as children, abuse survivors may health care practitioners must check in with their
be learning about it only in adulthood. Thus, clients throughout each encounter and adjust
22
their behaviour accordingly. The practitioner who are welcome. Boys and girls ... [and] have the
responds with under-standing and compassion in picture – boy and girl. (Man survivor)167 p.512
these circumstances contributes to the survivor’s
feeling of safety and to a stronger therapeutic Incorporating the principles of Sensitive Practice
alliance: into daily practice also indicates a health care
practitioner’s awareness of issues related to
Parts of my body at different times might be interpersonal violence.
untouchable. It’s going to change, depending
on what I’m dealing with. So, you’re not going
to be able to make a list and count on that 4.3 Using the principles to avoid
every time … it’s going to be a check-in every retraumatization
session. (Woman survivor)143p.255
The nature and quality of the relationship
Ninth Principle: Demonstrating awareness between a clinician and a survivor has
and knowledge of interpersonal violence implications for the safety and effectiveness
of health care. A good helping relationship
[The health care practitioner] had a book and not only contributes to an open exchange of
a pamphlet on a table nearby where I was information, but also creates the “human-
sitting that talked about sexual abuse, and to- human” environment that is essential for
so immediately that said to me, number one, the establishment of trust. Effective helping
she is open to this and therefore if it comes relationships are not ethereal, mystical
up I know that I’m in good hands because connections that “just happen,” nor are they a
[otherwise] this stuff would not be sitting here. naturally occurring byproduct of a charismatic
(Woman survivor) personality. Effective helping relationships are
intentional and skill-based interactions that exist
Many survivors look for indicators of a clinician’s to serve the needs of the patient.
awareness of issues of Effective helpers are genuine,
interpersonal violence. Posters and pamphlets from local
empathic, and warm. They are
Evidence of this organizations that serve those
also open-minded, knowledgeable,
awareness can take a who have experienced violence
attentive to verbal and nonverbal
variety of forms. Posters may help a survivor overcome
communication, self-aware, and
and pamphlets from hesitancy in raising the issue
reflective.
local organizations with a health care practitioner.
that serve those who Consciously applying the principles
have experienced violence may help a survivor of Sensitive Practice can not only enhance the
overcome hesitancy in raising the issue with therapeutic relationship with the survivor but also
a health care practitioner. In addition to an assist the practitioner to avoid retraumatizing
indication that their health care practitioners have the patient. Many survivors spoke about how
an understanding of interpersonal violence, male interactions with health care practitioners had left
survivors may also be looking for an indication them feeling violated and retraumatized:
that they are aware that men may be survivors:
It’s critical that they understand that we can
A poster in all the examining rooms. You know – be retraumatized as a result of how we are
victims of child abuse are welcome. That’s easy. treated by them ... Not that they’re meaning
Male victims of child abuse validated here. We to go there, but by not treating us respectfully
care about the victimization of children, help – giving us what we need to feel safe, and
prevent victimization of male children. Those being allowed to be seen as co-partnering
are messages that you can put on posters. Let’s and not as having no power at all – [they are
protect little boys and girls – see, inclusive. Boys making it] possible for us to be retraumatized.
and girls who have been victimized as children
23
And I would like them How do I ensure that
Without attention to these principles,
to get the information. patients have received
survivors’ umbrellas of safety can
(Woman survivor)159 what they feel is adequate
collapse, interfering with their ability
information about
Without attention to these to benefit from or perhaps even
examinations, treatment
principles, survivors’ tolerate health care interventions.
options, and treatment
umbrellas of safety can processes?
collapse, interfering with their ability to benefit
from or perhaps even tolerate health care What are my own personal boundaries?
interventions. Survivors told us repeatedly that How do I know if they are being violated?
this applies in all health care settings, including Could any of my actions be seen as
offices (physicians, dentists, chiropractors, boundary violations by clients?
massage therapists, naturopathic doctors, physical
and occupational therapists, etc.), acute care How do I balance the demands of my
hospitals, community-based care, long-term care, whole practice with the need to take
and rehabilitation settings. adequate time with each client?
What might get in the way of
4.4 Questions for reflection communicating my respect for my
patients?
How willing am I to share control with my
What is my own personal style of
clients?
interacting with clients? Does it seem
to foster rapport? Do I put effort into
maintaining rapport with each patient over
time?
24
5 Guidelines for Sensitive Practice:
Context of Encounters
5.1 Administrative staff and One survivor emphasized the need for receptionists
to learn about Sensitive Practice when she
assistants described her attempt to make an appointment
The quality of interactions with administrative with her family physician, who had previously
staff and assistants who work in health care agreed to see her if she was feeling suicidal:
environments can affect survivors’ feeling of What do I have to do, stand up on a chair and
safety. Participants overwhelmingly agreed that, say, “Yes, I look fine but at this moment I am
in an office environment, their interactions with thinking of a thousand and one ways to kill
administrative staff and assistants set the tone for myself”? [When the receptionist refuses to give
the practitioner-patient relationship. For these me an appointment] the shame and guilt kick
reasons, staff need to have some understanding in and I blame myself and I do go home and I
of the dynamics and long-term effects of OD or I slash my wrists. (Woman survivor)
interpersonal violence and require coaching in
applying the principles of Sensitive Practice in
ways that will work in their specific environments. 5.2 Waiting and waiting areas
In both hospitals and community-based settings, Survivor participants spoke at length about the
routines and procedures have evolved to be cost- extreme anxiety that they experience while waiting
efficient and to maximize the clinician’s time. for health care appointments because it takes them
They may, however, be experienced as more back to past abuse experiences. Because of their
clinician-centred and less patient-centred. In naiveté, children never anticipate the first episode
many offices, for example, it is common practice of abuse; it catches them unaware and defenceless.
for the receptionist to ask about the nature of The sexual acts seem strange and may be painful;
the problem in order to book the appropriate the secrecy is confusing; and the coercion or threat
type and time of visit. Many survivors said they of harm is frightening. Children have no prior
experienced this as an invasion of privacy, reference from which to understand why someone,
especially when they are seeking assistance especially someone they love and trust, would do
with psychosocial or mental health problems. these things to them. After the abuse has happened
The clinician participants in our working groups once, many children are haunted by the fear that it
suggested that a preferable approach would be could happen again. They become hypervigilant and
for receptionists to ask whether the appointment watchful, and wait in dread for the abuse to reoccur.
was for a discussion or an exam. Office personnel
Although waiting for appointments is a fact of
who usher individuals to examination areas
life, the experience may be particularly trying for
and carry out preliminary procedures could
survivors who have never completely shed the
also demonstrate respect for privacy by using
apprehension associated with waiting. Therefore,
this kind of question. Health care practitioner
participants urged practitioners to:
participants also reminded us that assistants and
technicians (such as physical therapy assistants or Create waiting areas that are warm and
x-ray technicians) who work directly with patient welcoming;
evaluation and treatment should use Sensitive
Practice in the same ways that the clinician does. Provide and clearly identify washrooms;
Provide printed materials related to 5.4 Other issues related to
interpersonal violence;
physical environment
Provide a realistic estimate of the length of
wait time. Having had so little control over what happened
to them in childhood, many survivors seek ways to
control the current physical environment in order
5.3 Privacy to feel safe. They offer the following comments
and suggestions:
Privacy is another important environmental aspect
of survivors’ feelings of safety. The balance between Designate separate washrooms for men
safety and privacy is not the same for all survivors: and women;
some will be most comfortable in a private
room; others may choose this option as long as Take the time to familiarize the client with
they can be accompanied by a support person; the physical environment (e.g., waiting
and still others feel safer in public spaces. Many area, washrooms, patient care areas,
survivor participants ask that health care providers equipment, and emergency exits);
approaching a waiting client knock or announce Whenever possible, offer clients a choice
themselves and await permission before entering. of where they may sit in examination,
Specifically, clinicians should consider the privacy treatment and waiting rooms (e.g., some
(or lack thereof) that their practice environment survivors prefer to sit near or be able to see
affords, by reflecting upon the following questions: the door);
What can be heard and seen in the Because some survivors are strongly
reception area? affected by lighting and views of floors and
ceilings, ask clients about their comfort
Are patients required to respond to level with the lighting. This is particularly
personal questions in a public reception important if treatment requires the patient
area where others may overhear the to assume a position facing the floor or
exchange of information? ceiling;
What can be heard and seen from the For practitioners who use music, candles,
hallway? or scent during treatment,
If your facility cannot provide an check with the patient
What can be
environment in which a particular client regarding their preference
heard between
feels safe, discuss the option of a referral to avoid triggering negative
examination
to another clinician or facility. responses.
rooms or cubicles?
Practitioners are further urged to have at least 5.5 Patient preparation
one soundproof examination or interview area
available for use. While privacy is even more The importance of sharing information about
difficult (and sometimes impossible) to achieve health care procedures prior to beginning any
in hospital settings, clinicians are urged to be exam, treatment, or hospital admission cannot be
creative and to consider the possibility of using overstated. Since advance preparation can help
areas that are not soundproof when others are not significantly to reduce an individual’s anxiety even
present, such as during mealtimes and outside of before the clinician and client meet, practitioners
peak hours. should consider the following possibilities:
Send printed information to clients before
their first appointment or give it to them
26
while they wait for their first appointment. 5.6 Encouraging the presence
Also consider displaying it in waiting rooms of a support person or
or treatment areas. These materials should
be written in clear, plain language that “chaperone”
avoids jargon or medical terminology. As
[The presence of the assistant] would make me
well as providing information about the
feel more comfortable if the door had to be
organization and service, these materials
closed ... it wouldn’t be that one-on-one. (Man
can also cue survivors to think about what
survivor)
they can do to facilitate their own safety
(e.g., bringing a support person or a small A third party observer (either a patient-
familiar object that symbolizes safety and nominated support person or clinician-nominated
security with them to appointments). “chaperone”) is commonly used for some
examinations and procedures. Survivors explained
Appendix E – Sample Introduction to a Facility
that having a support person with them often
helps to decrease their fears. The support person
Because not all clients are able to read can also serve as another set of ears to hear any
written material or understand English, information offered by the clinician:
alternate strategies can be used to inform
them about what they can expect in the If you’re being given a lot of information
health care encounter (e.g., consider using and you can’t necessarily hold it or get it all
drawings, photographs, or videos that straight or if you’re anxious ... and there’s a lot
answer frequent questions and explain of new information coming at you, it’s nice to
what will happen from the beginning to have somebody in the room that can help you
the end of the interaction). remember what’s being said. (Woman survivor)
Helping any client prepare The presence of a support

The presence of a support person person requires balancing
for hospitalization or
requires balancing competing competing demands for
outpatient procedures
demands for confidentiality, confidentiality, support, and
begins by assessing what
support, and protection of both protection of both patients
they know and identifying
patients and practitioners. and practitioners. To
any knowledge gaps.
Responding to those facilitate both the patients’
gaps may involve brainstorming and abilities to take advantage of the option of having
negotiation as well as information sharing. a support person present and the integrity of their
For example, when working with abuse practices, health care providers are encouraged to:
survivors it is important to discuss: (a) Inform patients verbally as well as via
ways that the survivor can get through the brochures and signs in the waiting areas
experience in the least traumatic way; (b) about the option of having a third party
ways to avoid identifiable triggers; and (c) observer with them;
plans to ensure sufficient ongoing support.
Remain aware that the presence of a
Collaborating with clients to develop a written support person may not always be in
plan of care ensures that everyone who works the client’s best interests (e.g., a violent
with them is aware of their particular needs. partner who seeks to control the client’s
interactions with others);
Speak privately with the client at the
beginning of the appointment to ensure
that the individual actually wants to have
27
Guidelines for Sensitive Practice: Context of Encounters
the support person present, to ascertain A critical cultural perspective, and
the role that the client wants the support understanding culture as relational, shifts
person to play, and to discuss issues of the gaze away from cultural Others onto the
confidentiality (keeping in mind that self, and requires examination of how each
individuals may want to speak privately individual is enmeshed within historical, social,
with the practitioner but may not know economic, and political relationships and
how to say so); processes. This then leads to questions such
as: How am I reinforcing certain norms (for
Establish the role of the support person example, Eurocentric norms perhaps) within
at the beginning of the appointment the culture of health care? How am I seeing
when all are present, so that the patient, certain behaviours, beliefs, and practices as
support person, and clinician are in clear “normal” and others as “cultural”? How am I
agreement; serving certain economic and political interests
Ensure that, when a third party must be through my daily practices?34p.163
in the examining room for medical or These ideas are also reflected in Irihapeti
legal reasons, patients both understand Ramsden’s work on cultural safety.124,125 Ramsden,
and consent to this witness, and then a Maori nurse leader in New Zealand, developed
offer them the choice between having a the concept of cultural safety to bring attention
personal support or staff person present. to the negative impact of colonization on the
health of Maori people and the ways in which
5.7 Working with survivors from colonization privileged Eurocentric health/illness
diverse cultural groups beliefs and many current practices perpetuated
inequalities. A full discussion of this topic is
Because Canadian society is composed of beyond the scope of this handbook; however,
individuals from many racial, ethnic, and health care practitioners and health care
cultural groups, it is imperative that health organizations are encouraged to examine current
care be culturally sensitive. Although much has practice with diverse groups on an ongoing basis.
been written about cultural awareness, cultural
While interpersonal violence is present in all
sensitivity, and cultural competence in health care,
cultural and ethnic groups, we pay special
ideas about how to address the topic of culture
attention to Aboriginal Peoples in this Handbook
are continuing to evolve. Early work in the area
because they represent a significant and growing
(for example,37,38,19,20,21)
portion of the Canadian
offered models of cultural
Health care practitioners and health population, they continue
competence as a framework
care organizations are encouraged to to experience the long-term
for delivering responsive
examine current practice with diverse effects of widespread abuse
health care services to
groups on an ongoing basis. in residential schools, and, in
individuals from culturally
our view, are likely to benefit
and ethnically diverse
from the universal application of the principles
backgrounds. More recently, proponents of the
of Sensitive Practice. It is our hope that even a
critical cultural perspective (e.g.,34,74,75) have
basic understanding of the abuses (many of them
encouraged practitioners to broaden their
systemic) that large numbers of Aboriginal people
thinking about culture beyond that described in
experience will help health care practitioners be
these early models and to recognize culture as
more sensitive and therefore more effective in
a complex, dynamic, and relational process that
health care interactions with Aboriginal peoples.
is shaped by historical, social, economic, and
political forces. As University of British Columbia
nursing professors Annette Browne and Colleen Appendix G – Working with Aboriginal Individuals
Varcoe explain,
28
5.8 Collaborative service As a survivor of abuse, [I feel that today’s
health care system] is reobjectifying ... to the
delivery
point where I scarcely exist ... as a whole being
Survivors spoke about instances in which they did because society [has] modeled a dissociative
not feel comfortable or safe working with health process that took my emotions to a psychiatrist,
care providers to whom and my body to a GP, and
they had been referred. For permanent transfer of care, the my teeth to a dentist. They
While options may be “outgoing practitioner” should ensure didn’t show me any model
limited, all patients that the new colleague is knowledgeable that would pull me back
have the right to referral about interpersonal violence and the out of dissociation. (Man
to another clinician or sensitive care of survivors. survivor)
facility. Clinicians may Survivors agreed that they did
also find themselves in a position in which they not expect any one person – including a health
cannot meet survivors’ expectations or needs care practitioner – to fix all of their problems.
for care. Broaching such discussions may not be Some suggested that access to a range of
easy, but practitioners are encouraged to respond practitioners from different health care disciplines
to requests for referral and to be supportive in would be an asset to their healing and those who
discussing situations in which they believe they had experience with primary health care teams
cannot meet patients’ needs. were very positive about that experience.
The transfer of care from one practitioner to Many participants were aware of the connections
another without prior notice can evoke feelings between mind, body, and
of abandonment and spiritual wellbeing and wished
erode trust. Whenever Most survivors agreed that they did
that health services were more
possible, individuals not expect any one person - including
holistic in their approach:
should be offered a choice a health care practitioner - to fix all
of alternate caregivers. of their problems. I think that the connection
Announcing planned between mental health and
absences well in advance provides clients with physical health can’t be separated ... The
the option of making alternative arrangements. [practitioner] would be able to help a client
In the best possible scenario, clinicians are able deal with their health issues significantly
to introduce their clients to the practitioner who more if they understood what the underlying
is taking over. Discussion about what information emotional stuff was as opposed to never, ever
regarding past abuse the individual consents asking the question and possibly figuring this
to be given to the out ... I think that the role of
temporary caregiver is Survivors urged health care providers the [practitioner] in health
essential. For permanent to consider making (with permission) should [include] a larger
transfer of care, the informal links with other practitioners component of emotional
“outgoing” practitioner with whom they were working to health ... I think that I ...
should ensure that address health problems more fully. could have got to the place of
the new colleague is dealing with the emotional
knowledgeable about interpersonal violence and place and impacts of sexual abuse an awful lot
the sensitive care of survivors. sooner if there had been some help to sort of
draw that out. (Man survivor)
Sadly, some survivors reported that their
encounters with the health care system actually Survivors urged health care providers to consider
detracted from recovery from childhood sexual making (with permission) informal links with
abuse: other practitioners with whom they were working
to address health problems more fully. For
29
example, a conversation between a counsellor and through difficult situations is never constant, even
a practitioner about a treatment that a survivor for experienced practitioners.
experiences as triggering intense negative emotion
might lead the counsellor to work with the Practitioners may need to seek the support of a
survivor on grounding techniques and to offer the colleague or counsellor to talk about their own
practitioner additional suggestions to minimize reactions to disclosures of childhood sexual
these reactions: abuse or other difficult situations with patients.
Obtaining this support can and must be done
I was quite amazed and thrilled that I could without breaching confidentiality. Seeking support
go in to see my [psycho]therapist and ... during is not a sign of weakness; rather, it is indicative
the week she and the medical doctor and the of taking professional responsibilities seriously.
psychiatrist had talked about my case and, Ignoring one’s distress or discomfort increases
you know, they were all concerned on a certain the risk for Secondary Traumatic Stress Disorder
level about a certain thing. (Man survivor) (STSD), also known as Vicarious Traumatization
(VT), or Compassion Fatigue (CF).109 Charles Figley,
director of the Traumatology Institute at Florida
5.9 Practitioners’ self-care State University, described the symptoms of
Taking care of oneself – eating well, getting STSD as being similar to those of Post-Traumatic
enough rest, engaging in Stress Disorder (PTSD) “except
regular physical activity, The basic tenet of self-care for that exposure to a traumatizing
taking time to relax, and so practitioners is the need to extend event experienced by one person
on – can be a challenge for to themselves the understanding becomes as traumatizing even
most people. For survivors and compassion that they for the second person.”66p.11
who learned as children demonstrate to their patients. Individuals with PTSD or STSD
that their needs are not may experience depression,
important, self-care may be even more difficult: anxiety, lethargy, overinvolvement with abused
patients, and undue fear of personal and familial
This is the first time in my life for the past three abuse. If these symptoms go unrecognized and
years that I’ve given a damn about my physical untreated, practitioners may react by avoiding
well-being. I never gave a damn before. That’s abused clients or inadvertently conveying to them
due to living with very poor self-esteem. (Man that they have done something wrong.
survivor)
For health care practitioners who are also
An important aspect of health teaching is the survivors. It is also important to keep in mind that
modelling of self-awareness and self-care. Patients childhood sexual abuse survivors and health care
who have difficulty in these areas may learn from providers are not categorically discrete groups. A
seeing their health care practitioners modelling proportion of clinicians are themselves survivors of
self-care and appropriate boundary setting. childhood sexual abuse.94 Practitioners who have
personal histories of childhood sexual abuse may
Section 4.2 – Sixth Principle: Respecting boundaries be especially empathic towards other survivors,
particularly if they have worked through and
The basic tenet of self-care for practitioners is the resolved their own wounds. However, practitioners
need to extend to themselves the understanding who have unresolved abuse issues may face great
and compassion that they demonstrate to their challenges when working with other survivors.24,109
patients. Every clinician needs to develop and They may be at risk for being triggered, developing
use a repertoire of strategies that promote and boundary problems, and counter-transferring
maintain health, particularly during stressful or harmful responses to patients. It is recommended
emotionally intense encounters with patients. It is that individuals work through and come to terms
also crucial to remember that the capacity to work with their own history of childhood sexual abuse to
30
avoid confusing their own difficulties with those of organization is appropriate for counselling
their patients. referrals:
The agency’s mandate and the nature of
5.10 Community resources for services offered (e.g., crisis intervention,
survivors and health care individual counselling, group therapy,
practitioners support groups).
The agency’s policy on fees for service
Survivors clearly do not expect health care
(e.g., what the fees are, whether the
practitioners to be all things to all people. At the
agency offers a sliding scale,
same time, practitioners
Practitioners can play a vital role in whether it accepts payment
can play a vital role in
helping their patients helping their patients locate and access from second parties such as
appropriate services and resources. employee health plans).
locate and access
appropriate services and How soon a prospective
resources. Organizations such as sexual assault client can expect to receive service and
centres, women’s centres, community mental whether there is a wait list.
health agencies, and residential addiction
treatment facilities may provide information Prominently displaying posters and brochures
for survivors and practitioners. Organizations for programs and agencies that serve survivors of
serving male survivors interpersonal violence offers
have emerged in Prominently displaying posters and patients the message that
some communities in brochures for programs and agencies the practitioner is aware of
recognition that many that serve abuse survivors offers patients the prevalence and potential
organizations established the message that the practitioner is long-term problems
earlier were serving only aware of the prevalence and potential associated with sexual,
women. Many sexual long-term problems associated with physical, and emotional
assault centres can offer sexual, physical, and emotional abuse. abuse. Materials should
specialized training provide information on:
or support for clinicians in their work with Sexual assault centres, women’s centres,
childhood sexual abuse survivors. Practitioners community mental health agencies, and
in the community who have expertise in working residential addiction treatment facilities;
with survivors may be available, and they may
be willing to consult or mentor other health Telephone help lines and suicide hotlines;
care providers. Professional associations and
Battered women’s shelters;
regulatory/licensing bodies may be able to suggest
other available resources. Mobile crisis units.
Gathering information on the following questions
will help practitioners determine whether an Recommended Reading and Resources
31
Encounters with Patients
6.1 Introductions and back to their abuse and leaves them feeling
negotiating roles powerless, vulnerable, and filled with shame:
If I had to take off clothing ... for a male
In all health care settings, steps must be taken to
[clinician] it’s ... hard because there’s the
ensure that the first moments of an encounter
trust issue there and for me there was a
set a tone consistent with Sensitive Practice. By
lot of guilt and shame ... I
introducing oneself,
struggle with body image and
explaining the nature Steps must be taken to ensure that the
of the appointment, first moments of an encounter set a tone sometimes ... I feel powerless
consistent with Sensitive Practice. then. (Man survivor)159
and asking patients
how they wish to be While the standards of care for
addressed, practitioners convey respect for their certain examinations require removal of clothing,
clients and begin to build a positive relationship survivor and clinician participants alike urged all
with them. health care practitioners to consider the following:
Further, before beginning any intervention, Discuss clothing requirements with patients
health care providers must ask clients about and collaborate with them to find an
their expectations for care. Doing so establishes agreeable solution (e.g., allowing clients to
a relationship that involves two-way sharing of wear their undergarments throughout the
information and control. It exam or inviting clients to
also creates an opportunity Undressing for someone in a position wear their own abbreviated
for the clinician to gain of authority transports many survivors clothing such as bathing suits
quick insight about back to their abuse and leaves them or shorts).
potential apprehensions, feeling powerless, vulnerable, and
which can help to avoid filled with shame. Leave the room while the
triggering negative patient is changing.
reactions. In long-term health care relationships, Provide a variety of sizes of gowns for all
the periodic revisiting of roles and responsibilities body sizes and instruct the patient about
allows for renegotiation and communicates whether the opening is to be at the front
genuine compassion and concern. or back.
Avoid paper gowns whenever possible
Section 4.2 – Fifth Principle: Sharing control
(they were widely described by survivors
as so flimsy that they escalate feelings of
6.2 Clothing vulnerability).
Few issues highlight survivors’ difficulties in Do not assume that all men are
health care settings as much as the need for comfortable baring their chests.
removal of clothing. While practitioners often
Meet patients when they are fully clothed
take for granted the need to disrobe and to don
(e.g., to make contact, ascertain the reason
an examination gown, undressing for someone in
for their visit, or perform a health history).
a position of authority transports many survivors
If clients need to disrobe for an patients an opportunity to share anything that
examination or procedure, explain what they consider relevant. A closed-ended inquiry
will happen next, what level of undress might be, “Have you ever had difficulty with
is required, and why. Before proceeding, examinations/procedures like this one?” If the
ask whether the client agrees to proceed individual answers in the affirmative, then an
with what has been explained and ensure open-ended question – such as “What can I do to
that the client’s questions have been fully make this easier for you?” – can help to minimize
answered. the patient’s discomfort. Before the examination
begins, extend a broad invitation to share relevant
Expose only the body area necessary for information (e.g., “Is there anything else I should
the specific intervention at any one time. know before we begin?”).
Cover clients’ bodies as soon as exams are Health care providers should recognize that,
completed to minimize the length of time while asking for this information may seem safer
that they are exposed. than talking about past abuse, survivors may
Meet with clients again once the still experience it as difficult. If an individual’s
examination or procedure is finished nonverbal cues indicate tension or anxiety,
and they have re-dressed to offer health the practitioner may need to ask very specific
teaching, provide an opportunity for questions such as, “Do you have any discomfort
questions, and say goodbye. While this may having your blood pressure taken?” or “Do you
take a few extra minutes, it brings closure have difficulty when someone touches your
to the interaction and allows the client to knees?” Survivor participants urged clinicians to:
leave on equal footing. Pick up on obvious things: “You seem very
anxious, is there something that you are
6.3 Task-specific inquiry uncomfortable with or is there something I
should know?” (Man survivor)
A task-specific inquiry involves asking patients
about their preferences for or potential difficulties There are many reasons that people experience
with a specific examination, procedure, or specific discomforts and sensitivities during health
treatment. It provides an opportunity for patients care encounters – some of these relate to past
to offer health providers information that is abuse, but others do not. Therefore, while task-
directly pertinent to the present situation without specific inquiry should be used for all patients,
any reference to past interpersonal violence. clinicians should be careful not to assume that a
Task-specific inquiry should be used during patient who offers a task-specific disclosure is an
an initial meeting with a patient, before any abuse survivor.
new examination or Asking if [the individual]
procedure, and any time Task-specific inquiry should be used has any issues or any
body language suggests during an initial meeting with a
concerns or are they
that the patient may patient, before any new examination or
uncomfortable, either
be uncomfortable or procedure, and any time body language
physically or emotionally, is
experiencing difficulty. suggests that the patient may be
a really good way to start.
Regardless of other uncomfortable or experiencing difficulty.
(Woman survivor)
factors, it should also
be done intermittently during interactions as an One woman suggested that clinicians:
ongoing invitation to offer feedback or to identify
Start out with, “What are your experiences
problems.
with a dentist [/doctor/massage therapist etc.]?
Task-specific inquiries involve a combination How often do you go? What are your fears?”
of closed- and open-ended questions that offer (Woman survivor)
33
Guidelines for Sensitive Practice: Encounters with Patients
Inquiries about sensitivities, discomforts, and Practitioners also need to be aware that, although
difficulties can also be included on questionnaires they should make task-specific inquires prior
that are part of an initial assessment. Some to any examination, some individuals may not
survivor participants told us that they are more be able to talk about their difficulties until they
comfortable with this approach. The practitioner develop a rapport with their health care provider.
may invite an individual who indicates having Further, the ability or willingness to talk about
difficulty with a number of components of an task-specific difficulties may be a function of the
examination to outline the issues in writing. survivor’s stage of healing; certain components of
Regardless of the mode used to elicit this an exam may be well tolerated at some times and
information, it is vital to the sensitive health care problematic at others.
of all clients.
[It] would be even better ... if every time you Section 4.2 – Eighth Principle: Understanding
went into a [practitioner’s] office, they gave you nonlinear healing
a little survey ... asking you ..., “Do you have Clinicians should not assume that an individual
a problem with getting undressed, or being has disclosed all task-specific difficulties during
touched?” It would be previous interactions. Survivors
great if they did that, Body language should be explored as who have been conditioned
‘cause then they’d have cues signalling that an individual may to be passive or to defer to
an idea of what kind of be experiencing difficulty. authority may need ongoing
person they’re dealing permission and encouragement
with when that person walks in that door. to talk about difficulties on a regular basis. Body
They’re prepared – that person’s prepared, language – such as trembling, flinching, tensing
because they think, or they’ll know that the muscles, changing breathing patterns, flushing,
doctor or the physiotherapist has an idea of crying, or dissociating (i.e., appearing spaced-out,
what they’re going to be dealing with. That if distant, or blank) – should be explored as cues
this person says, “Mm, I don’t feel comfortable signalling that an individual may be experiencing
with that,” they’re going to know. They’re difficulty:
going to understand ... And I think that would
be fantastic, if they did that. So then both We send out signals ... to people that we have
parties would be aware of things. (Woman been abused ... I was sending signals out, and
survivor) 164p.93 I don’t think the people were listening really
and picking up on them ... [I would] cringe and
It is important to note, however, that task-specific move and I often said “What are you doing?”
inquiry should not be reserved exclusively for (Woman survivor)143p.252
examinations involving touch. While touch can be
problematic for many survivors, other health care When these cues are evident, practitioners
interventions that clinicians may see as innocuous should explain that the exam or procedure will
(such as standing behind be easier to complete if the
a client during an Task-specific inquiry should not be patient can relax, and then ask
examination, taking a reserved exclusively for examinations for assistance in discovering
pulse or blood pressure, involving touch. another approach to that
or immersing a painful component of the exam (e.g.,
swollen hand in ice water) can also provoke “Would it help if I gave you a mirror to help you to
discomfort and trigger painful reactions. see what I am doing?”). Addressing an individual’s
apparent discomfort in these ways is vital to
establishing and maintaining rapport; ignoring
Section 6.7 – Touch
these things can undermine feelings of safety and
trust.
34
Documenting task-specific difficulties or reaction to part of an exam (or treatment), they
preferences can be done in a way that identifies should record the unexpected response as soon
the sensitivity or difficulty without any reference as possible after the incident, including both
to past abuse. In deciding what to include in objective (who, what, when, where, how, and how
the patient’s record, practitioners should ask much) and subjective (what the patient and others
themselves what other clinicians need to know in report about the event) information.
order to provide the best care. When practitioners
learn about task-specific sensitivities for the first
Section 8.7 – Legal and record-keeping issues
time only after a patient experiences an adverse
TABLE 2
A brief summary of task-specific inquiry
Task-specific inquiry involves asking patients about their preferences for or potential difficulties with
a specific examination, procedure, or treatment. It provides an opportunity for patients to offer health
providers information that is directly pertinent to the present situation without any reference to past
interpersonal violence.
Use combination of closed- and open-ended questions to offer patients an opportunity to share
anything they consider relevant.
An initial closed-ended question such as:
“Have you ever had difficulty with examinations/procedures like this one?”
If the individual answers in the affirmative, follow-up using an open-ended question such as:
“What can I do to make it easier for you?”
Before beginning an exam, offer one addi-tional opportunity to disclose something the patient
thinks might be relevant:
“Is there anything else I should know before we begin?”
When a clinician notes discomfort, return to task-specific inquiry. For example,
“Every time I go to stand behind you to take a look at your back you seem to tense up. Do
you have difficulty with having someone standing behind you or touching your back?”
If the patient responds in the affirmative:
“What can I do to make this part of the exam easier for you?”
For survivors who verbally deny discomfort but whose body language suggests the opposite,
task-specific inquiry is likely to facilitate feelings of safety for the survivor; explain that carrying
out the exam with the patient’s body more relaxed is ideal, and ask the patient’s assistance to
discover another approach to that component of the exam. For example,
“Would it help if I gave you a mirror to help you see what I am doing?”
Documentation of task-specific disclosures can be done in a way that identifies the sensitivity or
difficulty without any reference to past abuse. Focus on communicating the information that will
assist other healthcare professionals to avoid the difficulties or to problem solve with the patient to
minimize the difficulties.
35
6.4 General suggestions for Invite patients to make a list of questions
and concerns for each future appointment
examinations
in order to reduce their sense of anxiety.
In keeping with the principle of information Encourage questions throughout the
sharing, it is important that health care providers encounter.
not assume that their patients know what they
are doing or understand why they are doing it. Allow enough time to help individuals
Thus, it is important that they provide a running understand fully what is being done.
commentary of an examination or procedure
explaining what is being done and why. Further, Seek a balance between offering
repeated invitations for questions are crucial: descriptors of symptoms (“Would you
describe the pain as sharp or
I found quite often when you Repeated invitations for dull, throbbing or aching?”) and
go to a health care practitioner, questions are crucial. encouraging survivors to find
they automatically assume that their own words. This strategy can
you have some kind of knowledge of their job be particularly important since many
outline ... And why should I know? I didn’t go survivors have learned to ignore their
to school for that, so it’s really frustrating. And bodies and may require extra time to
they expect you to know something about it. describe their symptoms.
(Woman survivor)143p.255
Move on from topics that are making
While interactions with clients may be routine individuals seem uncomfortable or
by clinicians, for many survivors, health care questions that they are having difficulty
environments are strange and frightening answering, and return to them later.
places. Simply being in such environments can
challenge an individual’s ability to ask questions Use a written Informed Consent Form that
or to verbalize their needs. This fact cannot be uses readily understandable language and
emphasized strongly enough: avoids abbreviations, jargon, and technical
terms.
I feel very (pause) almost frightened. To some
degree the fight or flight syndrome kicks in Inform patients that consent can be
where I’m ready to hit the floor and head for withdrawn at any time, without penalty to
the door. I know it’s because of problems that them.
I’ve had as a kid. But at the same time those Pay close attention to language to ease
feelings come over me and then I lose all train the patients’ anxiety (e.g., ask patients to
of thought as to what I’m there for, what I change rather than to get undressed, use
want to ask him, I forget what day it is. (Man the term examination table rather than
survivor) bed, and use the terms underwear or
While employing the following strategies for undergarments instead of panties).
sensitively conducting an examination or
treatment may require extra time, they are Section 6.6 – Informed consent
important for establishing rapport, trust, and Appendix F – Using Plain Language in Consent
safety – and they may actually save time in the Forms (including a sample)
long run: Recommended Readings and Resources – Plain
Language: Websites
Complete the initial health history before
asking the client to remove any clothing
required for the physical examination.
36
Throughout the physical examination: 6.5 Time
Avoid using too many closed-ended yes- Most of the survivors we spoke with
or-no questions. (Intellectually challenged recognize the time pressures under which
individuals may try to answer in a way to health care practitioners work and do
please the clinician. Because the prevalence not expect exceptional treatment. The
of childhood abuse is even higher among following three suggestions are offered
disabled individuals than it is among by survivor and health care practitioner
children without disability, clinicians need participants as ways to use the available
to be particularly attentive to nonverbal time more effectively:
cues when working with these patients.)
Inform clients at the outset of an
Do not approach patients from behind and, appointment/interaction how much time
because some individuals startle easily, you have to spend with them and negotiate
avoid quick, unexpected movements. how best to use it. In a clinic setting, a
Notify patients before shifting focus from health care practitioner might say, “We
one area of the body to another. have 15 minutes for this appointment,
what do we need to focus on?” or “We
Explain the rationale for examining areas have 15 minutes and I plan to ... Is there
of the body other than the site of the anything else that you need or want?” A
symptom. health care practitioner
Even though employing these in a hospital emergency
Encourage individuals
strategies may require some extra department might say, “My
to ask that the
time, they are important for name is ... I am a Registered
examination or
establishing rapport, trust, and safety Nurse and will be looking
treatment be paused,
- and they may actually save time in after you. We are very busy
slowed down, or
the long run. here today, so you may have
stopped whenever it
to wait an hour or more to
is necessary to lessen
see a doctor.” The nurse might go on to
their discomfort or anxiety.
say, “I need to get some information from
Inform patients when procedures/ you and then I’ll be in and out every 15
examinations are likely to be uncomfort- minutes or so to check on you. Please use
able and collaborate with them to the call button if you need me.”
minimize the discomfort by soliciting and
Aim to keep interruptions (from
responding to feedback throughout the
assistants, colleagues, pagers, cell
procedure (e.g., ask, “How are you doing?
phones, BlackBerries, phone calls, etc.)
Can we continue?” and, if they say “No,”
to a minimum. Eight or ten minutes of
take a break until they can continue).
uninterrupted time allows the health care
Avoid glib or false assurances which practitioner to focus on the patient and is
sound dismissive or indicate lack of more likely to achieve the objectives of the
understanding of their concerns (e.g., interaction than 20 minutes of interrupted
instead of saying “Trust me” or “Don’t time.
worry, you’ll be fine,” say “I know this is
Use both verbal and nonverbal
difficult for you. How can I help you to feel
communication to convey interest and
more comfortable?”).
attention. For example, when a health
care practitioner conducts office interviews
while standing with his or her hands on
the door knob or abruptly leaves patients
37
to take telephone calls without any didn’t know that you were ... going to be taken
explanation, the message to patients is that elsewhere and what was going to happen. So
the practitioner is not focused on them. it’s where you’re going. (Man survivor)
Throughout this project, we have heard repeatedly
that short-term interactions pose the greatest Appendix F – Using Plain Language in Consent
difficulty for integration of Sensitive Practice Forms (with an example written by a survivor with
because of the reality of time pressures. Survivor the goal of increasing patient understanding)
and health care practitioner participants alike In many instances, it is necessary to seek consent
urged that while it may take some commitment for each separate component of an examination
and ingenuity to incorporate the principles of or procedure:
Sensitive Practice in short-term interactions, it is
important to make the effort to do so. Ongoing [consent is required] – it’s not a
blanket consent when you’re touching me.
(Man survivor)
6.6 Informed consent
The nature of that consent, however, can vary
Obtaining informed consent for examination and by circumstance. Some men indicated that
treatment is an important part of practitioners’ inquiring about their comfort was synonymous
responsibility to their clients and is regulated with asking for consent once an examination had
by professional/licensing bodies as well as begun. For yet other survivors, once trust had
legislation. Clinicians are urged to ensure that been established, the need for the practitioner
they are thoroughly familiar with all appropriate to repeatedly seek consent for each segment of a
sources of information about informed consent. procedure was unnecessary:
Informed consent involves: (a) explaining the
health problem; and (b) making recommendations As the trust builds in our relationship you
for addressing the problem (which must include: would get to a point that perhaps you wouldn’t
a discussion about the nature, benefits, material need to ask me and perhaps I would get to a
risks, and side-effects of treatment; alternative point where I would say, “You don’t need to ask
courses of action; and likely me for permission any more.
consequences of not having Clinicians are urged to ensure that We’re now at a point where I
the treatment). Written they are thoroughly familiar with all trust you and I know you’re
consent forms are part of appropriate sources of information not going to hurt me ... But
the process of obtaining about informed consent. there are some instances where
informed consent in many health practitioners need to
health care settings and health care providers ask for permission to go to those places. (Man
are urged to draft written consent forms in plain survivor)
language.
The inclusion of other individuals in any
This section highlights aspects of informed examination/procedure requires additional
consent that are particularly pertinent to consent. It is important to inquire about student
survivors. Because survivors have had early participation when the student is not present. In
experiences of boundary violation, it is essential addition, even if clients have previously agreed to
that practitioners be particularly attentive student involvement for other procedures, always
to obtaining consent which goes beyond the reconfirm their willingness to have the student
standardized forms and which is an ongoing present, especially during sensitive examinations.
aspect of their work with patients: Some individuals may agree to have a student
present for part of the examination but not for all
When I was a child ... you might say yes of it:
[consent] to [one thing] but, my God, you
38
She just told me that ... she was bringing a rechecking. It doesn’t have to be every minute
student into the room with her and that she but perhaps as they move on to another
would be helping remove the packing. She sensitive stage of whatever they’re doing, just
didn’t ask permission ... I think it’s a privilege recheck. “How are you doing? I’m going to be
for a student to be in that situation and you doing something different now, if at any point
still need to be respectful of how a patient feels you feel uncomfortable, let me know and we’ll
about you being there. proceed from there.” (Man survivor)
(Woman survivor) In all circumstances, the onus for
ensuring that the patient is fully To establish a context for ongoing
In all circumstances, informed and consents to what is informed consent, practitioners must:
the onus for ensuring happening is on the practitioner.
that the patient is fully Allow ample time for patients
informed and consents to what is happening is on to explore concerns, ask questions,
the practitioner: and decide whether or not they want to
proceed;
When [the practitioner] came back, right
before she was going to [proceed with further Seek consent for each component of an
treatment], she’d ask me again, “Are you examination or treatment;
comfortable with this? Is everything all right? Obtain consent before bringing in students
And do you understand what I’m doing?” And to observe or work with individuals;
that was so much easier, because one minute
you can feel comfortable, and the next minute, Keep in mind that the onus of ensuring
you could feel uncomfortable ... so she gave that the client’s consent is truly ongoing is
me an opportunity that, if I were to change my on the clinician;
mind and feel uncomfortable, all of a sudden,
Respond to the client’s verbal and
for whatever reason, she would know, and I’d
nonverbal communication when discerning
be able to say something. So I felt like I was
consent.
in control, and I did have the say of what was
going on. (Woman survivor)143p.254
6.7 Touch
The clinician’s responsibility to monitor and
respond to the client’s verbal and nonverbal I rarely go to the doctor; I only go when I
communication cannot be overstated. Some absolutely have to and also for physicals. I
survivors may be working to overcome the would just disassociate, that was my only way
passivity towards authority figures they learned as of coping with that ... any time they touched
children: me. (Woman survivor)
I don’t think it’s good All forms of physical touch, Most survivors we spoke with told us
enough to just say, “At from all types of practitioners, that all forms of physical touch can
any point if you are can provoke anxiety. provoke anxiety. This includes touch
uncomfortable ...” because from all types of practitioners and
some people will say, “Okay I understand,” in a wide variety of situations, from having blood
and may never say anything because ... we’re pressure taken or blood drawn to undergoing a
just taught to not say anything. We just don’t complete physical exam:
question. I know there are a lot of people
out there like me, and we would say, “Okay, Touch is difficult, but if I feel safe, then I can
yeah, I hear ya!” and then wouldn’t say a tolerate more. (Man survivor)
word no matter what. So I think on the part Survivor participants agreed that having
of the health care practitioner they’d be doing information before and while being touched is
those people a great service by checking and crucial to their sense of safety:
39
Information and knowing just before you’re As far as gentle touch goes, you would want a
going to be touched that it is coming [helps], firm but not aggressive touch. Something that’s
so, it isn’t sort of a shock to you that you are too soft can be seen as an advance on you.
being touched. (Man survivor)159 (Man survivor)
An understanding of the dynamics of abuse Despite the fear and anxiety that many survivor
and some of the difficulties behind survivors’ participants experience with touch, some told us
experience of touch can help health care about its positive aspects:
practitioners develop strategies to use during
interventions that require touch: I think that touch for healing ... has its place
based on my own experience and it helps for
When people used to touch me, it took me rebuilding trust. (Man survivor)
right back to the sexual abuse and the physical
abuse ... Health care practitioners, if they see Because touch is such a fundamental issue for
their patients sort of backing off or shutting survivors of childhood sexual abuse, health care
down a bit, they should investigate why. (Man practitioners – before and during any encounters
survivor) which involve touch – must:
For some survivors, the use of touch by the Recognize that, for many survivors of
clinician to explain a physical problem or as a childhood sexual abuse, no touch is
component of treatment may be difficult: routine;
[Some clinicians] have automatically assumed Provide patients with information about
that it’s okay for them to go, “Okay, well we’re the reason for and nature of the touch
going to work ... on these muscles [as they which is involved in any examination or
touch me] ... because we need to strengthen this procedure;
because this does this and –” ... It’s not meant Be sensitive to the intent and nature of
[to be sexual touching] ... Once I’ve gone home all touch, and discuss patient reactions to
and calmed down, [and I] thought that they different types of touch;
did [not do] anything inappropriately sexual.
But at the time, when you first get triggered, Create a context wherein responses to
it’s an extremely difficult situation to deal with. touch can be freely articulated and the
It triggers a lot of memories ... and then you healing nature of touch can be explored.
completely lose whatever you are there for. (Man
survivor) 6.8 Pelvic, breast, genital, and
Other survivors spoke of continuously monitoring rectal examinations and
and reacting to the intent and quality of touch procedures
they receive.
Understandably, pelvic and breast exams for
If you’re with [health care workers who are] women and genital and rectal exams for men and
aggressive ... in the way that they touch you, women were cited as being the most difficult parts
then you’re instantly intimidated and then it’s of a physical exam. Some survivor participants
not safe any more. (Woman survivor) described how these examinations triggered
No one approach to touch is appropriate for every flashbacks for them:
client. Gentle touch, which may be appropriate for It can trigger ... physical night sweats and
some, may be experienced by others as sexually severe rectal pain, enormous inexplicable
suggestive: attacks of anxiety. (Man survivor)
40
Others are unable to tolerate such exams at all: and ask for the client’s feedback about
ways to decrease difficulty;
I don’t think I would allow anybody to touch
me now ... nobody would get an internal on Minimize the time a patient must remain
me. No. I will not allow myself to be that in a subordinate position;
vulnerable again. (Woman survivor)
Drape parts of the body not being
Participants suggested that practitioners begin by examined;
describing the usual sequence of an examination
and ask individuals whether they need to adapt it Allow patients to wear clothing on parts of
in any way: their body not involved in the examination
(e.g., chest, arms, feet, etc.);
And you know, they take your blood pressure
and I said, “You know you’d better do the Pap Offer clients a mirror with which to watch
smear first and then take the blood pressure the examination or treatment;
because right now it will be off the charts and In some cases, suggest to a tense patient
after it will be okay.” (Woman survivor) that she insert the speculum herself,
I think being uptight about the actual allowing her to have some control over the
procedure also made it very difficult for me intrusion;
to talk in general about the other parts of the When possible, conduct pelvic
examination or the other examinations with the
questions they had to ask There is no single approach that is woman’s head and upper body
about the pregnancy or appropriate in every situation. slightly elevated, as described
about that kind of thing ... below:
The question-and-answer
thing was always before the actual physical I had been seeing [my family physician] for
exam and I would be really stressed out and one and a half years. I kept postponing my
really kind of paralyzed feeling, and so I don’t physical and the MD noticed that. She kept
think I ever gave really great information bringing it up and reminding me until I finally
because of that. So maybe having the physical told her that I was frightened of laying flat on
exam first would have helped, get it all over my back in a paper gown. She told me that it
with first, get yourself all back together again would not be a problem for me to be partially
… Or have someone come with you, which sitting up throughout the whole examination
I never did, but I suppose that would have including the pelvic exam. Now she tells all of
[helped]. (Woman survivor) her patients that that is an option. She told me
that it had been an important conversation for
Because there is no single approach that is her. (Woman survivor)159
appropriate in every situation, it is important to:
Use task-specific inquiry before the exam Section 6.3 – Task-specific inquiry
to learn about anticipated difficulties and
negotiate with the individual to minimize
discomfort;
6.9 Body position and proximity
Offer a running commentary about what Both women and men survivors spoke about
you are doing; the difficulty they experienced being in
certain positions, partially clad, with a fully
Pay attention to nonverbal signs of distress clothed clinician standing over them. Health
(e.g., tense muscles, flinching, “spacing care practitioners can approach the topic of
out,” facial flushing, tears, or stuttering) positioning in the same manner as they do other
41
aspects of the examination or treatment: explain A time of monumental change for women – a
the rationale for the proposed position, obtain time when the past, present, and future all
consent, monitor for signs of distress, and offer a come together, a time of openness, a time of
running commentary: vulnerability. Being pregnant causes memories
of one’s own childhood to surface. Past events
[I had to lie on my stomach] and I was really are stirred up. The present evokes the paradox
uncomfortable. Finally, I told him, “I can’t do of excitement over the baby on the one hand,
this.” I didn’t tell him why. I said ... “I can’t lay and fears and anxiety on the other.
on my stomach; can I do it some other way?”
[He said,] “Oh yeah, well – you can sit up.” So According to these authors, some survivors
there was an alternative. (Man survivor) welcome pregnancy as a sign that they are
“normal” and develop a growing trust and
I don’t like somebody standing behind me, confidence in themselves as their bodies change
but if they [must] ... the to support a new life.
explanation is important. Health care practitioners can approach For others, however, the
(Man survivor) the topic of positioning in the same experience of pregnancy
manner as they do other aspects of the stirs up memories of
Other participants talked
examination or treatment: explain the past childhood sexual
about experiencing
rationale for the proposed position, abuse. In her personal
difficulty when a clinician
obtain consent, monitor for signs of account, Christine,42 an
had to be in certain
distress, and offer a running commentary. incest survivor, describes
positions or was in close
physical proximity, as is not having conscious
the case when practitioners examine the eyes, memory of her abuse until sometime after her
ears, and oral cavity or carry out treatments such third child was born. In retrospect, that knowledge
as spinal adjustment. has helped her to understand the difficulties she
had with each of her pregnancies: the tears she
shed for no apparent reason after every prenatal
6.10 Pregnancy, labour and visit; her severe nausea and vomiting; her long,
delivery, postpartum slow, overdue labours; and the serious postpartum
depression. It also explained her life-long shame
[Pregnancy is] a very vulnerable [time] ... for and distrust of her
women that have been body, her high need
sexually abused. Like There is evidence that childhood sexual for control, and her
for me it was a little bit abuse survivors: are more reluctant to life-long struggles with
scary because I wasn’t address their health care needs, have poorer depression. Although
sure how the end result relationships with caregivers, have more she remembers the
would be, like during anxiety and fear about labour and delivery, practitioners who
my labour, would report disappointing birthing experiences, attended her during and
I have flashbacks? are (re)traumatized by the birth experience after her pregnancies as
(Woman survivor) itself, have more emotional problems in the being caring individuals,
postpartum period, and experience more none of them ever
While childbearing is a
problems with breastfeeding and parenting. asked whether she had a
profound experience for
most women, it can be history of abuse.
particularly difficult for women with histories of There is some evidence that, compared with
childhood sexual abuse. In their book When Survivors women who do not have histories of childhood
Give Birth, Penny Simpkin and Phyllis Klaus151p.33 sexual abuse, survivors: are more reluctant to
describe pregnancy as: address their health care needs, have poorer
42
relationships with caregivers, have more anxiety and I need you to understand this and I need
and fear about labour and delivery, report you to help me if I zone out. (Woman survivor)
disappointing birthing experiences, are (re)
traumatized by the birth experience itself, have A practising midwife who participated in our
more emotional problems in the postpartum second study told us that she may spend the
period, and experience more problems with first two to three prenatal visits just chatting
breastfeeding and parenting.76,84,92,130,134,148,151,180,182 with clients and waits for them to let her know
when they are ready for a physical assessment.
In the Western world, “good” prenatal care She tries to minimize invasive procedures and
involves frequent contacts with health care possible triggers as much as possible, performs
practitioners (physicians, nurses, midwives, only necessary interventions, and tries to be
ultrasound technicians, lab personnel, etc.) and flexible (e.g., allowing women to perform certain
typically includes a number of examinations, procedures – such as swabs – themselves).
tests/procedures, and treatments that may prove
difficult for some survivors. Debra Hobbins84 offers The principles and guidelines for Sensitive
the following list of perinatal experiences that Practice presented in this Handbook are a useful
might trigger memories of past childhood sexual foundation for perinatal care. We encourage
abuse: health care practitioners who work closely with
women through pregnancy, birthing, and the
Disrobing; postpartum period to read Simpkin and Klaus’s
When Survivors Give Birth151 for more specific and
Genital exposure/examinations; detailed guidance concerning the provision of safe
Raised side rails; and respectful care.
Restraint or entrapment in bed by

Recommended Readings and Resources –
equipment (such as fetal monitor leads,
Pregnancy, labour, and postpartum
belts, blood pressure cuffs, or oxygen
masks);
6.11 Oral and
Being drugged
(pain medications); We encourage health care practitioners facial health care
who work closely with women
Delayed or absent Although the guidelines
through pregnancy, birthing, and the
response to calls for Sensitive Practice are
postpartum period to read Penny
for assistance. pertinent to all types
Simpkin and Phyllis Klaus’s When
of practitioners, there
This list underscores the
Survivors Give Birth for more specific
are special concerns for
and detailed guidance concerning the
importance of inquiring practitioners who work with
provision of safe and respectful care.
about violence and abuse the mouth, jaw, and face.
during health history Because childhood sexual
taking with all patients: abuse may be oral in nature, many survivors have
difficulty tolerating various aspects of oral or facial
I was afraid of how the care would be, because
health care (e.g., the body position they must
they didn’t know in my first pregnancy, they
assume during treatment, the physical proximity
didn’t know at all, they didn’t ask and I didn’t
of the clinician, and the smells and textures of
feel comfortable with telling them because of
certain materials such as latex gloves or alcohol):
where I was at and I didn’t have that voice to
be able to speak out and say, you know, this is Too many things in my mouth at once ... You’re
what I need and this is what happened to me making me hold my mouth open too long
because you have to do that when somebody’s
forcing you to do oral sex, like when you’re a
43
child, like, ‘cause your next. And that has been
mouth is too small. Many survivors have great difficulty extremely helpful. (Woman
(Woman survivor) tolerating various aspects of oral or survivor)159
facial health care.
This means that knowledge Although practitioners may
of a patient’s past history perceive these frequent
of abuse is extremely relevant to oral and facial explanations and step-by-step consent as
health care: repetitious, they are valuable to the apprehensive
patient. Intermittently inquiring about a patient’s
Because I was anticipating [difficulty with] a comfort and following up on negative body
certain procedure I said, “I think you should language are also helpful, as are establishing hand
also know that I am a sexual abuse survivor signals to indicate the need to stop.
and ... maybe that’s part of my reaction here.”
. . . So if I happen to freak out when he’s Most of the time [the dentist says] “You know
poking around in my mouth, that he would the signals, right?” And I go, “Yeah.” And he’d
have more information there and would know always review the signals ... “This is what you
more of what he’s dealing with. (Man survivor) can do for yes, this is no, this is stop.” (Man
survivor)157p.1280
Section 7.6 – Triggers and dissociation Allowing breaks during an appointment or, when
possible, breaking a long appointment into two
Oral health care can regenerate the feelings of
shorter ones can be helpful options for many
powerlessness and vulnerability that survivors felt
patients.
as children:
[When I told my dentist that I was having
You have no control because you’re in the
problems that day, he responded,] “Well,
chair, your mouth is
what do I need to do? Are you
frozen and you’re pretty The practitioner who can help the
comfortable in the chair? Are
much at the mercy survivor feel some sense of control we going to need more breaks
of that person. (Man during treatment will be addressing today?” ... There’s just an
survivor) the patient’s abuse-related fears and unbelievable level of respect
The practitioner who laying the groundwork for greater with this man. He’s fabulous.
helps the survivor to compliance during treatment. (Woman survivor)
feel some sense of
control during treatment can allay abuse-related Section 6.3 – Task-specific inquiry
fears and increase the likelihood of greater
cooperation during treatment. As noted earlier, Childhood sexual abuse survivors also can feel
sharing information and asking permission before uncomfortable being in a reclining position in a
performing a procedure can reduce the patient’s dental chair with practitioner in close proximity:
feelings of anxiety and powerlessness.
I feel really trapped in the chair, in a very
[The dentist] would talk his way through what vulnerable position – you know, where you
he was doing. He would say, “Now I’m going to have your mouth open, you’re laid back. For
clean your teeth” or “Now I’m going to spray me a lot of my trauma occurred, like, when I
a little water on that tooth, it may be a bit was in a laid back position ... and [so having
sensitive.” He doesn’t overdo it but he explains a health care provider] ... over the top of me, I
everything he does, so that I have a very clear find that very threatening. (Man survivor)
sense of where he’s going and what he’s doing
While supine positioning cannot be avoided, the
initial exchange of information and obtaining of
44
consent should be done while the patient is still they expect to be judged harshly. This makes
sitting upright. Furthermore, reclining may be it critical that oral health practitioners use a
accepted more readily if patients are given an supportive, nonjudgmental tone when presenting
ongoing explanation of what is being done and treatment options. Instead of reprimanding their
are offered the opportunity to watch part of the patients, oral health practitioners can engender
treatment using a mirror. trust by asking how they can best help patients
take better care of their teeth.
Survivors also talked about difficulties with
materials that were reminiscent of condoms and Survivors indicated that, while oral health care
other objects used during abuse: was difficult for many of them, working with
practitioners to address the difficulties together
Dentists, for me, even on a good day, [are] a often resulted in a positive experience:
total, absolute nightmare. I’ll tell you why.
Number one, the gloves smell like condoms ... He ... doesn’t ignore what I tell him. He has
I can’t ground myself, so ... I am back there compassion ... He listened to me. He addressed
[being abused] . . . it’s not the dentist any my situation ... When it’s over ... I feel really
more. (Woman survivor)157p.1280 great. I really do. Like he’s so gentle, he’s so
kind, soft-spoken, yeah, he’s amazing. (Woman
While gloves are a necessity, opting for gloves survivor)
made of vinyl or other materials may be an
alternative that helps patients who seem To minimize the strain which many childhood
particularly anxious about the smell or sensation sexual abuse survivors experience with oral and
of latex. facial care, practitioners are encouraged to:
A further issue that arises in oral care is evidence Undertake the initial exchange of
of neglect. In many information and obtaining
instances, neglect of Because many survivors believe that they of consent while patients are
oral health may indicate are bad or undeserving, they expect to still sitting upright;
fear of treatment or be judged harshly. This makes it critical
that a patient does not that oral health practitioners use a Opt for gloves made of
consistently value or supportive, nonjudgmental tone when vinyl or other materials for
care for his or herself presenting treatment options in instances patients who are anxious
or his or her body. In of dental neglect. about the smell or sensation
such cases, fears can of latex;
compound: the fear of Establish and use hand signals for “stop”
treatment that keeps a patient from treatment and always respond promptly to them;
can be a source of shame and can lead to a fear of
being reprimanded for the neglect: Share information with patients on an
ongoing basis;
When they do my teeth they are going to
say, “Oh you haven’t been taking care of Address patient comfort on an ongoing
them, you should have come in before.” (Man basis by frequently checking in with
survivor)157p.1280 patients and using task-specific inquiry;
While patients deserve and expect a realistic Follow up on negative body language;
evaluation of their oral health, they may find it
Allow breaks during an appointment or
difficult to hear a poor prognosis for a condition
divide long appointments into two shorter
that may have been preventable if it had been
ones;
treated in a timely fashion. Because many
survivors believe that they are bad or undeserving, Offer patients the opportunity to watch
part of the treatment using a mirror;
45
Address issues of oral health care neglect is warranted, we urge clinicians who work in the
in a supportive, nonjudgmental tone and correctional system to examine current practices
offer to collaborate with patients in finding and seek ways to introduce the principles and
a way to take better care of their teeth. guidelines of Sensitive Practice.
Section 6.3 – Task-specific inquiry 6.13 After any physical

examination
6.12 Care within the correctional
When ending any interaction, it is essential that
system practitioners establish a sense of equality with
their patients. This will need to be handled
The proportion of childhood sexual abuse
differently in different settings:
survivors is higher within the correctional
system than in the general In clinic or office settings,
population. Prevalence The strict health care protocols
see patients when they are
rates of childhood sexual which are standard procedures
fully dressed for health
abuse among incarcerated within the prison health care system
teaching and before they
women range from 47% to dramatically decrease the likelihood
leave an appointment.
90%;97,152,162 among men, that childhood sexual abuse
these rates are 40% to 59% survivors will seek health care. In hospital settings, allow
(for sexual and/or physical patients who are remaining
abuse). 91,131 in hospital garb to regain composure and
experience themselves being recognized as
Two of the men who participated in our studies a whole person (e.g., shake hands and say
were incarcerated in federal institutions at the good-bye).
time of their interviews. They spoke about feeling
unsafe when seeking health care not only because In all settings, invite final questions and,
of the lack of privacy and confidentiality but also when appropriate, provide a briefly stated
because of standard procedures used within the plan for future meetings.
prison health care system. While the need for strict
health care protocols is understandable, it is likely 6.14 Questions for reflection
that such protocols dramatically decrease the
likelihood that childhood sexual abuse survivors Might any of my current practices be
will seek health care: interpreted as insensitive by survivors?
What needs to change?
[When I went to the clinician for a topical
nonprescription medication for haemorrhoids, In what ways might I adapt my own
she] wanted to physically check ... I was practice to incorporate specific guidelines?
thinking, “No, no that’s not necessary” ... So
Do any of these guidelines seem unrealistic
she refused me treatment ... [and told me,] “If
or unworkable in my practice? What are
you’re refusing [to let me examine you] then
some alternate ways of following such
I can’t give you anything, so I’ll just assume
guidelines?
that there’s nothing wrong with you.” (Man
survivor) How committed am I to incorporating
these guidelines into my routine practice
It is likely that similar difficulties exist for women
and into the routine practice of those who
survivors as well, as has been documented by
assist me in my work? What does this level
Pamela Dole,51 a physician who worked in the
of commitment mean to my clients?
US correctional system. Although further study
46
How aware am I of nonverbal Am I aware of resources in my community
communication of discomfort? Do I follow to which I can refer survivors for care
up on these indicators with my clients? outside my scope of practice? Is this
information readily available?
47
Problems in Encounters
7.1 Pain suck it up” and “What’s she doing back here
again? She was here all day” ... I thought they
Pain is a complex issue involving the dynamic were derogatory things because they didn’t
interaction of biological, psychological, and know my history ... My history was all there
social factors that is only partially understood. but obviously they hadn’t looked at it. (Woman
Research has repeatedly found an association survivor)
between childhood sexual and physical abuse
and increased risk of chronic pain syndromes. An Because an individual’s experience of pain is
individual may experience real, whether or not the pain is consistent with
pain associated with body objective findings, it is the
(somatic) memories of past Research has repeatedly found an clinician’s responsibility to
abuse in addition to the association between childhood sexual assess the client’s pain in a
pain of the disease, illness, and physical abuse and increased risk systematic, thorough, and
or injury for which they seek of chronic pain syndromes. nonjudgmental manner. The
treatment. clinician can also:
Include other practitioners on the
Section 2.5 – Childhood sexual abuse and health treatment team (e.g., mental health
practitioners, pain specialists, or
In keeping with the responses learned in pharmacists) to ensure a comprehensive
childhood, some survivors cope with their treatment regime;
memories by ignoring pain, dismissing its
significance, or dissociating from it: Initiate a discussion of other options,
including referral to other practitioners
The experience as a child is to discount the who specialize in the management of
pain, [the abuser will] threaten [the child], chronic pain (considering both traditional
say “Don’t tell anyone about this,” [and so the and complementary practitioners) if an
child will] hide the pain, to begin to dissociate individual’s experience of pain does not
from the pain. (Woman survivor) remit despite the practitioner’s best efforts;
These responses may make it more difficult for Offer a referral, where appropriate, for
health care practitioners to assess patients’ level psychotherapy, clearly explaining the
of pain, factors that may aggravate the pain or reasons for the suggestion and carefully
change their experience of pain during the course documenting the details of the discussion;
of treatment.
Follow up on any referral in future
To complicate matters further, some survivors interactions with the client.
come to health care encounters having had
negative experiences with other practitioners who
have either discredited the patient’s pain because 7.2 Disconnection from the
it was inconsistent with objective evidence or body
questioned the client’s rating of pain severity:
Judith Herman81 emphasizes the importance
While I was lying there I did hear some of the of reconnecting with the body in healing from
[clinicians] saying things like “Why doesn’t she trauma. Being out of touch with one’s body can
make looking after one’s body difficult for a include a description of what the activity
survivor. Indeed, for many survivors, the body should feel like and give upper and lower
becomes nothing more than “a vehicle to get limits for the performance of the activity
around [in]” (Woman survivor). Such individuals (e.g., “If your pain increases after making
often remain unaware of the messages that one bed, rest before continuing” or “If
their bodies are sending and fail to recognize you are out of breath, you are doing it too
or attend to signs and symptoms of things such vigorously”).
as stress, anxiety, fatigue,
or overexertion. These Feeling out of touch with their bodies Monitor performance and
individuals may require can make self-care difficult for progress.
specific guidance about childhood sexual abuse survivors. Help clients set small,
activities of daily living achievable goals to develop
and leisure time, physical neuromuscular skills and understand how
activity (from doing laundry to gardening), or to perform the activities correctly.
exercise (either therapeutic or physical fitness
training). Provide careful instructions to facilitate
adherence to the treatment program.
For many survivors, assistance from a health care
provider to help them become more aware of Teach the signs and symptoms of overuse
their bodies may be a critical step in their process so that survivors can learn how to monitor
of recovery: activity both during treatment and, later,
independently of the clinician.
[One part of treatment] has been for me to
start to get in touch with my body ... I think Suggest a range of strategies to aid self-
that a physiotherapist can really affect that awareness and connection to the body
[by giving] that supportive invitation to ... including: (a) physical activity; (b) somatic-
come back into [one’s] own body. (Woman based re-education strategies (e.g., guided
survivor)143p.256 visualizations, relaxation exercises,
breathing exercises, or
I needed ... my [massage yoga); or (c) referrals to
therapist to] introduce me The inability or apparent unwillingness other health care providers
to my body ... [to] talk to of clients to adhere to treatment may including complementary
me about my body because be related to childhood sexual abuse. health care practitioners.
I’m not in touch with it.
(Man survivor)
7.3 Non-adherence to treatment
Accordingly, health care providers who encounter
patients who seem out of touch with their bodies As stated previously, the inability or apparent
should: unwillingness of clients to adhere to treatment
may be related to childhood sexual abuse. Factors
Repeatedly invite those individuals to focus such as depression and negative self-perception
on their bodies. can lead to unsuccessful courses of treatment
Offer ongoing health teaching about the for patients and frustration for practitioners. In
importance of paying attention to somatic some instances, the difficulties which survivors
signs and symptoms. experience are directly related to the specifics of
past abuse:
Provide detailed verbal and written specific
instructions for activities of daily living that There [were] some of the exercises ... that
are problematic as well as for leisure time they wanted me to do [after a total hip
physical activity. These instructions should replacement] ... and one of them that I still
49
Guidelines for Sensitive Practice: Problems in Encounters
today cannot do ... You lie on your side ... it’s undermines their motivation and sense of
a scissor ... [Even when the practitioner] had agency.
the sling ... around my ankle and it had a
handle and I could pull it and my leg would Where adherence to treatment is
go up, I couldn’t even do that. I’d get it so far, particularly important (e.g., for
but I wouldn’t go any further because I had to postoperative mobilization), work
keep [my legs] so tight ... [and the practitioner] with individuals to achieve small and
got frustrated, she really did ... she thought reasonable goals (e.g., by ensuring
I wasn’t trying, and that wasn’t true at all adequate analgesia, teaching splinting
because I was doing the other [exercises] very techniques, etc.), and acknowledge all
well. (Woman survivor)143p.257 successes.
Remember that blame and guilt are
Section 2.4 – The dynamics of childhood sexual more likely to lead to withdrawal than
abuse adherence.
Chapter 3 – What Survivors Bring to Health Care At the beginning of the meeting, check
Encounters with clients about reactions during or
Appendix C – Traumagenic Dynamics of Childhood after the previous meetings, address any
Sexual Abuse
problems that have occurred, and answer
questions.
In other instances, fear and anxiety decrease
survivors’ ability to hear and retain information. If Encourage the view that actively taking
they are in a dissociative state while information care of oneself fosters autonomy and
or instructions are given, they may be unable independence.
to recall them or to decipher cryptic written
instructions.
7.4 Appointment cancellations
The following suggestions may help practitioners
For many survivors, “walking through the door
elicit survivors’ participation in their health care:
[for a health care appointment] is a big deal,”
Always explain the rationale for the (Man survivor) and they cancel appointments as a
recommendations being offered. means of avoidance:
Avoid using words My wife had been
such as must and bugging me for a while
It is helpful for service providers to
should. understand why survivors may cancel now, “The dentist has
appointments and, wherever possible, been calling you. You’ve
Provide detailed got to go.” “Okay I’ll call
written as well as to make changes in their practice
her back,” and I don’t
verbal instructions. environment to facilitate feelings of safety. call her back. But then
Ask clients whether they feel able and eventually ... the adult
willing to follow the recommendations. part of me says, okay you need to go to the
dentist ... but the emotional side of me [says]
Explore barriers to treatment adherence no way I’m going there at all. (Man survivor)
(e.g., values, social factors, finances, or
past abuse) and make adaptations where Certainly, cancellations are problematic in that
possible. they waste valuable health care resources and
are a liability to fee-for-service practitioners and
Adapt at-home treatment to fit the organizations. Nonetheless, it is helpful for service
client’s lifestyle and abilities, particularly providers to understand why survivors may cancel
for individuals whose low self-esteem appointments and, wherever possible, to make
50
changes in their practice environment to facilitate (e.g., informing a family of the death of a loved
feelings of safety. one, diagnosing a life-threatening disease or
condition, or encountering someone who is angry,
To help minimize cancellations, practitioners could: anxious, or extremely distressed). These emotionally
Offer “same-day” appointments that would charged situations may leave practitioners feeling
allow survivors to book appointments on unsure about how to respond. In such instances,
days when they feel able to cope. (This reference to the “SAVE the Situation” model may be
can be particularly helpful for oral health helpful. The model uses “SAVE” as an acronym for
practitioners.) the following four steps: Stop, Appreciate, Validate
and Explore. A particular benefit of the “SAVE the
Work with clients who have identified Situation” approach is that it can be effective in any
their apprehension and tendency to cancel difficult situation and is not reserved exclusively for
appointments to develop a strategy that work with survivors.
will assist them.
Section 7.6 – Triggers and dissociation
7.5 “SAVE the Situation”: Recommended Reading and Resources – The
A general approach for therapeutic relationship, boundaries, and
responding to difficult managing challenging situations
interactions with patients
All health care practitioners encounter difficult
situations in the course of their day-to-day practice
TABLE 3
S A V E the situation
The acronym SAVE is a guide for responding effectively and compassionately in a variety of emotionally
charged situations.
STOP
Stop what you are doing and focus your full attention to the present situation.
APPRECIATE
Try to appreciate and understand the person’s situation by using the helping skills of empathy and
immediacy. Empathy involves imagining the other person’s experience (thoughts, feelings, body sensations)
and communicating an understanding of that experience. Immediacy is verbalizing one’s observations
and responses in the moment, using present tense language. For example, ‘Your fists are clenched and you
look angry. What is happening for you?’ or ‘You seem upset’ or ‘I doubt there is anything that I can say that
will make this easier. Is it okay with you if I sit here with you for a few minutes? If the patient is unable or
unwilling to answer, the practitioner can shift the focus to determining possible ways to be helpful (e.g.,
“How can I help you?”).
VALIDATE
Validate the other person’s experience. For example, “Given what you have just told me, it makes sense
that you feel angry.”
EXPLORE
Explore the next step. For example, “Who can I call to come and stay with you?” or ‘This has been
difficult for both of us. I am not sure where to go from here. Can I call you tomorrow to see how you
are doing?”
51
7.6 Triggers and dissociation had victimized me ... [in] bathrooms. Being
in the tub area ... had quite an effect. (Man
A trigger is anything (e.g., a sight, sound, smell, survivor)
touch, taste or thought) associated with a
past negative event that activates a memory, Because triggers are directly associated with a
flashback or strong emotion. While the focus particular event or events, they are unique to each
of this section is on triggers related to abuse, individual. This explains why different stimuli will
it is not the only cause of this type of adverse trigger different people and why a practitioner
reaction to examination can never remove or avoid every potential trigger
and treatment. The in a practice setting. At the
Different stimuli will trigger different same time, common themes
suggestions in this
people and a practitioner can never in triggers (see Table 4) are
section can be used
remove or avoid every potential trigger apparent and practitioners are
regardless of the origin
in a practice setting. encouraged to consider whether
of the trigger.
some of these potentially
[After] surgery on my arm ... the [clinician] triggering situations can be anticipated. If a
would put my arm in water ... [That was patient is able to identify a trigger, the clinician
something] that my perpetrators had done,
TABLE 4
Common triggers
Sense Trigger
Sight An individual who resembles the abuser or who has similar traits or objects (e.g., clothing,
colouring, mannerisms).
A situation where someone else is being threatened or abused (e.g., a scowl, a raised hand,
actual physical abuse).
The sight of an object that was part of the abuse or similar to such an object (e.g., a belt, rope,
sex toys) or that is associated with the site where the abuse took place (e.g., a dark room, a
locked door).
Sound Sounds associated with anger (e.g., raised voices, arguments, loud noises, objects breaking).
Sounds associated with pain or fear (e.g., sobbing, whimpering, screaming).
A situation in which the survivor is being reprimanded.
Sounds associated with the place or situation before, during, or after the abuse occurred (e.g.,
footsteps, a door being locked, a certain piece of music, sirens, birds chirping, a car door
closing).
Anything that resembles sounds that the abuser made (e.g., particular words, phrases or tone
of voice, whistling, cursing, groaning).
Smell Odours associated with the abuser(s) (e.g., cologne or after-shave, tobacco, alcohol, drugs).
Odours associated with the place or situation where the abuse occurred (e.g., mildew,
petroleum products, food odours, outdoor smells).
Touch Any type of physical contact or proximity that resembles the abuse (e.g., touch on certain parts
of the body, touch that comes without warning, standing too close, the sensation of breath on
the skin, the manner in which someone approaches).
The sensation of any type of object that was used during abuse (e.g., ice, gel similar to lubricant
or semen, the sensation of equipment that is reminiscent of restraints used during abuse).
Taste Any taste related to the abuse (e.g., certain foods, alcohol, tobacco).
52
and patient can problem-solve together to either through what’s going on in their head. (Woman
avoid or minimize that trigger during future survivor)159
interactions.
If you have a guy crying in front of you and
Clinical practice incorporates many experiences especially if he’s a victim, [if you understand
in addition to touch that may trigger a negative triggers], at least you can have some type of
response in a survivor even though they seem understanding of where this person’s coming
innocuous to the clinician. Survivors described from. (Man survivor)
triggers such as the use of water, ice, traction, or
ultrasound gel. They also spoke about medical Health care practitioners should be attuned to the
procedures and treatments during which they following behaviours, which may be nonverbal
had to remain immobile or silent or heard others indicators of discomfort, distress, or dissociation:
crying out with pain or anxiety, reminding them Rapid heart rate and breathing (breath
of abuse experiences. Other participants told us holding or sudden change in breathing
that a practitioner’s body language or reprimands pattern may also be seen);
for behaviours interpreted as deliberate non-
adherence to recommendations could also trigger Sudden flooding of strong emotions (e.g.,
intensely negative experiences. anger, sadness, fear, etc.);
Survivors may or may not be aware of their Pallor or flushing;

triggers and may realize that they have been
Sweating;
triggered only after they have had this experience.
Individuals may also be triggered whether or not Muscle stiffness, muscle tension, and
they have conscious memory of past abuse or inability to relax;
have disclosed to anyone:
Cringing, flinching, or pulling away;
[During] my first experience [with this type of
practitioner], they didn’t have any Kleenex, Trembling or shaking;
and the minute [the clinicians started] touching Startle response.
me I just started sobbing, without having any
idea of ... why. (Woman survivor)143p.258 These behaviours are probably best understood as
“freeze-fight-or-flight” responses to the perception
When he did the physical examination I just of a threat (i.e., sympathetic nervous system
basically dissociated myself from my body and arousal).
I never had any idea why ... or how I did it. But
looking back now, I used to do that quite a bit. The following responses may be clearer
After the examination was over I had no idea indications of dissociation:
what he said to me. The only thing I wanted
Staring vacantly into the distance;
to do was get out of there. I felt extremely
violated. (Man survivor) Spacing out or being uninvolved in the
present;
Survivors stressed that it is important that all
clinicians have a general understanding about Being unable to focus, concentrate, or
triggers and how to respond to an individual who respond to instructions;
is triggered:
Being unable to speak.
The flashbacks that could happen while you’re
having an exam. The not being present in the After being triggered into a dissociative state,
moment ... It would be helpful for a [clinician] an individual may seem confused or vague and
to be able to help bring a patient back into the ask questions such as “Where was I?”, “What did
present moment and give them the time to sort I just say?”, or “What just happened?” However,
53
it is possible that the clinician and even the the count of six) and (if possible) sitting up
clients themselves may not know that they have and placing their feet on the floor;
dissociated. Indeed, some survivors only discover
as adults that they dissociate under stressful Remind individuals to keep their eyes open
circumstances: and to look around the room;
The health care practitioner would come Encourage patients to notice physical
into my personal space and.... I would just sensations (e.g., the feeling of their back on
dissociate. She’d touch me and then I’d just be the chair and their feet touching the floor,
gone. She worked with a lot of women who or the sensation of the air on their face).
were survivors and she knew it. She’d just stop As clients become more oriented and responsive:
and say, “Where did you go?” And I didn’t have
a clue what she was talking about. But over the Do not touch them;
years I started getting a clue. (Man survivor)
Offer verbal reassurance in a calm voice;
Now, [clinicians] don’t have to handle the
Avoid asking complicated questions or
[whole] crisis, but they do need to know how
giving complex instructions; instead, ask
to recognize [it]. And how to make a referral in
simple questions to try to connect with
a nice way [by saying, for example,] “Do you
the person (e.g., “Are you with me?”, “Are
see your counsellor tomorrow?” or “Is there
you following me?”, “Do you have ways of
someone you can talk to?” . . . They wouldn’t
staying present?”);
need to go beyond [their scope of practice],
but [it is helpful] if they can recognize what Offer them a glass of water;
can happen when a woman is going through
a flashback ... [and know] how to ground Allow them the necessary time and space
a person. It’s not hard; ... [it’s] just basic to regain their equilibrium (a quiet room
humanity and reassurance. You know, “You’re may be helpful);
okay, it’s safe here,” or [validating] the energy Normalize the experience. If the patient
and the courage that it takes to go through has disclosed abuse prior to this incident,
[the specific intervention] ... And [they can say,] let her or him know that health care
“Yes, [this treatment] can trigger memories, interventions commonly trigger flashbacks
and it can be really disturbing and distressful, or emotional responses, but do not ask
and what you’re feeling is normal.” (Woman for details of past abuse that may have
survivor)143p.258 contributed to being triggered. If the
To support clients who have been triggered and patient has not disclosed abuse, frame the
ensure that they do not leave the encounter normalizing comments in terms of anxiety
feeling disoriented or embarrassed about their that many people feel when seeing health
reactions to treatment, practitioners should: care practitioners;
Follow the SAVE protocol; Ask what the clients need right now (e.g.,
do they want your company, or would they
Orient clients to the present by reminding rather be left alone);
them where they are and what was
happening when they began to have Offer continuity of care (i.e., if time
trouble staying present; constraints prevent you from staying with
upset clients as long as you would like,
Encourage slow, rhythmic “4-6 breathing” explain this and ask if someone else can
(inhale to the count of four and exhale to help, such as another staff member or a
friend whom you could call).
54
Being triggered can be a frightening or be- The next time the practitioner sees the client who
wildering experience. Some clients may benefit has been triggered or dissociated:
from talking about the experience with someone.
Thus clinicians should: Discuss the experience with clients to
ensure that they are feeling better and to
Inquire about reaffirm the message that
whether the patient Being triggered can be a frightening the event does not alter the
has someone to offer or bewil-dering experience. esteem in which they are
support and whether held;
they would like to contact that person now
(e.g., “A new exam like the one we were Problem-solve with clients to identify what
doing today can be scary for many people to avoid or modify in the future to prevent
and can bring about very strong emotions, further triggering, keeping in mind that
as you just experienced. Sometimes it helps they may or may not be able to identify the
to talk about what happened. Do you have trigger of a particular incident;
anyone you can process this with? Would Learn from the individuals what techniques
you like to call this person to be with you they use to stay present and grounded,
now?”). including any reminders or instructions
Find out whether patients would like to that you can give them;
explore what has happened; if they have Suggest – if the severity of the client’s
no one to talk with, ask them whether they reactions and subsequent difficulty so
want a referral to a counsellor or other indicates – a consultation with a mental
community resource and whether they health practitioner to develop additional
know about telephone help lines that exist strategies for coping with triggers.
in your community.
Some survivor participants
Ask whether the client A person who has been triggered suggested that practitioners offer
feels able to continue or has dissociated may not retain general cautionary messages to
the examination or or recall important information. clients about adverse reactions to
treatment. procedures or treatment that are
A person who has been triggered or has invasive or uncomfortable (e.g., pelvic and rectal
dissociated may not retain or recall important exams and dental work):
information shared by the clinician. Thus, it is Something that my orthodontist may have
helpful for practitioners to: never realized, for me with that history of
Repeat all instructions; abuse, [is that] when I got the braces on,
for three nights in a row I just had horrible
Write down instructions and nightmares. I was phoning my counsellor and
recommendations in clear language. saying, “Can I book an appointment, get in
right away?” Because I didn’t have a clue what
For individuals who have repeated experiences was going on ... All of a sudden I’m having
of dissociation during their interactions with nightmares being that little kid again because
clinicians: of all this prodding and pulling going on in my
Suggest that they use a notebook to write mouth. I would want an orthodontist handing
information, instructions, and suggestions; out a leaflet going, if you’ve had sexual abuse,
keep in mind this could give you nightmares or
Share with clients the responsibility for this could trigger you. (Man survivor)
ensuring that essential information is
recorded before the end of the interaction.
55
If health care providers are shaken or upset by the realizing that anger (an emotion) and violence
triggering or dissociation of a client, they should (a behaviour) are distinct entities, not to be
talk with a colleague, a supervisor, or someone confused or seen as one response. Participants
within their support system. This can be done recommended that practitioners use the SAVE
without breaching confidentiality. guidelines to understand the cause of the anger.
They advised against trying to control agitated
patients’ behaviours; rather, they suggested that
Section 3.5 – Specific behaviours and feelings
arising during health care encounters the clinician: (a) allow clients time to cool down;
(b) reflect their observations back to the clients;
Section 5.9 – Practitioners’ self care
and (c) work with them in seeking a solution to
the problem (i.e., “Don’t dictate, negotiate!” (Man
survivor)).
7.7 Anger or agitation
A situation can quickly escalate if a practitioner
[Anger is] my initial response to almost
responds to an angry or agitated client with
everything ... I try to hold on to myself, which
defensiveness or anger. Managing one’s own
I do much better than before I was 40. But
anger is critical to interpersonal effectiveness.
initially my reaction is to get angry. (Man
Although many institutions and organizations
survivor)
have established policies to deal with angry and
Many men survivors and a few women survivors violent patients, it remains crucial that health care
talked about responding with anger when they are providers:
anxious or fearful or have
Anger often elicits responses of Manage their own feelings
been triggered:
defensiveness, irritation, or withdrawal. of anger;
Anger shows up often
Pay attention to personal
when you are triggered –
safety (e.g., do not stand too close, do not
like [when] somebody touches you in the wrong
make quick or sudden movements, identify
place. (Man survivor)
an escape route);
While it is generally easy to respond
Adopt non threatening body language
compassionately to someone who is sad or
(e.g., stand with arms uncrossed, at a slight
afraid, anger often elicits the opposite response –
angle to the person to avoid the experience
defensiveness, irritation, or withdrawal. This type
of face-to-face confrontation);
of response, however, can leave survivors in an
even more difficult situation: Speak slowly in a low voice, breathe slowly
and rhythmically.
You are frightened and everybody is frightened
of you. (Man survivor) Encourage agitated individuals to relax and
assure them that you are interested both in
Health care providers will benefit from
listening to their concerns and in helping
recognizing the connection between anger and
them find solutions to their problems.
past abuse for some survivors as well as from
56
8 Guidelines for Sensitive Practice: Disclosure
8.1 The challenge of disclosure [I’m] not saying that I didn’t remember things
that happened to me. I did, but I didn’t
for survivors appreciate the dynamic that was there and I
[Choosing whether to disclose] depends on just sort of thought of them as early sexual
where you are in your journey. Because experiences and said [to myself], “Well, doesn’t
sometimes in your journey you don’t want that happen to everyone?” Then you suddenly
them [health care providers] to know [you’re a discover that no, it doesn’t happen to everyone.
survivor]. (Woman survivor) The real dynamic just really clicked one day
and it really hit me hard. (Man survivor)
Although this discussion speaks of survivors
collectively, survivors are not a homogenous Participants described a number of factors that
group; each survivor is a unique individual influenced their decisions about whether to
with a unique history and point of view. While disclose to practitioners, and also how much
survivors may or may not disclose their histories, and what information they shared. Some did so
their abilities to recall the abuse and their places spontaneously early in the relationships, while
in the journey towards recovery consistently others held back until they felt more comfortable
play significant roles in disclosure. For example, with the clinicians. Still others chose not to
most of the study participants have always had disclose at all.
clear memories of the abuse Survivors who disclosed their
they experienced, while a Survivors who disclosed their abuse spontaneously (i.e., not
smaller number only began abuse spon-taneously did so in in response to questioning by a
to remember the abuse in the hope that the information practitioner) did so in the hope
adulthood. Some attempted to would help the practitioners to that the information would help
deny to both themselves and understand them better. the practitioners to understand
others that the abuse occurred: them better:
I just buried it and pretended that it didn’t [I disclosed so that the clinician would] have
happen ... and sort of just [said to myself], some of the understandings of the feelings that
“No, no-how could that affect my life?” And it are associated with that part of the physical
wasn’t until last year I really started to realize exam ... – the shame and the guilt and the
that it did affect my life. I knew it wasn’t right things that you have going on inside your head,
at the time, way back, but I didn’t know that the flashbacks that could happen while you’re
it could potentially have the effect that it had. having an exam, the not being present in the
(Man survivor) moment. (Woman survivor)
Some survivors also told us that they had always For many survivors, disclosure is a process. Unlike
remembered their childhood abuse, but did survivors who want to “get it over all at once,”
not identify it as abusive (believing that what others prefer to reveal their history gradually over
happened to them happens to all children) until time, often so that they can take control of the
some new learning prompted them to reconsider timing and pace of disclosure:
their experience:
[My doctor’s response] helped me, little by
My awareness of my childhood sexual abuse little, disclose more of my deep dark secrets
only dates from about nine or ten years [ago].
and helped me to ask more questions. (Man Others fear being blamed for the abuse or being
survivor)159 judged:
Finally, some survivors want to avoid having to One [practitioner] that I saw ... reacted with
disclose repeatedly and take a proactive approach insensitivity, by asking me, “How did you let it
to the issue: happen?” In the moment I felt revictimized and
took all of the blame for what happened. That
At this point in my life I think differently [than really had an impact on me. (Woman survivor)
I used to about disclosing]. I want “survivor”
written on the front of my chart so that Many male survivors, in particular, are fearful that
[clinicians] know and recognize that I want to if they disclose past abuse a clinician will assume
be treated sensitively. Then, if a new [person] that they are also perpetrators:
in the practice sees me it would be a reminder
to them. Other survivors may not want that, I called the hospital to talk about sexual abuse
but I think it would be great if I did not have and they thought that I was the abuser and
to disclose every time I see a new [practitioner]. referred me to domestic sexual abuse centre.
(Woman survivor) (Man survivor)
A reluctance to disclose may relate to: (a) Both men and women whose abuser(s) were
survivors’ feelings about themselves; (b) pressure women were reluctant to disclose for fear of not
from families, friends, or abusers to remain silent; being believed:
(c) their fear of negative responses; and/or (d) the Female survivors of female-perpetrated abuse
sense that their practitioners do not have the time ... experience disbelief as to the likelihood of
to listen or seem unaware of the potential long- having been abused by a woman. (Woman
term health implications of violence. survivor)
Many individuals spoke about how their own If it was with a woman it’s, “Well aren’t you
feelings of shame and guilt affected their attitudes mistaking it for nurturing?” (Man survivor)
towards disclosure:
Finally, both survivor participants and health care
There’s a whole lot of shame [about having practitioner participants identified practitioners’
been victimized] … and disclosing that. apparent lack of time as a huge barrier to
(Man survivor). disclosure:
Others told us of the vulnerability they feel when I was almost 60 when I started [to deal
disclosing: with issues of sexual abuse] and it came
Every time you disclose, you expose yourself. to light after a lot of very significant
(Woman survivor)159 [psychotherapeutic] work of mine ... So these
are deep things. In other words, this is a deep
Previous experiences with disclosure play a major question and to think of it in terms of a
role in survivors’ decisions about disclosure. Many 15-minute segment [with a clinician] is hard.
were reluctant to say anything because they feared (Man survivor)
a negative reaction, particularly rejection:
I’m really hesitant on mentioning it to people, 8.2 Possible indicators of past
especially ... [to health practitioners] – I don’t abuse
want to start talking about it or mention it
and get that rejection. ‘Cause that’s the worst. While there is no single indicator or cluster of
‘Cause then I clam up and I – my headaches symptoms and/or behaviours that provides
will probably get worse and everything will just evidence of past abuse, there is a growing body of
get worse. (Woman survivor)143p.258,164p.94 research that documents a relationship between
58
adverse childhood experiences and certain the patient should alert a clinician to consider the
behaviours and/or experiences in later life. Some possibility of abuse or violence:
of these include:
But I would ask [practitioners] to go a step
Avoidance of all health care practitioners further, to [talk] ... to men, particularly males
and/or health serving agencies; who have addiction problems, who have eating
disorders, sleep disorders, depression, anything
Repeated cancellations of appointments; that has to do with emotion, emotional things
Repeated postponement of a physical or mental health issues. I think it’s important
exam; that these [clinicians] ... get trained to be able
... to identify [behaviours that may be related
Poor adherence to medical to past abuse] and to be up on what the actual
recommendations; symptoms are. (Man survivor)159
Chronic unexplained pain (e.g., headache, It is crucial that health care providers be aware
pelvic, back, muscular); that these indicators, although clearly suggestive
of abuse or psychological
Unexplained
Recognizing clusters or patterns of trauma, may actually
gastrointestinal
these behaviours and symptoms stem from other causes.
symptoms/distress;
along with inconsistencies or gaps in Abuse is not always the
Disordered eating, information provided by the patient source of these behaviours;
obesity, or wide should alert a clinician to consider nonetheless, inquiry about a
fluctuations in weight; the possibility of abuse or violence. history of childhood sexual
abuse is essential.
Sleep disturbances
(insomnia, hypersomnia);
8.3 Inquiring about past abuse
Sexual problems (e.g., avoidance, many
sexual partners, unsafe sex practices); A growing body of evidence indicates a
relationship between abuse or violence and health
Alcohol or drug misuse; problems. Our studies further demonstrate a
Depression; range of ways in which past abuse can negatively
affect survivor-practitioner interactions.
Pattern of difficulty in interpersonal Accordingly, inquiring about violence and abuse
relationships; should be an integral part of collecting a health
history:
Self-harm behaviours and/or suicide
ideations/attempts; I think it’s important that [health care
practitioners] ask questions about abuse as
Posttraumatic Stress Disorder or other
part of a medical history, particularly of
anxiety problems;
women, and I think that anyone dealing with
Dissociative states (blanking out, long women’s pain who doesn’t ask questions about
silences). violence in a woman’s life is not doing their
job. I feel that very, very strongly. (Woman
survivor)164p.93
Recognizing clusters or patterns of these Section 2.5 – Childhood sexual abuse and health
behaviours and symptoms along with
inconsistencies or gaps in information provided by By routinely asking about past violence and
abuse, practitioners open the door for individuals
59
Guidelines for Sensitive Practice: Disclosure
to disclose if they choose to do so. In asking the times I will ask if stress or being emotionally
question, practitioners: (a) demonstrate that upset causes their symptoms to worsen. If they
they have an understanding of the relationship respond “Yes,” then I will ask what the greatest
between interpersonal violence and health; (b) causes of stress are for them (“Is the source
break the harmful silence surrounding abuse of your stress: home life, relationships, work,
and violence; (c) signal that they recognize school, finances, family issues etc.?”). Once the
interpersonal violence as a health issue; and (d) patient confirms that stress is a factor and that
validate their patients’ experiences. Asking about they can identify what their main stress reaction
a history of abuse can also lead to improvements triggers are, then I will ask if they have a good
in health care and may help avoid or reduce support system (“Do you confide in friends,
retraumatization, which often occurs in health significant others, other family members?”). I
care settings. next will ask if they actually use their support
system. Many patients will respond with
Some survivors who want to disclose find the comments such as “Not as much as I should” or
topic too difficult to initiate on their own and are “Yes, and I think that they are tired of listening
relieved when a practitioner broaches the topic: to me.” At this point I am able to intervene by
It was a huge relief to have my doctor ask, explaining to the patient that I have a good
“Were you ever abused?” (Man survivor) referral network, and that perhaps they should
consider seeing a counsellor. I reassure the
Inquiring about past abuse may also be a first step patient that I do not necessarily require any
towards helping a survivor develop a network of details regarding their stress, but many patients
support. Because some survivors deal with chronic will spontaneously divulge ... In short, history
health problems related to childhood abuse, taking allows me to develop a relationship
they may experience with the patient. During
ups and downs in their Inquiring about violence and abuse should history taking, when
health – that is, periods be an integral part of a health history. the patient feels heard
of time during which they and cared for, then the
are relatively healthy patient will often disclose childhood sexual
interspersed with exacerbations of symptoms abuse. Patients are always reassured that they
(e.g., pain, anxiety, or depression). Assessing are in control of everything that takes place
this pattern as part of the routine health history during their visit. Communication is established
allows the practitioner to work with the individual during history taking and is reinforced during
proactively to ensure that adequate supports are examination and treatments.
in place in times of relative health. On the other
hand, if a clinician learns about the past abuse While our own research and that of others
for the first time during a crisis, it can be more makes it clear that health care practitioners
difficult to respond effectively: have a professional and ethical responsibility to
inquire about abuse or violence, it is important
If we don’t talk about it for years and suddenly to understand this statement in relation to
open up the can [of worms], it becomes the debate regarding the evidence pertaining
difficult to deal with the outburst of reactions. to inquiry about/screening for interpersonal
(Man survivor) violence. It is also important to acknowledge that
not all survivors want to be asked about past
As one practitioner participant reported:
abuse and may choose not to disclose:
Most patients present for chiropractic care for
If I wanted to tell him, I’d tell him. It’s not his
pain (lower back pain, neck pain, headaches).
business. (Man survivor)159
During history taking I ask if they can identify
aggravating factors. Sometimes patients will As long as health care providers respect the
relate stress as an aggravating factor. At other wishes of survivors who prefer not to disclose a
60
history of abuse to them, there is no harm caused Both women and men described a number of
by inquiring about abuse. The Family Violence factors that might encourage disclosure. They look
Prevention Fund’s Research Committee made this for signals that the clinician has an understanding
point when it stated, “We know of no research to of the effects of interpersonal violence, including
suggest that assessment and/or interventions [of posters and pamphlets (directed at both women
family violence or intimate partner violence] in and men) prominently displayed in waiting rooms,
health care settings are harmful to patients.”57p.5 As washrooms, and examination rooms. Survivors
one survivor participant explained: also stressed the importance of feeling safe, and
trusting their practitioners:
I don’t know that there’s any harm in asking.
My guess is that if you are denying it or you My doctor made me comfortable from the
aren’t sure that you want to reveal any secrets, beginning so I felt I had someone to talk to.
you probably won’t say anything. But at least I’ve been married for 28 years and I wasn’t
it would give an opportunity to either ask, even able to tell my wife, but I was able to tell
“What are you talking him. If I wasn’t able to
about?” or to say a little tell him I don’t know if I
History taking allows me to develop a
bit about that ... If I’m would have been able to
relationship with the patient. During
not ready to talk about move in the direction of
history taking, when the patient feels
it, I’ll just skip over that recovery. (Man survivor)
heard and cared for, then the patient will
and say I don’t know
often disclose childhood sexual abuse. There was this one
anything. (Man survivor)
- Health care practitioner - specific [practitioner
who] was just so, so kind
Appendix I – The ... that person would definitely be someone
Evidence Debate Pertaining to Inquiry about that I would not have a problem sharing, you
Interpersonal Violence know, what had happened to me, what I had
For many practitioners, the first step towards experienced. (Woman survivor)
routine inquiry about interpersonal violence is an Survivors emphasized the importance of
attitudinal one. Studies have shown that barriers confidentiality in their decision to disclose:
to inquiring about interpersonal violence include:
(a) a lack of knowledge and training about the I guess the primary issue is ... confidentiality. [I
topic and how to ask relevant questions;44,80 (b) need to know,] are you going to tell anybody?
55
lack of privacy and time limitations; (c) the belief Are you going to do anything with the
that abuse is not a problem for their patients; information? (Man survivor)
and (d) frustration with being
Although a number
unable to help the victim.119 A For many practitioners, the first of professional and
clinician’s own experience with step towards routine inquiry
regulatory/licensing bodies
violence might also factor into about interpersonal violence is an have guidelines and
an unwillingness to address attitudinal one. recommendations in place for
the topic with patients.110
inquiring about past violence
Nonetheless, routine inquiries
or abuse (e.g.,6,7,12), most are not specific about
about interpersonal violence are fundamental to
how to approach the task. As gastroenterologists
Sensitive Practice:
Alexandra Ilnyckyj and Charles Bernstein88
Surely [practitioners] realize that it’s a part of observe, this lack of specificity contributes to the
who I am and it needs to be acknowledged, fact that, in practice, inquiries about past violence
and it does have an impact in terms of how I or abuse are not part of routine care, even when
need to be treated. (Woman survivor) health care providers may suspect that it is
relevant for an individual.
61
Recommended Reading and Resources – Screening Statements and questions such as these may open
tools the door to disclosure, either in the moment or
at some later time. If an individual hesitates or
The therapeutic relationship and the health care seems very reluctant to respond, another effective
environment are crucial factors in the inquiry response from a clinician would be something
about past abuse. The Society of Obstetricians and such as:
Gynaecologists of Canada153p.366 clinical practice
guidelines offer a valuable reminder to clinicians “I know these things can be hard to
about the therapeutic relationship: “Several talk about. I think it is important to ask
validated questionnaires exist for enquiring about because there is growing evidence that
[interpersonal violence]; however, the nature violence and abuse can affect a person’s
of the clinician-patient relationship and how health and create difficulties when they see
questions are asked seem more important than health care practitioners. You don’t have
the screening tool.” Regarding the environment, to discuss this with me if you don’t want
survivor participants emphasized that privacy to. If you do, I can work with you to ensure
and clearly visible and available information you are comfortable when you see me and
(e.g., posters or brochures) convey the impression to get whatever support or assistance you
that a practitioner acknowledges the relationship need.”
between interpersonal violence and health. Regardless of how the questions are framed,
Verbal inquiry. There is no one correct way to participants told us that trust in their healthcare
ask about a history of childhood abuse. Direct provider influenced their decision to disclose:
approaches are a relief I had one [practitioner]
to some survivors, but There is no one correct way to ask about ask me, “Was there any
may be too intrusive a history of childhood abuse. Direct trauma in your childhood
for others. Introducing approaches are a relief to some survivors, or lately that could cause
questions in a way that but may be too intrusive for others. these symptoms?” And
relates past abuse to right then, I thought, “Oh,
health and health care okay. I can talk about it. And I’m not going to
provides context and rationale. Practitioners could get rejection.” (Woman survivor)
draw on the following statements as possible
lead-ins to an inquiry of childhood sexual abuse Some men survivors told us that they were
history: unclear whether clinicians were asking if they
were victims or perpetrators of sexual abuse when
“Research tells us that child sexual abuse asked questions such as, “Have you encountered
among both girls and boys is much more sexual abuse?” Therefore, they urged health care
common than was once believed. We also practitioners to clearly ask if the man is a victim of
know that it can have long-term health past abuse.
effects.”
Most of the survivors in our research, both women
“Is there anything in your history that and men, indicated that they did not want to
makes seeing a practitioner or having a discuss the details of their abuse with their
physical examination difficult? If there is, I practitioners:
would like to hear about it so that we can
work together more easily.” Some people press for more info upon
disclosure and that is invasive and
“Some women (or men) want to talk with unacceptable. (Woman survivor)
their health care providers about very
personal or difficult topics. If you do, I am Written inquiry. Survivors in our studies varied in
open to hearing about them.” their views about the merits of written and oral
62
inquiries. Proponents of written questionnaires When survivors disclose their history of abuse,
believe that they are less intimidating than it is usually because they hope that something
verbal inquiries. Others prefer verbal inquiries, positive will come from it. If practitioners do not
because they open the door for an ongoing respond, survivors may interpret the silence as
conversation. Given what survivors told us about an indication of lack of interest, which may deter
their preference for a written or verbal approach them from mentioning it again. Moreover, they
to assessment, it seems that the most prudent may stop seeing that particular clinician or, in the
strategy is for health care providers to use both extreme, avoid all health services:
written and verbal forms to collect every health
history and to keep in mind that survivors may or I told the [health care provider] about my
may not choose to disclose. history of abuse. She didn’t acknowledge [it]
... She just kept right on going with what she
was doing ... Oh boy! If somebody says it, then
8.4 Responding effectively to you’ve got to acknowledge it. Because then
disclosure what that says to me is that it’s not valid, it’s
not important, it doesn’t have anything to do
Well, for one thing, it’s really important [to tell with us. (Woman survivor)164p.95
survivors] ... that you believe them, because
this might be the first person they’ve told. And Express empathy and caring. Survivors also want
also, it’s really important to accept them as a to know that their practitioners care about them.
person. You can say Simple statements of
whatever your real The most prudent strategy is for health care empathy and concern can
feelings are. [For providers to use both written and verbal convey both compassion
example,] “I’m really forms as part of every health history. and interest:
sad to hear that.” He just looked at me
(Woman survivor)143p.258,164p.95 and he said, you know, I’m really sorry this
Communicating to survivors that they have been happened to you. And that was the best thing
heard and believed is crucial whenever survivors he could have said. (Woman survivor)159
disclose. While follow-up is also important (as I remember feeling comforted by her, probably
the next section indicates), the practitioner’s by her words. She probably said, “It’s okay to
immediate verbal and nonverbal responses to cry” or she might have even rubbed my arm. I
disclosure can have a tremendous impact on the remember her telling me that she was going to
survivor. give me a phone number where I could call so I
Accept the information. Individuals need to could talk to somebody about it, which she did.
know that their health care providers have heard She handled it very professionally. (Woman
them, have accepted the information, and believe survivor)
that children are never responsible for abuse: Clarify confidentiality. Confidentiality is a vital
His response was first one of acknowledging concern for many survivors. Although a clinician
what I said and, you know, genuinely looking may have already discussed it previously, following
like he cared and kind of going with that and a disclosure of abuse, health care practitioners
not really pushing anything, not giving me need to repeat information about the level of
advice or telling me what to do but, you know, confidentiality that they can extend. For example,
just kind of going slowly with me through the clinician might say, “Because you are an adult
that. And I found that was excellent. (Woman now, I am under no legal obligation to report this
survivor) to police or a child welfare agency” and “I think
it is important to write something about your
63
childhood history in the chart. What would you Address time limitations. Time pressures are
like me to put down?” one of the biggest impediments to disclosure.
If individuals disclose a history of abuse and
the health care provider can spend only a few
Section 8.7 – Legal and record-keeping issues
minutes with them afterward, it is important
The most important thing is, “Whatever that the time constraints are communicated
you say is confidential with me.” Because in a way that will not leave survivors feeling
confidentiality is so huge. (Man survivor) dismissed or that they have done something
wrong by disclosing (e.g., “Thank you for telling
Acknowledge the prevalence of abuse. me about being abused. I can only imagine how
Understandably, many survivors feel very isolated difficult things have been for you. I have another
and alone in their experience. Having health patient waiting – do you want to book a longer
care providers demonstrate awareness about the appointment later this week?”).
prevalence and long term effects of childhood
sexual abuse normalizes the experience for
survivors and may reduce their sense of shame. For Section 4.2 – Second Principle: Taking time
example, a clinician might say, “We know that as Section 6.5 – Time
many as one in three women and one in seven men Section 8.5 – Additional actions required at the
are survivors of childhood sexual abuse. It is sad to time of disclosure or over time
realize that so many children have suffered in this Section 8.6 – Responses to avoid immediately
way.” following a disclosure
Validate the disclosure. Health care practitioners Offer reassurance. Because individuals who
must validate the courage it took to disclose have disclosed have shared some very personal
and communicate that they believe what they information, they may feel vulnerable and
have been told. Visible distress needs to be exposed – both at the time of the disclosure and
acknowledged (e.g., “I see that this is painful during future encounters with the practitioner to
[distressing, disturbing] for you right now. What whom they have disclosed. To minimize this sense
can I do to help?” or “It is okay if it takes more of vulnerability, practitioners
than one visit to do a
complete examination”). Health care practitioners must validate can reassure survivors that
the courage it took to disclose and they applaud the courage it
Failure to validate the takes to talk about past abuse
individual’s experience, communicate that they believe what
they have been told. and that the information that
silence, or judgemental has been shared will be useful
comments can be in providing appropriate
shaming and contribute to a reticence to disclose health care.
in the future:
Collaborate to develop an immediate plan for
[It is important] to validate that experience self-care. Some survivor participants identified
because ... [it is hard] to keep that buried for unsettled feelings or flashbacks of their abuse as
20 years and then bring it out and start talking an immediate after-effect of disclosure:
about it and then look across and see a look
of what you might perceive to be disbelief in I was triggered more, and I was getting more
somebody’s eyes and you’re wondering inside flashbacks after [disclosing the abuse].
yourself, you know, . . maybe I am crazy and (Man survivor)
it didn’t really happen or it wasn’t like that or,
you’re supposed to be a man and it wasn’t that Accordingly, health care providers should caution
bad and just shake it off and carry on right? individuals who have just disclosed to be prepared
(Man survivor)167p.510 for these feelings. They should then work with
survivors to make a specific plan for self-care
64
(e.g., “Sometimes talking about past abuse stirs Section 8.5 – Additional actions required at the
up upsetting memories. Tell me what you can do time of disclosure or over time
to look after yourself if this happens to you.”). In
working out this plan, clinicians should encourage Ask whether this is the patient’s first disclosure.
individuals to: As well as responding to a disclosure as outlined
above, health care providers can inquire whether
Include activities and coping strategies that the patient is disclosing for the first time. By
have been successful (i.e., are supportive, asking “Have you talked with anyone else about
comforting, or help the individual to this?” practitioners can get a sense of whether the
manage distressing emotions). survivor has previously taken any steps to address
Be specific and realistic, and include things the abuse. An answer of “No, I have never told
that are easy to implement in a moment anyone before today,” as compared to “Well, my
of distress. An unspecific plan (e.g., to take counsellor knows and suggested that I tell you,”
it easy for the next few days) may be too can help clinicians to shape their next response.
ambiguous to translate into meaningful It may also help them learn what supports the
activity, whereas a more specific plan (e.g., clients have in place and what they may need.
to call a specific support person or engage
in a specific activity, such as going to the 8.5 Additional actions required
gym, meditating or praying, writing in at the time of disclosure or
a personal journal, or attending a self-
help group meeting) gives survivors clear
over time
direction. Either immediately following the disclosure
Include ideas about what to do if the usual or during the next interaction, health care
coping strategies do not work. This step providers should seek to understand the survivors’
is particularly important if the individual reasons for disclosing and determine what (if
has a history of depression or self-harm. It anything) they want from the practitioners. It is
might involve calling a health information also important to clarify the survivors’ general
line or crisis line or going to the emergency expectations of the clinician and to explore
department of the local hospital. any implications that the disclosure has for the
survivors’ health care. Such questions need to be
Recognize that action is not always required. asked in a manner that indicates clear support
Health care practitioners tend to be problem- for the individuals’ choice to disclose and may
oriented and may respond to disclosure as a provide a bridge to discuss ways to maximize
problem that requires immediate action or their feelings of safety and comfort. While such
resolution; however, survivors may simply want discussions may take some time (and be spread
the clinician to have the information. Survivors over a few interactions), the information which
who have just disclosed may not necessarily comes from them will provide a basis for future
expect clinicians to do anything except to be interactions:
present with them in
the moment. While it is When I came in, [the
Survivors who have just disclosed may clinician] said, “I did
important to ask survivors
not necessarily expect clinicians to do some reading up on your
if there is anything they
anything except to be present with condition,” and he said,
want done related to
them in the moment. “This is what we’re going to
their disclosure, it may
be preferable to identify do.” He says, “We’re going
a later time for discussion about what actions (if to work out a system, okay, so that I know if
any) the survivors want from the practitioner. you’re having trouble and you need to stop.”
(Woman survivor)
65
Practitioners might say, for example, “Knowing [Practitioners] should never assume. Just
this will help me care for you better. Can we because I was abused, that doesn’t or shouldn’t
talk about things that might make you more rule out the possibility that there could be
comfortable during your appointments?” or “Is something physical and serious that is wrong.
there anything I can do differently?” The ensuing That’s one of the reasons I don’t like to tell ...
discussions may lead to disclosures of task-specific health practitioners about my abuse. They tend
issues as survivors gradually feel freer to express to write everything off as nerves and don’t even
their needs or preferences. As difficulties are check to see if the problem is something else.
identified, clinicians can integrate changes into (Woman survivor)
the individual’s ongoing care. Regardless of what
is accomplished, health care practitioners should While an abuse history may contribute to some
not assume that all issues illnesses, it is the clinician’s responsibility to
have been dealt with in ensure that health
one or two discussions; Health care providers should not assume problems are investigated
rather, they should that all issues have been dealt with in one thoroughly for all
check in with their or two discussions; rather, they should patients.
clients throughout each check in with their clients throughout each
Because of the
interaction and make appointment and make repeated invitations
vulnerability that they felt
repeated invitations for for feedback.
after disclosing their abuse
feedback: histories, some survivors
[The practitioner could say,] “Just let me know were wary about being referred to other health
[what you need]; the lines are open. I know care practitioners. Although clinicians typically
this [abuse] happened and if you need to talk see referrals as a normal and reasonable action to
about it or have any questions [you can talk ensure accurate diagnosis and treatment, survivors
about them with me].” (Man survivor) may think that the referral implies that their
practitioners cannot take care of them because they
[After] I told him I was a survivor ... he always are “too complicated.” As well, survivors may feel
questioned if I was comfortable doing anything uncomfortable or anxious about having to meet one
... Communication was more [important]. more clinician, whom they do not yet know or trust.
(Woman survivor)
All patients have the right to make an informed
Some survivors hope for a response that is beyond choice about the health care practitioners with
the clinician’s ability or scope of practice. It is whom they will work. Thus, before making
therefore important for practitioners to be clear referrals, practitioners are encouraged to discuss
about what they can and cannot do to help. If the issue with their clients in order to come to an
clinicians feel that individuals require assistance agreement on a new practitioner. These discussions
beyond that which they can offer, then a referral may be very significant for survivors who, for
to someone more able or qualified may be example, are uncomfortable working with clinicians
suggested. who are the same gender as their abuser(s).
Whenever possible, practitioners should refer to
Most survivors recognized that disclosing their health care providers who are knowledgeable
history of abuse was important to both their about and sensitive to issues of interpersonal
health and their health care. Nevertheless, many violence. Local resource registries may maintain
were concerned that, once they had disclosed a list of service providers (including health care
their history of childhood sexual abuse, their practitioners) who specialize in working with
health care practitioners would tend to attribute survivors.
their health problems to the abuse before
thoroughly investigating other possible reasons for While some survivors may disclose past abuse as
the problems: a lead-up to asking for a referral to specialized
66
counselling or support services, it is a mistake counsellor, spiritual advisor, or self-help group)
to assume that all survivors who disclose need available to the survivor. Such questioning
or want to be referred to a mental health gives the practitioner information about the
practitioner. By offering a referral before exploring survivor’s current resources and helps identify
the survivors’ intentions, practitioners may give gaps. Questions such as “To whom do you turn for
the impression that they think they know what support?” or “Do you have enough support in your
is best for the individual or do not want to deal life?” can help assess the individual’s situation.
with the disclosure. An immediate referral to a Further questions can help the practitioner
mental health practitioner, regardless of whether make survivors aware of the organizations in the
the client is having difficulties related to past community that offer information, support, and
abuse, can feel like a clear statement that the other services to survivors:
clinician has judged the survivor to be “not okay.”
Under many circumstances, raising the issue I needed to be reminded of resources and
of referral to a mental health practitioner may also that it was okay for me to call and use
best be postponed to a later interaction so that the resources. I needed permission to get the
practitioners can reinforce their acceptance of the support I need. (Man survivor)
survivor after the disclosure.
8.6 Responses to avoid
Section 5.10 – Community resources for survivors following a disclosure
and health practitioners
There are, unfortunately, instances when health
A preferable response to disclosure is for care practitioners fail to respond sensitively
practitioners to ask about the presence and to a disclosure. This failure often leaves the
effectiveness of supports (e.g., friends, family, survivor who has risked sharing deeply personal
information feeling more distressed.
TABLE 5
Components of an effective response to disclosure
After hearing a disclosure of past abuse, the clinician should:

Accept the information
Express empathy and caring
Clarify confidentiality
Normalize the experience by acknowledging the prevalence of abuse
Validate the disclosure
Address time limitations
Offer reassurance to counter feelings of vulnerability
Collaborate with the survivor to develop an immediate plan for self care
Recognize that action is not always required
Ask whether it is a first disclosure
At the time of disclosure or soon after:
Discuss the implications of the abuse history for future health care and interactions with clinician
Inquire about social support around abuse issues
67
[Sometimes] someone [will start] to disclose [and
the practitioner will say,] “You don’t have to tell
Responses to avoid after a disclosure
me this if you don’t want to.” People who are Survivors identified the following responses as
really nervous about hearing [a disclosure] keep clearly not helpful:
saying that, and it gives the message, “I don’t
want to hear this.” (Woman survivor) Conveying pity (e.g., “Oh, you poor thing”).
Offering simplistic advice (e.g., “Look on the
Negative responses (such as ignoring the bright side,” “Put it behind you,” “Get over it,”
disclosure, disbelief, denial of the negative impact or “Don’t dwell on the past.”).
of the abuse, or telling a survivor to “just get over Overstating or dwelling on the negative (“A
it”) are both painful and silencing: thing like that can ruin your whole life”).
Smiling (while you may hope that your smile
He told me that I should just get over this and conveys compassion, a neutral or concerned
move on. (Woman survivor) expression is more appropriate).
Touching the person without permission even
Don’t push the person and be really aware not if you intend it as a soothing gesture.
to use the “shoulds,” like “You should call the Interrupting (let the individual finish speaking).
Minimizing or ignoring the individual’s
crisis line.” (Woman survivor)143p.259
experience of abuse, the potential impact of
Men survivors also cautioned against minimizing past abuse, or the decision to disclose (e.g.,
“How bad could it be?”, “I know a woman that
the effects of female-perpetrated abuse. Viewing
this happened to and she became an Olympic
the survivor as lucky to have had such an early gold medalist,” “Let’s just concentrate on your
introduction to sex or perceiving the abuse as back pain,” or “What’s that got to do with your
merely a sowing of wild oats was very damaging. sprained ankle?”).
Asking intrusive questions that are not
pertinent to the examination, procedure, or
8.7 Legal and record-keeping treatment.
issues Disclosing your own history of abuse.
Giving the impression that you know
Legal obligations. In our studies, we use the term everything there is to know on the subject.
disclosure to refer to survivors telling health care
If clinicians think that they have inadvertently
practitioners that they have a history of childhood
responded to the disclosure in an inappropriate
abuse, as distinct from task-specific disclosure, way, or if the patient’s nonverbal feedback
which occurs when individuals identify discomfort suggests a negative reaction to their initial
or difficulty with all or part of a specific responses, they should immediately clarify the
examination or treatment. With the exception of intended message and check with the survivor for
this section, when we speak about disclosure in further reaction.
this handbook, we are referring strictly to adults
revealing a history of past abuse. cases of suspected abuse or neglect of children to
child welfare agencies or to police.103,127 Although
Health care practitioners do not have a legal the definitions of a child and the definitions of
obligation to report past child abuse disclosed by an a child at risk vary somewhat among individual
adult, unless, in disclosing his or her own experience, provinces,127 these same laws require that all cases
an individual identifies a child who may be currently of suspected abuse of children (under the age of
in need of protection (e.g., if a male patient who was majority) be investigated by the appropriate child
abused by a family member tells the practitioner welfare service to determine whether the children
that he has reason to believe that the same are in need of protection. When the suspicions
perpetrator is continuing to abuse children). are substantiated, child welfare authorities are
In contrast, all Canadian jurisdictions, except mandated to intervene.
Yukon, have laws that mandate a duty to report
68
It is the responsibility of all health care A guiding principle underlying the Framework78 is
practitioners to know the legal requirements that the collection, use, and disclosure of health
for reporting child abuse and neglect in their information are to be done on a need-to-know
jurisdiction. Information and guidance about basis and with the highest degree of anonymity
this obligation is available from regulatory/ possible under the circumstances. Furthermore,
licensing bodies and local child welfare authorities the Framework understands privacy as a consent-
(Children’s Aid Societies or Child and Family based right and, unless otherwise stated in
Services). legislation, an individual’s consent must be
obtained for any collection, use, and disclosure
Health care records. Health of personal health
care records are both a It is the responsibility of all health information. As well,
means of communication care pra-ctitioners to know the legal Alberta, Saskatchewan,
among health care requirements for reporting child abuse Manitoba, and Ontario
practitioners and legal and neglect in their jurisdiction. have enacted provincial
documents. The type of legislation that addresses
information collected the collection, use, and disclosure of personal
and how it is documented and shared must health information by health care providers and
comply with national, provincial, and territorial health care organizations.
legislation. The onus is on all practitioners
to understand and comply with the privacy Documenting a history of abuse. Some of the
and confidentiality requirements within their survivors in our studies specifically asked their
jurisdiction. health care providers not to document past abuse.
In responding to this request, a practitioner needs
In the interests of safeguarding the privacy of to balance the patient’s right to privacy and legal
Canadians, the federal, provincial, and territorial reporting requirements. While not reporting
deputy ministers of health have undertaken suspected abuse of a child clearly contravenes
the development of the Pan-Canadian Health the intent of the law, the same is not true of past
Information Privacy and abuse of a person who is
Confidentiality Framework.78 In responding to survivors’ requests currently an adult. Both
The aim of the Framework not to document their abuse histories, practitioner and survivor
is to address Canadians’ a practitioner needs to balance the participants concluded that
privacy and confidentiality patient’s right to privacy and legal it is important for clinicians
needs and to articulate reporting requirements. to discuss with their patients
“a harmonized set of core how documentation of past
provisions for the collection, abuse might be done while still protecting their
use, and disclosure of personal health information privacy. Survivors, for example, might agree to a
in both the publicly and privately funded sectors.” chart note that states they have a history of abuse
The Pan-Canadian Health Information Privacy and but provides no further details. Privacy may,
Confidentiality Framework outlines a set of core however, be an issue when working with patients
provisions aimed at protecting the privacy and whose care is being paid for by a third party
confidentiality of individuals’ health information, (e.g., insurance companies, employee assistance
while at the same time enabling the appropriate programs, or workers’ compensation). Clinicians
sharing of information to facilitate effective health involved in fee-for-service practices are urged to
care. These core provisions are consistent with the pay particular attention to the reporting that is
Canadian Charter of Rights and Freedoms and with required of them.
The Personal Information Protection and Electronic
Documents Act (PIPEDA)40 and endeavour to reflect Health care practitioners are further urged to
the realities of the current health system. consider the possible ramifications of sharing
information about patients’ histories of abuse
69
when referring them to other health care of events. Regarding consent for the provision of
practitioners: medical records to insurance companies, survivors
should be advised that they have the option of
On many occasions when I’ve been referred to sharing all or only specific portions of their record.
a specialist, it has been noted in the referring Health care practitioners are strongly encouraged
letter/form that I have a history of abuse. to seek legal advice in situations where a client’s
Too often the referring [practitioner] assumes health record is requested by a third party before
it is sexual abuse although I have never taking any action.
specified. I have learned the hard way that this
information is not seen only by the [receiving
health care practitioner] ... but is also read by Section 5.8 – Collaborative service delivery
some of the staff at the clinic I am going to. I
don’t want my history of abuse broadcast to 8.8 Questions for reflection
the world so I now ask the referring clinician to
state that a sensitive approach to any physical Does my environment foster a sense of
examination is required rather than disclose safety for potential disclosure?
my abuse history. If the referring doctor needs
to know, I am in a position to disclose or not Do my clients trust me enough to disclose?
and to only that person. (Woman survivor) Are there any steps I could take to increase
their feelings of trust and safety?
Documentation about past abuse may have legal
implications for clients who are (or may in the How do I want to integrate routine inquiry
future be) involved in a court case. If, for example, about child sexual abuse? Do I have a
a client chooses to press criminal charges or “script” that feels natural to me?
launches a civil action against an abuser, or if civil How would I feel if a client disclosed a
litigation follows a motor vehicle crash, relevant history of child sexual abuse? Are my
health records may be subpoenaed. Sometimes reactions different for males and females?
the records will be sought to support the client’s How would I know whether my reactions
case; however, in other instances, they might be are helpful for my clients?
used to challenge the client’s credibility or account
70
9 Summary and Concluding Comments
9.1 Clinicians’ contributions perspective. While the Handbook includes

to survivor’s healing from neither all possible ways that practitioners can
be sensitive to survivors nor all of the ways that
childhood sexual abuse interpersonal violence can affect an individual’s
I think that we’re talking about really health or health care experiences, we have come
long-term partnerships with a number of to see Sensitive Practice as a refinement or “fine
medical people ... maybe a physiotherapist, tuning” of patient-centred care. If all practitioners
a psychotherapist, a family doctor. We need were knowledgeable about the association
these nuclei of support, and they need to be between abuse and health, then Sensitive Practice
in touch with each other, and I have that, so I might not be necessary. Unfortunately, many
feel like I have a network of support. (Woman curricula devote little attention to violence and
survivor)143p.259 abuse and their implications for health and health
care,169 and some practitioners remain convinced
All forms of violence and abuse can leave an that our health care system cannot afford the few
individual feeling disempowered and disconnected extra minutes it takes to enact Sensitive Practice.
from others. Healing from abuse involves re- We suggest that, especially in light of the pressures
empowerment and reconnection with self and on the health care system, failure to practice
others.81 Because the harm of abuse occurs in sensitively is tantamount to abdicating our ethical
the context of relationships and because it affects responsibility to do no harm.
individuals’ ability to relate with others, healing
can only occur in relationships. Relationships with Thus, we encourage all health care providers to
caring others provide the substrate – the nutrient become more aware of the effects of violence
medium – for healing the parts of the self that and abuse and to ensure that their words and
were damaged by past trauma. The absence of behaviour communicate this understanding in a
trusting relationships leaves survivors isolated in sensitive way. By fine-tuning our patient-centred
their shame. Through engagement with others, approach, we will make greater strides in helping
survivors can learn to rebuild their basic capacities patients become healthier and better functioning
for autonomy, trust, and intimacy.81 Health care members of society. Although a practitioner’s
practitioners can be allies in that process by contributions to an individual’s healing are not
offering effective and sensitive health care in the always measurable, survivors have reminded us
context of genuine human connection. They can that the trust and safety that allow (re)connection
also facilitate reconnection by helping survivors within a strong therapeutic relationship can be
learn about their bodies and how they function in hugely helpful to them. And the possibility that
health and illness. the survivor will be further empowered to make
gains, however slow, holds bright promise:
9.2 Sensitive Practice and So, what we have is a relationship of ...

patient-centred care mutual give and take ... [The clinician] gives
me a lot of responsibility; I give her a lot of
Some would argue that the Sensitive Practice information; we negotiate how best to work
paradigm is redundant – that client-centred [together] to help me to fulfil my needs and to
care, by definition, incorporates all that this let me have power over my own life. (Woman
Handbook describes. However, we have a different survivor)143p.260
APPENDIX A: Empirical Basis of the Handbook
This Handbook is informed by two multi- In the second phase of the project, working groups
disciplinary, multisite research studies that of four survivors and four physical therapists in
employed grounded theory67 and action each group met in Saskatoon, Saskatchewan,
research126 methods. The overall intent of the and Waterloo, Ontario, four to six times over
project has been to facilitate a process by which six months to refine the themes into principles
childhood sexual abuse survivors and health and guidelines for Sensitive Practice. In the final
care practitioners collaborate to develop practice phase of the project, the information from the
knowledge that influences health care.166 In interviews and working groups was used to draft
the first study, we explored women survivors’ the first edition of the Handbook. Approximately
experiences of physical therapy, consulted 200 survivor participants, other survivors,
with survivors, physical therapists and physical physical therapists, physical therapy students,
therapy students to develop guidelines for and counsellors across Canada commented on
Sensitive Practice, and summarized the results successive drafts in writing or during focus groups.
of the study in a handbook. In the second study, This lengthy and broad consultative process was
we addressed gaps and questions from the first intended to ensure the clinical relevance of the
project, by asking men and women survivors first edition of the Handbook.
about their experiences with and ideas about
Sensitive Practice for a wide range of health In our second study, we focused on survivors’
care practitioners (including but not limited to experiences with all types of health care providers.
physicians, nurses, nurse practitioners, oral health We conducted individual interviews with 49 men
practitioners, massage therapists, complementary survivors and talked with one group of nine
therapy practitioners, and other health care men. Interviews were conducted in six provinces
practitioners without special training in mental (British Columbia, Alberta, Saskatchewan, Ontario,
health/psychiatry or psychotherapy). We then Nova Scotia, and New Brunswick). We also
engaged health care practitioners and survivors conducted interviews with 19 women survivors
in a dialogue about Sensitive Practice and the in Saskatchewan and Ontario. Repeated efforts to
creation of this second edition of the Handbook. recruit Aboriginal survivors and survivors of colour
were not overwhelmingly successful. Eight men
The first research project was conducted in and one woman self-identified as Aboriginal (Métis
three phases. In the first phase, 27 adult female or First Nations). Participants ranged in age from
childhood sexual abuse survivors in Saskatchewan 24 to 62 years. Participants were from a broad
and Ontario were interviewed. The women were range of educational backgrounds, professions,
between 19 and 62 years of age and from a broad and income levels.157,159,167
range of educational backgrounds, professions,
and income levels; 26 identified themselves as As in the first study, themes from these interviews
Caucasian and one woman self-identified as Métis. served as the starting point for two working
All had been referred for physical therapy in either groups in each of two cities. In Winnipeg, one
inpatient or outpatient clinics; four had declined working group was made up of four male
to see physical therapists. Transcripts of the survivors and three nurses and nurse practitioners
interviews were analyzed and the central themes and the other working group consisted of four
identified.142,143,158,164 male survivors and four physicians. In Saskatoon,
one working group included four female survivors
and three nurses and the other was made up
72
of three female survivors and four physicians. therapists, chiropractors, dentists, dental hygienists,
The groups met three or four times over four dental assistants, individuals teaching and
months. Interview findings and recommendations researching in the area of kinesiology and sport,
from the working groups in both studies were massage therapists, mental health practitioners,
incorporated into a draft of the second edition midwives, naturopathic doctors, nurses, nurse
of the Handbook that was sent to all participants. practitioners, physicians, physical therapists,
Feedback was incorporated into draft 2 and was occupational therapists, and reiki practitioners.
sent to 110 health care practitioners representing Draft 3 was developed from this consultation and
a wide range of health disciplines and perspectives was used for further consultations with six focus
(including those from academic training programs, groups of health care practitioners and students. In
professional associations, regulatory/licensing total, approximately 200 survivors and health care
bodies and various practice settings). Feedback practitioners from across Canada participated in
was received from 56 consultants, including aroma this consultation process.
73
Appendices A to I
APPENDIX B: Prevalence of Childhood Sexual
Abuse
Because childhood sexual abuse is often have had an unwanted sexual experience before
unreported in childhood or adolescence, adult the age of 18 years.122 After adjusting for sample-
retrospective studies are the most common source related variation, response rates, and differences
of prevalence estimates. The most current and in definitions across 16 cross-sectional community
reliable lifetime prevalence estimates are that as sample surveys, Kevin M. Gorey and Donald
many as one third of women and 14% of men are R. Leslie70 determined that the prevalence of
survivors of childhood sexual abuse.25,31,62 Accurate childhood sexual abuse was 16.8% for women and
accounting of the occurrence of childhood sexual 7.9% for men. In his review of large community-
abuse is hampered by methodological issues based studies in 19 countries around the globe,
related to reporting barriers (e.g., shame, guilt, Finkelhor63 found that the prevalence of childhood
self-blame, fear, etc.), definitional controversies, sexual abuse was 7%-36% for females and 3%-29%
population sampled (community vs. clinical), for males, indicating that childhood sexual abuse
method of data collection (e.g., self-report is an international problem and has been found
questionnaire vs. interview), response rates, and in every region where it has been studied. More
the number of questions researchers ask about recent studies in non-Western countries confirm
childhood sexual abuse.62,122,135,184 This helps to this (e.g.,41,98). David Murray Fergusson and Paul
explain the wide range in reported results and E. Mullen,60 after examining community-based
suggests caution when interpreting results and prevalence from several countries, concluded that
making cross-study comparisons. between 15% and 30% of females and between 3%
and 15% of males report exposure to some form
Large community-based studies of the incidence of unwanted sexual attention in childhood. This
and prevalence of childhood sexual abuse is consistent with John Briere and Diana Elliot’s
among children and youth are rare, with the recent study,31 which found 32.3% of women
most comprehensive one being a telephone and 14.2% of men reported sexual abuse in
survey of 2,000 U.S. residents (aged 10-16 years) childhood. In the latter work, 21% of adults who
done by David Finkelhor and Jennifer Dziuba- reported histories of childhood sexual abuse also
Leatherman.65 These authors report that in the experienced physical maltreatment.
year preceding the interview, 3.2% of girls and
0.6% of boys had experienced contact childhood The prevalence of childhood sexual abuse
sexual abuse, which was defined as “a perpetrator is even higher among individuals with
touching the sexual parts of a child under or over disabilities. A review of literature regarding
the clothing, penetrating the child, or engaging children with disabilities,83 defined as “the full
in any oral-genital contact with the child.”65p.419 In spectrum of physical, mental, and emotional
the overall sample, the combined prevalence of impairment,”83p.1018 cited research that reported
attempted and completed childhood sexual abuse children with disabilities are almost twice as
categories was 10.5%. likely to be neglected, 1.6 times more likely to
be physically abused, and 2.2 times more likely
Community-based probability samples typically to be sexually abused than are children without
find that 12%-35% of women and 4%-9% of men disabilities.83 Other studies report even higher
rates of sexual abuse for children with disabilities.
74
APPENDIX C: Traumagenic Dynamics of
Some of the common problems experienced by dynamics of childhood sexual abuse.64 These
childhood sexual abuse survivors are summarized dynamics describe the impact that abuse-related
in Table 6 using David Finkelhor and Angela behaviours, events, and experiences can have on
Browne’s conceptualization of the traumagenic their victims.
TABLE 6
Traumagenic dynamics of childhood sexual abuse
Characteristic Dynamics Possible Manifestations

Traumatic Rewarding a child for sexual behaviour Avoidance of all things sexual
Sexualization may heighten the salience of sexual issues
Preoccupation with sexual matters or
for him or her
compulsive sexual behaviours
Receiving attention and affection for sex
Precocious sexual activity
can affect a survivor’s ability to achieve a
healthy sense of love and belonging Aggressive sexual behaviours
Sexual parts of the child may be Promiscuity
fetishized
Prostitution (making use of or working in
Abuse may impart misconceptions about the sex trade)
sexuality (e.g., sexual identity, sexual
Sexual dysfunctions (e.g., lack of desire,
orientation, sexual behaviour, and sexual
difficulty with sexual arousal, inability
morality)
to experience orgasm, and avoidance of
Sexual activities may become conditioned sexual intimacy)
to negative emotions and memories,
creating an aversion to sex or intimacy
Betrayal Childhood sexual abuse manipulates Overdependence or clinginess
a child’s vulnerability, violates the
Vulnerability to subsequent abuse and
expectation that others will provide care
exploitation
and protection, and may interfere with
the ability to trust Failure to accurately judge the
trustworthiness or motives of others,
The child’s autonomy and wellbeing are
leading to subsequent abuse and
disregarded, which may affect the sense
exploitation and/or inability to protect
of self
one’s own children from abuse
Deep-seated guilt and shame develop
Social withdrawal, isolation, and/or
because children believe something bad
avoidance of intimate relationships
about them caused the abuse
Chronic relationship difficulties
Profound sense of grief over lost
innocence or the “perfect” or “normal” “Acting out” behaviours (e.g., aggression,
family; depression delinquency, risk-taking, etc.)
Extreme anxiety or fear, which engenders
a sense of dependency
75
Appendices A to I
Characteristic Dynamics Possible Manifestations
Stigmatization Abuser(s) and others blame or denigrate Dysphoria or chronic depression
the victim engendering a sense of shame
Stigmatization, isolation, and
or guilt
marginalization may contribute to
The abuser and others pressure child for substance abuse
secrecy
Criminal behaviour
The victim feels “damaged,” “abnormal,”
Failure to care for oneself (e.g., risk-taking
“bad,” which may contribute to a
behaviours, poor hygiene, poor health
distorted sense of self and lowered self-
practices)
esteem
Self-harm or self-mutilation
Powerlessness Unwanted invasion of one’s body or Hyper-arousal (i.e., chronic anxiety,
personal space can interfere with the phobias, tendency to startle easily,
establishment and maintenance of irritability, poor sleep)
healthy boundaries and increase risk of
Intrusion (e.g., flashbacks during waking
repeated victimization
states, traumatic nightmares during sleep)
Abuser(s) may use violence, threats,
Constriction (dissociation to endure
trickery, or bribery to involve their victim
danger that one is unable to fight off or
If others do not believe and respond escape) -alters perception, sensation, and
appropriately to disclosure of abuse, an time sense and may result in avoidance
individual may develop a lowered sense of reminders of the trauma, emotional
of efficacy numbing/blunting, detachment, and an
inability to experience joy
Some victims develop a high need for
personal control and may even identify Stress-related disease and illness; chronic
with the abuser and/or vague somatic problems
Adapted from Finklehor and Browne64 with permission of D. Finkelhor.
76
APPENDIX D: Diagnostic Criteria for Stress
Disorders
Acute Stress Disorder (ASD) D. Marked avoidance of stimuli that arouse

recollections of the trauma (e.g., thoughts,
Reprinted from The Diagnostic and Statistical Manual
feelings, conversations, activities, places,
of Mental Disorders (4th ed., Text Revision)11p.471-472 with
permission of the American Psychiatric Association. people).
A. The person has been exposed to a traumatic E. Marked symptoms of anxiety or increased
event in which both of the following were arousal (e.g., difficulty sleeping, irritability,
present: poor concentration, hypervigilance,
exaggerated startle response, motor
the person experienced, witnessed, or was restlessness).
confronted with an event or events that
involved actual or threatened death or F. The disturbance causes clinically significant
serious injury, or a threat to the physical distress or impairment in social, occupational,
integrity of self or others or other important areas of functioning or
impairs the individual’s ability to pursue some
the person’s response involved intense fear, necessary task, such as obtaining necessary
helplessness, or horror assistance or mobilizing personal resources by
telling family members about the traumatic
B. Either while experiencing or after experiencing
experience.
the distressing event, the individual has
three (or more) of the following dissociative G. The disturbance lasts for a minimum of 2 days
symptoms: and a maximum of 4 weeks and occurs within
4 weeks of the traumatic event.
a subjective sense of numbing,
detachment, or absence of emotional H. The disturbance is not due to the direct physio-
responsiveness logical effects of a substance (e.g., a drug of
abuse, a medication) or a general medical
a reduction in awareness of his or her
condition, is not better accounted for by
surroundings (e.g., “being in a daze”)
Brief Psychotic Disorder, and is not merely an
derealization exacerbation of a pre-existing Axis I or Axis II
disorder.
depersonalization
dissociative amnesia (i.e., inability to recall
Posttraumatic Stress Disorder (PTSD)
an important aspect of the trauma) Reprinted from The Diagnostic and Statistical Manual
of Mental Disorders (4th ed., Text Revision)11p.467-468 with
C. The traumatic event is persistently re- permission of the American Psychiatric Association.
experienced in at least one of the following
ways: A. The person has been exposed to a traumatic event
in which both of the following were present:
recurrent images, thoughts, dreams,
(1) the person experienced, witnessed, or was
illusions, flashback episodes, or a sense of
confronted with an event or events that
reliving the experience involved actual or threatened death or serious
distress on exposure to reminders of the injury, or a threat to the physical integrity of
self or others.
traumatic event
77
Appendices A to I
(2) the person’s response involved intense fear, (7) sense of a foreshortened future (e.g., does
helplessness, or horror. Note: In children, this not expect to have a career, marriage,
may be expressed instead by disorganized or children, or a normal life span)
agitated behaviour.
D. Persistent symptoms of increased arousal (not
B. The traumatic event is persistently reexperienced in present before the trauma), as indicated by two (or
one (or more) of the following ways: more) of the following:
(1) recurrent and intrusive distressing recollections (1) difficulty falling or staying asleep
of the event, including images, thoughts, or
perceptions. Note: In young children, repetitive (2) irritability or outbursts of anger
play may occur in which themes or aspects of
the trauma are expressed. (3) difficulty concentrating
(2) recurrent distressing dreams of the event. (4) hypervigilance

Note: In children, there may be frightening (5) exaggerated startle response
dreams without recognizable content.
E. Duration of the disturbance (symptoms in Criteria
(3) acting or feeling as if the traumatic event B, C, and D) is more than 1 month.
were recurring (includes a sense of reliving
the experience, illusions, hallucinations, and F. The disturbance causes clinically significant distress
dissociative flashback episodes, including those or impairment in social, occupational, or other
that occur on awakening or when intoxicated). important areas of functioning.
Note: In young children, trauma-specific
reenactment may occur. Specify if: Acute: if duration of symptoms is
less than 3 months
(4) intense psychological distress at exposure to
Chronic: if duration of symptoms
internal or external cues that symbolize or
is 3 months or more
resemble an aspect of the traumatic event.
(5) physiological reactivity on exposure to internal Specify if: With Delayed Onset: if onset of
or external cues that symbolize or resemble an symptoms is at least 6 months
aspect of the traumatic event. after the stressor
C. Persistent avoidance of stimuli associated Disorders of Extreme Stress not Otherwise

with the trauma and numbing of general Specified (DESNOS)
responsiveness (not present before the
trauma), as indicated by three (or more) of the Judith Herman81 has challenged the ability of
following: the diagnosis of posttraumatic stress disorder
(PTSD)9,10,11 to capture the full range of human
(1) efforts to avoid thoughts, feelings, or
response to trauma. She and others (e.g.,173) suggest
conversations associated with the trauma
that it is more accurate to think about human
(2) efforts to avoid activities, places, or people that responses to trauma as a spectrum anchored at
arouse recollections of the trauma one end by an acute stress reaction that resolves
on its own without treatment, and on the other by
(3) inability to recall an important aspect of the
trauma what Herman calls “complex posttraumatic stress
disorder,” with “classic or simple” PTSD residing
(4) markedly diminished interest or participation somewhere between the two.81p.119
in significant activities
When the DSM IV10 was being developed, a field
(5) feeling of detachment or estrangement trial was completed to explore whether the
from others construct of complex PTSD, also termed disorders
(6) restricted range of affect (e.g., unable to of extreme stress, not otherwise specified (DESNOS)
have loving feelings) should be included as a diagnosis separate from
78
PTSD. Although many argue that the field trial and dissociative symptoms;
other more recent studies support the legitimacy somatic complaints;
of the DESNOS diagnosis,174 DESNOS was not
included in the DSM IV. However, the categories feelings of ineffectiveness;
of symptoms included in the conceptualization shame, despair, or hopelessness;
of DESNOS were listed under the “Associated and feeling permanently damaged;
Descriptive Features of PTSD.”171
a loss of previously sustained beliefs;
In the most recent version of DSM-IV-TR, the hostility;
authors state that the following constellation
social withdrawal;
of symptoms may be associated with PTSD, and
are generally seen when the stressor involves feeling constantly threatened;
interpersonal trauma such as childhood sexual or impaired relationships with others;
physical abuse or domestic battering:
a change from the individual’s previous
impaired affect modulation; personality characteristics.11p.465
self-destructive and impulsive behaviour;
79
Appendices A to I
APPENDIX E: Sample Introduction to a Facility
Survivors pointed out that they are unfamiliar survivors and clinicians to provide an understandable
with the scope of practice for many health care introduction to an out-patient physical therapy facility.
practitioners and much of what is involved in Health care providers are encouraged to work with
examination and treatment. The following is an patients to develop introductions to their practice and
information sheet for new patients developed by facilities similar to this physical therapy example.
Suggestions for clients at out-patient physical therapy facilities

Welcome to physical therapy! We are glad to work with you. Physical therapy will include an assessment and treatment by
the physical therapist. Direct and open communication between the client and the therapist is important. Below is a list of
suggestions that may help you at physical therapy.
You have the right to choose a male or female physical therapist.
If you know this is important for you, please tell us when you book your first appointment.
If you decide later in treatment that you would rather work with a therapist of a different gender, you may tell
us then too.
If we are unable to book you with your choice of a male or female therapist, we may refer you to a facility that can.
You can choose to have someone accompany you during your physical therapy appointments.
This person can be:
a family member or friend.
a staff member from the clinic.
Physical therapy works best when you and your therapist work as a team.
For example, your physical therapist will explain your treatment to you. Please tell your physical therapist if:
you are not comfortable with the treatment.
you do not understand the treatment or language your therapist is using.
you do not agree with the treatment.
Also, physical therapy works best when you talk to your physical therapist about how the treatment is working (or not
working!) for you. The more you are able to tell your physical therapist, the better he or she will be able to help you.
We will do our best to ensure your privacy.
Your physical therapist may need you to wear a gown for some treatments. If you would prefer to bring loose
fitting clothing from home, please tell your physical therapist.
In some cases it is necessary to change your clothing for your treatment: you will have privacy to change your
clothing.
Please tell us if you would like the curtains drawn around your treatment table during any part of treatment.
Physical therapy involves touch and movement of your body.
Tell your physical therapist if:
certain parts of your body are sensitive to touch or movement.
you are nervous about touch.
there is something your physical therapist can do to make you more comfortable.
You have the right to stop treatment at any time, during or after a session.
Reasons people might stop treatment may include:
discomfort during treatment.
deciding to try a different type of medical care.
If you decide to try a different type of care, your physical therapist may be able to give you the name of someone
she or he thinks can help you.
Above all, we want you to notice an improvement in your health.
80
APPENDIX F: Using Plain Language in Consent
Forms
The following form was created by a survivor easier to understand. Clinicians are urged to work
who revised a “standard” consent form used in with both legal advisors and clients to develop
a physical therapy clinic to illustrate how Plain forms that include all legal requirements but are
Language can be used to create forms that are written in Plain Language.
Consent Form for Examination and Treatment by a Physical Therapist
I am about to be examined and treated by a physical therapist and her/his assistants.
In order for me to be properly examined or treated, I will need to wear shorts and a T-shirt. The physical
therapist will need to observe my body while it is still and while it is moving. It will be necessary for the
therapist to touch and move my body in assessment and treatment. Should I feel uncomfortable about the
assessment and treatment process at any time, I can inform the physical therapist and request that assessment
and/or treatment be stopped. I can have someone else in the room with me; either a friend or relative, or
someone else from the clinic, if available. In the latter case, I can choose the gender of this person.
I will need to tell the physical therapist about my health problems, both past and present. The therapist will
ask my permission to contact my doctor if he or she finds any new problems. I am aware that all information
I disclose and all information that will be charted is confidential.
Physical therapy treatment may involve: __________________(plain language, be specific). Soreness after
treatment is common because joints and muscles are stretched. If I have any other symptoms, I will tell my
physical therapist.
My signature below indicates that I understand all of the above information.
81
Appendices A to I
APPENDIX G: Working with Aboriginal
Individuals, by Dr. Rose Roberts, RN, PhD
A brief history of Aboriginal Peoples bridge, and there are theories arguing that there
were three distinct migrations.50 On the basis of
Abundant literature describes the history of archaeological findings, it appears that, through
the First Nations, Métis and Inuit in Canada. An multiple generations, the first wave of people
abbreviated list of recommended readings is found travelled down the Pacific coast into South
in the bibliography. The purpose here is to provide America. As the glaciers retreated, some headed
an overview as a starting point for health care back up north. The second wave, the Athapascans
practitioners working with First Nations, Métis, and (Dene), stayed in the north, but began to move
Inuit peoples in the area of Sensitive Practice. south following a volcanic eruption. The third
wave, the Inuit, spread eastward through the
Aboriginal Peoples constitute a diverse population
north.50
in Canada. There are several terms that have
been introduced in the literature in an attempt to There have been several attempts to categorize
categorize these populations into one group, such the First Nations people of Canada. Linguistics is
as aboriginal, native, Indian, and indigenous. The one common method, and there are 11 different
Constitution of Canada uses the term Aboriginal to language families: Algonquian, Athapaskan,
include Status and Non-Status Indians, Métis and Eskimo-Aleut, Haida, Tlingit, Siouan, Tsimshian,
Inuit. Status Indians are those whose ancestors Wakashan, Salishan, Kutenai, and Iroquoian.175
signed treaties; Non-Status Indians are those It has been hypothesized that around the time
whose ancestors refused to sign treaties or were of European contact there were between 50 and
absent at the time of the signing. A subpopulation 60 languages, but the most commonly spoken
of Non-Status Indians was also created through languages today are Cree, Ojibway, and Inuktitut.
loss of treaty rights for various reasons such as Many First Nations are diligently working to
serving in the armed forces, voting, obtaining save their languages.175 Another method of
a postsecondary degree, and, for Status Indian categorization is culture areas, and these areas
women, marrying non-Aboriginal men. For the are based on geography and a group of people
most part, members of this subpopulation have sharing similar cultures. These culture areas are:
regained their treaty rights through a revision in Arctic, Western Subarctic, Eastern Subarctic,
the Indian Act in 1984 (Bill C-31). Northeastern Woodlands, Plains, Plateau, and
Northwest Coast.175 It is interesting that these
Our knowledge of the history of indigenous
geographical culture areas closely resemble the
people in Canada prior to the arrival of the
geographical separation according to linguistics.
Europeans is very limited. The majority of
Today there are more than 610 First Nations
information has been gleaned through the
communities in Canada, and the total population,
sciences of archaeology and anthropology. The
living both on and off reserve, is more than
most commonly held theory in the Western world
733,000.13
is that the ancestors of the First Nations came
from Asia over the Bering Strait. Time immemorial, The time following contact with Europeans
a phrase often used by First Nations to describe brought many changes to First Nations peoples
how long they have been here, has been roughly in Canada, including the creation of an entirely
translated to mean between 50,000 and 15,000 different people: the Métis. The Métis were
BC.50 There have been three separate times when primarily the offspring of First Nations women
the Bering Strait could have been used as a land and French men. The term half-breed was more
82
often used to describe children of First Nations provinces and it is estimated that more than
women and Scottish or English men. The Métis 150,000 students attended them. The Assembly
of today define themselves according to the of First Nations estimates that more than 105,000
following definition adopted by the Métis National survivors of residential schools are still alive
Council, the national governmental organization today.14
representing the Métis: “Métis means a person
who self identifies as Métis, is of Historic Métis The premise of the residential schools was
Nation ancestry, is distinct from other Aboriginal assimilation through education, religious
peoples and is accepted by the Métis Nation.”106 indoctrination, and cultural degradation
The “Historic Métis Nation” means the Aboriginal (teaching the children to be ashamed of their
people then known as Métis or Half-Breeds who heritage). Physical, emotional, and sexual
resided in the Historic Métis Nation Homeland, abuses were rampant and living conditions were
the area of land in west central North America often substandard. Former residents say that
used and occupied as the traditional territory they were often hungry and that their parents
of the Métis or Half-Breeds. The Métis National brought them food on their weekend visits;72
Council estimates that there are between 350,000 others report being forced to steal food from the
and 400,000 Métis in Canada.106 kitchens. The education the children received
was also substandard. As late as the 1950s, more
The Inuit are peoples who live in the Arctic regions than 40% of the teaching staff at the schools had
of Canada, Alaska, and Greenland. They have no professional training.1 Cultural degradation
very similar cultural and physical characteristics practices included physical and emotional abuse
despite the wide geographical area in which they for speaking a traditional language, cutting
live. The Inuit have survived in one of the world’s students’ hair (hair has strong cultural and
harshest environments for more than 5,000 spiritual implications), imposing foreign religious
years.90 The areas are mostly coastal, consisting practices, and intentionally separating students
of shallow basins with rivers flowing through from visiting parents.
and many islands covered with permanent
ice and mountain glaciers. The treeless shores The residential school experiences continue
provide no wind protection, temperatures are to have a detrimental impact on Aboriginal
below freezing for eight or nine months of the communities today. These “intergenerational
year, and total precipitation is so slight that the impacts refer to the effects of physical and
area nearly qualifies as desert. According to the sexual abuse that were passed on to the children,
2001 census, there are more than 45,000 Inuit in grandchildren, and great-grandchildren of
Canada, representing about 5% of the Aboriginal Aboriginal people who attended the residential
population.160 They are represented nationally by school system.”2 Some of these effects include:
the Inuit Tapiriit Kanatami. Alcohol and drug abuse;
Past and ongoing physical, emotional, and
The residential school legacy
sexual abuse;
Between 1892 and 1969, approximately 135 Low self-esteem;
residential schools were established to meet Dysfunctional families and interpersonal
the treaty right to education.1 Although First relationships;
Nations leaders wanted schools built on the
reserves, the federal government decided that Parenting issues;
residential schools would be cheaper and entered Suicide;
agreements with the Roman Catholic Church, the Teen pregnancy.
Church of England, the Methodist Church, and the
Presbyterian Church to operate the schools. The The Aboriginal Healing Foundation (AHF) was
vast majority of these schools were in the western established in 1998 in response to the Royal
83
Appendices A to I
Commission on Aboriginal Peoples. The AHF’s Health care systems
mandate is to fund and support Aboriginal healing
initiatives. As of November 2005, the federal Health care is not a provision specifically addressed
government had committed $378 million to 1,346 in the treaties between Canada and First Nations
community-based grants and has pledged another and Inuit. The only direct mention of health care
$125 million over the next five years. The AHF can be found in Treaty 6 which was signed in the
has received more than $1.3 billion in funding mid-prairies of Saskatchewan and Alberta in 1876
proposals and estimates that $600 million is and reads, “That a medicine chest shall be kept
required over the next 30 years to fully address the at the house of each Indian Agent for the use and
residential school legacy. For more information, benefit of the Indians at the direction of such
interested readers are encouraged to visit the agent.”39 Subsequent court proceedings involving
AHF website (www.ahf.ca). The Indian Residential Treaty 6 have ruled that at the time the treaties
School Survivors’ Society is another organization were signed, the Chiefs were looking for the best
that offers resources to survivors as well as those possible agreement for their members, and within
that work within the healing field (www.irsss.ca). that understanding, the clause could mean the
Among other services, it provides a national 24- provision of any and all services necessary for
hour toll-free crisis line (1-866-925-4419). continued health for First Nations.112 The intent of
the medicine chest clause has been applied to all
With respect to Sensitive Practice, health care First Nations and Inuit peoples.
practitioners working with Aboriginal clients
should be aware of the following personality The federal government provides comprehensive
characteristics that may indicate past residential health care services to First Nations and the Inuit
school trauma: (a) unconscious internalization through the First Nations and Inuit Health Branch
of residential school behaviours (e.g., false (FNIHB). FNIHB provides direct care to on-reserve
politeness, not speaking out, passive compliance, populations and reimburses the provincial and
excessive neatness, or obedience without thought); other health care agencies for services provided
(b) flashbacks and associative trauma (e.g., certain to off-reserve populations. There has been a
smells, foods, sounds, sights, and people trigger recent shift in responsibility as First Nations are
flashbacks and memories, anxiety attacks, physical reclaiming some aspects of self-government.
symptoms, or fear); (c) internalized sense of Health transfer payments to individual First
inferiority or aversion in relation to white people Nations or Tribal Councils has allowed First
and especially white people in power.2 Nations to administer the funding and given
them the freedom to determine their own health
Health care practitioners are strongly encouraged needs and plan their programs accordingly.
to approach individuals of Aboriginal heritage Non-Status and Métis people are left out of these
with respect and openness, allowing more time arrangements and receive their health care within
than usual for introductions and the development the provincial or territorial health system.
of a trusting relationship. The Sensitive Practice
protocols presented in this Handbook are Aboriginal health beliefs
appropriate to use when working with Aboriginal
clients, especially when they are accompanied by The most common health model found in the
concerted efforts to increase one’s awareness and literature and the oral tradition of Aboriginal
understanding of Aboriginal cultures. peoples is the medicine wheel model (see Figure
2). Actual medicine wheels are circular stone
formations found in all parts of North America.
Recommended Readings and Resources –
The term medicine wheel has been borrowed from
Aboriginal Peoples: Readings (especially the policy
these stone structures and applied to the theory
statements by Dr. Janet Smylie)
of health and other areas of Aboriginal traditions.
The medicine wheel is a circle, which means there
84
is no end and no beginning. The same could be no distinction such as the separation between
said for one’s health status. The four areas of the mind and body that is often found in Western
wheel are intellectual, emotional, spiritual, and health paradigms. Specific programs have been
physical. Some Aboriginal people believe that all developed in many Aboriginal communities
four areas have to be in balance if one is to be and organizations using the medicine wheel as
in an optimum state of health; in other words, the framework. An Internet search of the term
if any of the four areas are out of balance, then medicine wheel reveals the diverse situations and
the individual becomes ill. All four areas are disease entities to which this framework has been
also connected and interrelated, so that there is applied.
FIGURE 2
Medicine Wheel
Physical Spiritual
Intellectual Emotional
85
Appendices A to I
APPENDIX H: A Note about Dissociative
Idenity Disorder
Dissociative Identity Disorder (DID) – which was Researchers believe that DID is almost always
previously called Multiple Personality Disorder – is associated with a history of severe child abuse69
a psychiatric condition which requires specialized and requires very specialized treatment by
training to diagnose correctly. The DSM-IV-TR a multidisciplinary team. If a health care
criteria for DID include “the presence of two practitioner encounters a person who has been
or more distinct identities or personality states diagnosed with DID and is not already receiving
(each with its own relatively enduring pattern of treatment from a mental health team, a referral to
perceiving, relating to, and thinking about the and collaboration with such a specialized service
environment and self).”11p.529 is essential.
86
APPENDIX I: The Evidence Debate Pertaining to
Inquiry about Interpersonal Violence
While the empirical evidence is clear about the of symptoms, specificity, sensitivity, positive
high prevalence of childhood sexual abuse and predictive value, negative predictive value, etc.).
links between childhood adversity and adult Those who oppose universal screening point
health problems, it is less clear about whether to the “absence of any high quality evidence
health care practitioners should routinely assess of the benefit and a similar lack of evidence
for current and past abuse/violence (usually that screening does not harm.”181p.163 Those
including intimate partner (or domestic) violence who support routinely inquiring about violence
and childhood abuse). Three recent systematic point out that such inquiry does not equate
reviews from the United States,115 Britain,123 and to screening but rather, represents “asking
Canada179 concluded that there is insufficient questions about domestic violence during a
evidence to recommend routine screening health care contact.”181p.163 The SOGC reiterates
for family and/or intimate partner violence. this in its consensus statement on intimate
In contrast, the Intimate Partner Violence partner violence screening:
Working Group of the Society of Obstetricians
and Gynaecologists of Canada (SOGC)153 and the Asking women about violence is not a screening
Registered Nurses of Ontario128 both issued clinical intervention [emphasis added]: victims are not
practice guidelines endorsing routine assessment asymptomatic; disclosure is not a test result,
for intimate partner violence/woman abuse as it is a voluntary act, and the presence or
standard practice. Furthermore, existing practice absence of violence is not under the victims’
guidelines and recommendations for management control; and most interventions required to
of a number of conditions also call for an protect and support survivors are societal, not
assessment of abuse history (e.g.,6,7, 8,12). medical.153p.366
Because the three systematic reviews looked
Section 2.5 – Childhood sexual abuse and health only at those studies that met the criteria for
“screening,” they considered only a small portion
This debate is pertinent to any discussion of of the existing intimate partner violence research.
making inquiries about a history of child sexual For example, of the 806 abstracts that related
abuse. Exposure to childhood violence or abuse to screening for intimate partner violence,
increases an individual’s risk for intimate partner only 14 met the inclusion criteria that Nelson
violence in adulthood (e.g.,17). Because the two and colleagues115 used; similarly, only two of
co-occur with some frequency, childhood abuse/ the 667 abstracts on intimate partner violence
violence and intimate partner violence may not be intervention studies were considered.57 This led
categorically discrete entities. This means that if the Family Violence Prevention Fund’s Research
an individual discloses intimate partner violence, Committee to conclude:
there is also the possibility of past childhood
abuse/violence. As a consequence of this overly narrow
approach to what the most relevant research
Considerable expert opinion (including57,153,181) questions are, an important body of studies
disagrees with the findings of the systematic related to IPV [intimate partner violence] was
reviews cited above. Much of this disagreement not considered. The outcomes most closely
centres around the distinction between inquiring focused on are harm, death, and disability. In
about violence and screening (which by definition contrast, most researchers in the field would
must meet strict requirements related to lack expect that measurable benefits (desirable
87
Appendices A to I
outcomes) would include improved health We believe that the research on which this
and safety of the patient and their children, Handbook is based further supports the argument
enhanced protective factors, and decreased that routinely inquiring about a history of past
frequency and severity of physical and/or abuse is not harmful to individuals and, if done in
emotional abuse.57p.2-3 a sensitive and informed manner, is likely to lead
to improved health for all patients.
88
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Recommended Reading and Resources
Childhood sexual abuse and trauma: Readings
Dorais, Michel. 2002. Don’t tell: The sexual abuse of boys. Montreal: McGill-Queen’s University Press.
Everett, B. & Gallop, R. (2001). The link between childhood trauma and mental illness: Effective
interventions for mental health professionals. Thousand Oaks: Sage Publications.
Herman, J. (1992). Trauma and recovery. New York: Basic Books.
Hulme, P.A. (2004). Theoretical perspectives on the health problems of adults who experienced childhood
sexual abuse. Issues in Mental Health Nursing, 25, 339-361.
Lew, M. (2004). Victims no longer: The classic guide for men recovering from sexual child abuse. Harper
Collins Publishers: New York.
Rosenbloom, D. & Williams, M.B. (1999). Life after trauma: A workbook for healing. New York: Guilford.
Rothschild, B. (2000). The body remembers: The psychophysiology of trauma and trauma treatment. New
York: Norton.
Saakvitne, K.W., Gamble, S., Pearlman, L.A. & Tabor Lev, B. (2000). Risking connection: A training
curriculum for working with survivors of childhood abuse. Lutherville, MD: The Sidran Press.
van der Kolk, B. A., McFarlane. A., & Weisaeth, L. (Eds.). (1996). Traumatic stress: The effects of
overwhelming experience on mind, body, and society. New York: Guilford Press.
van der Kolk, B.A. (1998). The psychology and psychobiology of developmental trauma. In: Stoudemire, A. (Ed)
Human Behaviour: An Introduction for Medical Students. (pp. 383-399). Philadelphia: Lippincott-Raven.
van der Kolk, B.A. (2003). The neurobiology of childhood trauma and abuse. Child and Adolescent
Psychiatric Clinics, 12, 293-317.
Pain: Readings
Gatchel, R.J., Peng, Y.B., Peters, M.L., Fuchs, P.N., & Turk, D.C. (2007). The biopsychosocial approach to
chronic pain: Scientific advances and future directions. Psychological Bulletin, 133, 581-624.
Mailis-Gagnon, A., & Israelson, D. (2003). Beyond pain: Making the mind-body connection. Ann Arbor, MI:
University of Michigan Press.
Radomsky N. (1995). Lost Voices: Women, Chronic Pain and Abuse. New York: Haworth Press.
Childhood sexual abuse and trauma: Websites

National Clearinghouse on Family Violence has many resources available free of charge. Toll free
telephone 1-800 267-1291; (613) 957-2938; Fax (613) 941-8930; http://www.phac-aspc.gc.ca/nc-cn
Canadian Association of Sexual Assault Centres is a pan Canadian organization of sexual assault centres in
Canada. Their website has contact information and links for sexual assault centres across Canada.
http://www.casac.ca/english/home.htm
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Tamara’s House, a residential treatment centre for women survivors of childhood sexual abuse
(Saskatoon, Saskatchewan) http://www.tamarashouse.sk.ca/
British Columbia Society for Male Survivors of Sexual Abuse (Vancouver, BC) http://www.bc-malesurvivors.
com/html/mission_purpose.htm
Men’s Resource Centre (Winnipeg, Manitoba) http://www.elizabethhill.ca/mrc.html
The Men’s Project (Ottawa/Cornwall Ontario) http://themensproject.ca
Ritual abuse: Readings

Clay, Colin. (1996). More than a survivor: Memories of satanic ritual abuse and the paths which lead to
healing. Saskatoon, SK: Author.
Oksana, Christine. (1994). Safe passage to healing: A guide for Survivors of ritual abuse. New York: Harper
Perennial.
Smith, Margaret. (1993). Ritual Abuse: What it is: Why it happens: How to help. New York: Harper Collins
Sexual abuse in sport: Readings

Brackenridge, C.H. (1994). Fair play or fair game: Child sexual abuse in sport organisations. International
Review for the Sociology of Sport, 29(3), 287-299.
Brackenridge, C.H. (1997). “He owned me basically”: Women’s experience of sexual abuse in sport.
International Review for the Sociology of Sport, 32(2), 115-130.
Brackenridge, C.H. (2000). Harassment, Sexual Abuse, and Safety of the Female Athlete. Clinics in Sports
Medicine, 19(2), 187-198.
Brackenridge, C.H., & Kirby, S. (1997). Playing safe? Assessing the risk of sexual abuse to young elite
athletes. International Review for the Sociology of Sport, 32(4), 407-418.
Kirby, S., & Wintrup, G. (2002). Running the gauntlet in sport: An examination of initiation/hazing and
sexual abuse. Journal of Sexual Aggression, Special Issue on Sexual Harassment and Abuse in Sport, 8.
Kirby, S., Greaves, L., & Hankivsky, O. (2000). The dome of silence. Sexual harassment and abuse in sport.
Halifax, NS: Fernwood Publishing.
Critical cultural perspective: Readings

Gustafson, D.L. (2005). Transcultural nursing theory from a critical cultural perspective. Advances in
Nursing Science, 28(1), 2-16.
Gustafson, D.L. (2007). White on whiteness: Becoming radicalized about race. Nursing Inquiry, 14(2), 153-161.
Gustafson D.L. (Accepted). Beyond sensitivity and tolerance: Theoretical approaches to caring for newcomer
women with mental health problems. In S. Guruge & E Collins (Eds.). Working with women and girls in
the context of migration and settlement. Toronto, ON: Centre for Addiction & Mental Health.
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immigrant Muslim women in St. John’s, Canada. Maternal and Child Health Journal.
Swendson, C. & Windsor, C. (1996). Rethinking cultural sensitivity. Nursing Inquiry, 3(1), 3-10.
Aboriginal Peoples: Readings

Adams, H. (1995). A tortured people: The politics of colonization. Penticton, BC: Theytus Books.
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Smylie, J. (2001). Guide for health professionals working with Aboriginal peoples. Health issues affecting
Aboriginal peoples. SOGC Policy Statement No. 100. Retrieved June 7, 2006, from http://www.sogc.
org/guidelines/pdf/ps100%5F2.pdf
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epidemiological perspectives. Toronto, ON: University of Toronto Press.
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University of Toronto Press.
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programs: A review of literature since the 1970s. Canadian Circumpolar Institute, Northern Reference
Series No. 2. Edmonton, AB: University of Alberta.
Young, T.K. (1988). Health Care and Cultural Change: The Indian Experience in the Central Subarctic.
Toronto, ON: University of Toronto Press.
Aboriginal Peoples: Websites

Assembly of First Nations: http://www.afn.ca/
First Nations & Inuit Health Branch website: http://www.hc-sc.gc.ca/fnih-spni/index_e.html
Métis National Council: http://www.metisnation.ca/
Aboriginal Healing Foundation: http://www.ahf.ca/
Plain Language: Readings

Human Resources and Social Development Canada. http://www.hrsdc.gc.ca/en/hip/lld/nls/Resources/
plainws.shtml
Plain language.gov. Plain language guidelines and manuals. http://www.plainlanguage.gov/howto/
guidelines/index.cfm
Plain Language: Websites

NIH plain language training. http://plainlanguage.nih.gov/CBTs/PlainLanguage/login.asp
The Plain Language Association International. http://www.plainlanguagenetwork.org/
Pregnancy, labour, and postpartum

Hobbins, D. (2004). Survivors of childhood sexual abuse: Implications for perinatal nursing care. Journal
of Obstetric, Gynecologic, and Neonatal Nursing, 33(4), 485-97.
Jacobs, J. L. (1992). Child sexual abuse victimization and later sequelae during pregnancy and childbirth.
Journal of Child Sexual Abuse, 1(1), 103-112.
Kendall-Tackett, K. (1998). Literature review. Breastfeeding and the sexual abuse survivor. Journal of
Human Lactation, 14(2), 125-33.
Rhodes, N., & Hutchinson, S. (1994). Labor experiences of childhood sexual abuse survivors. Birth, 21(4), 213-20.
103
Bibliography
Rose, A. (1992). Effects of childhood sexual abuse on childbirth: One woman’s story. Birth, 19(4), 214-8.
Seng, J.S., Sparbel, K.J.H., Low, L.K., & Killion, C. (2002). Abuse-related posttraumatic stress and desired
maternity care practices: Women’s perspectives. Journal of Midwifery & Women’s Health, 47(5), 360-70.
Simkin, P and Klaus, P. (2004). When survivors give birth: Understanding and healing the effects of early
sexual abuse on the childbearing woman. Seattle, WA: Woman Classic Day Publishing.
Waymire, V. (1997). A triggering time: Childbirth may recall sexual abuse memories. AWHONN Lifelines, 1(2), 47-50.
The therapeutic relationship, boundaries, and managing challenging situations: Readings

College of Physiotherapists of Ontario. (2007). Guide to standard for managing challenging situations when
providing patient care. Retrieved November 7, from http://www.collegept.org
College of Physical Therapists of Alberta. (2007). Managing challenging situations. A resource guide for
physical therapists. Retrieved November 7, 2007, from http://www.cpta.ab.ca
College of Physiotherapists of Ontario. (2005). Guide to the standard for establishing and maintaining
therapeutic relationships. Retrieved November 7, 2007, from http://www.collegept.org
College of Nurses of Ontario. (2006). Practice standard. Therapeutic nurse-client relationship, Revised 2006.
Retrieved November 7, 2007, from http://www.cno.org
Nurses Association of New Brunswick. (2000). Standard for the therapeutic nurse-client relationship.
Retrieved November 7, 2007, from http://www.nanb.nb.ca/index.cfm
College of Registered Nurses of Nova Scotia. (2002). Professional boundaries and expectations for nurse-
client relationships. Retrieved November 7, 2007, from http://www.crnns.ca
Screening tools
Roy, C.A., & Perry, J.C. (2004). Instruments for the assessment of childhood trauma in adults. Journal of
Nervous & Mental Disorder, 192(5), 343-51.
Thombs, B.D., Bernstein, D.P., Ziegelstein, R.C., Scher, C.D., Forde, D.R., Walker, E.A., et al. (2006). An
evaluation of screening questions for childhood abuse in 2 community samples: Implications for
clinical practice. Archives of Internal Medicine, 166(18), 2020-6.
Thombs, B.D., Bernstein, D.P., Ziegelstein, R.C., Bennett, W., & Walker, E.A. (2007). A brief two-item screener
for detecting a history of physical or sexual abuse in childhood. General Hospital Psychiatry, 29, 8-13
104
Index
Aboriginal individuals, working with, 82 Legal obligations, 68

Acute stress disorder, 77 Possible indicators of past abuse, 58
Adherence/non-adherence to treatment, 49 Responding effectively, 63
Administrative staff and assistants, 25 Additional actions required, 65
Agitation, 56 Responses to avoid, 67
Anger, 56 Disconnection from the body, 48
Appointment cancellations, 50 Disorders of extreme stress not otherwise specified, 78
Body position, 41 Dissociation, 13, 52, 86
Boundaries, 21 Dissociative identity disorder, 86
Care within the correctional system, 46 Empirical Basis of the Handbook, 72
Chaperone, 27 Environment, physical
Childhood sexual abuse Other issues, 26
And health, 6 Privacy, 26
Definition, 5 Waiting and waiting areas, 25
Dynamics of, 6 Examinations
Perpetrators of, 6 After, 46
Prevalence, 74 General suggestions, 36
Survivors of, 5 Pelvic, breast, genital and rectal, 40
Traumagenic dynamics, 75 Flashbacks. See Triggers
Clinicians’ contributions to survivors’ healing, 71 Gender socialization, women, 9
Clothing, 32 Gender socialization, men, 10
Collaborative service delivery, 29 Guidelines of Sensitive Practice
Community resources, 31 Summary, 108
Control, 20 Health care records, 69
Counter-transference, 12 Documenting a history of abuse, 69
Diagnostic criteria for stress disorders, 77 Informed consent, 38, 81
Disclosure, 57 Introductions and negotiating roles, 32
Challenges for survivors, 57 Legal obligations and record-keeping issues, 68
Components of an effective response, 67 Limitations of the Handbook, 4
Documenting a history of abuse, 69 Oral and facial health care, 43
Health care records, 69 Patient-centred care and Sensitive Practice, 71
Inquiring about interpersonal violence, 59, 87 Physical pain, 14, 48
Verbal inquiry, 62 Possible indicators of past abuse, 59
Written inquiry, 62 Posttraumatic stress disorder, 77
105
Index
Pregnancy, labour and delivery, postpartum, 42 Self-care for practitioners, 30
Principles of Sensitive Practice Practitioners who are survivors, 30
Avoiding retramatization, 23 Self-harm, 15
Demonstrating awareness and knowledge of Sharing information, 19, 26
interpersonal violence, 23 Societal myths about the cycle of violence, 11
Fostering feelings of safety, 17 Specific behaviours and feelings arising during health
Fostering mutual learning, 22 care encounters
Rapport, 19 Ambivalence about the body, 14
Respect, 17 Conditioning to be passive, 15
Respecting boundaries, 21 Discomfort with persons who are the same gender
Sharing Control, 20 as the abuser, 13
Sharing Information, 19 Dissociation, 13
Summary, 107 Distrust of authority figues, 12
Taking Time, 18 Fear and anxiety, 13
Understanding nonlinear healing, 22 Physical pain, 14
Proximity of practitioner, 41 Self-harm, 15
Questions about sexuality and sexual orientation, 15 Triggers, 13, 52
Rapport, 19 Support persons, 27
Reflective practice, questions, 24, 46, 70 Task-specific inquiry, 33
Residential school legacy, 83 Terminology, 3
Responding to difficult interactions with patients, 51 Third party observer, 27
Responses to avoid after a disclosure, 67 Time, 18, 37

Retraumatization, 23 Touch, 39
S A V E the situation, 51 Transference, 12
Safety, 17 Triggers, 13, 52
Umbrella of, 18 Varying tolerance to treatment, 22
Sample Introduction to a Facility, 80 Working with survivors from diverse cultural groups, 28
106
Sensitive Practice At-a-Glance
The goal of Sensitive Practice is to foster a sense to all patients. By adopting the principles of
of safety for patients. Although the principles Sensitive Practice as the standard of care, health
and guidelines articulated in this Handbook and care providers convey respect, support clients’
outlined in Tables 7 and 8 are based on studies autonomy and right to participate in healthcare,
with Canadian men and women with histories and decrease the likelihood of inadvertently
of childhood sexual abuse, they represent a retraumatizing the survivors of abuse with whom
basic approach to care that should be extended they work knowingly or unknowingly.
TABLE 7
Summary of principles of Sensitive Practice
Respect Acknowledging the inherent value of clients as individuals with unique beliefs,
values, needs, and histories means upholding and defending their basic human
rights and suspending judgment of them.
Taking time Taking adequate time with patients ensures that they do not feel depersonalized
or objectified.
Rapport Developing and maintaining an interpersonal style that is professional, yet
conveys genuine caring, promotes trust and a sense of safety.
Sharing information Informing patients of what to expect on an going basis and inviting them to ask
questions and offer information and feedback helps reduce anxiety and promotes
active engagement in their health care.
Sharing control Seeking consent and offering choices enables the clinician to work with rather
than on patients, and ensures that patients become full active participants in
their own health care.
Respecting boundaries Paying ongoing attention to boundaries and addressing difficulties that arise
reinforces patients’ right to personal autonomy.
Fostering mutual learning Fostering an environment in which information sharing is a two-way process
encourages survivors to learn about their health and how to become active
participants in their own health care. It also assists clinicians to learn how best to
work with individuals who have experienced interpersonal violence.
Understanding nonlinear Checking in with patients throughout each encounter and over time, and being
healing willing to adjust their actions accordingly, enables caregivers to meet the needs
of individuals whose ability to tolerate health care examinations and procedures
vary over time.
Demonstrating awareness Showing that they are aware of interpersonal violence helps professionals foster
and knowledge a sense of trustworthiness and promotes an atmosphere in which patients are
willing to work alongside their health care providers.
107
TABLE 8
Summary of guidelines of Sensitive Practice
Context of encounters
Administrative Train all personnel about Sensitive Practice
staff and Work with staff and assistants to establish a few “routine responses” that are survivor-
assistants friendly
Waiting areas Keep patient informed of length of wait or invite patient to check intermittently
Provide printed materials related to interpersonal trauma
Provide and clearly identify washrooms
Privacy Knock and wait for acknowledgement before entering
Have at least one soundproof examination or interview room
Problem-solve with patients to meet their needs for privacy and safety
Preparation of Provide introductory information in plain language, both written and verbal
clients Negotiate with patient to identify needs and workable solutions
Encourage presence of support person or chaperone; agree upon roles for all parties
Encounters with patients
Introductions Discuss and negotiate roles for patient and clinician prior to all examinations or
treatments
Allow enough time to help individuals understand fully what you are doing
Do not assume the patient knows what is involved in an exam, treatment, or procedure
Seek consent in an ongoing way throughout the encounter
Clothing Meet patient fully clothed before and after
Explain why removal of clothing is necessary
Discuss clothing requirements with patients and collaborate with them to find an
agreeable solution
Minimize amount of clothing being removed and length of time patient must be disrobed
Provide gowns in a wide variety of sizes for all body types
Leave the room while the patient is changing
Task-specific Inquire about patient’s past experiences, preferences, difficulties with the exam/
inquiry procedure
Inquire about how to increase the person’s comfort
Inquire about whether the patient thinks there is anything else that the clinician should
know about
Repeat inquiry intermittently over time, and if body language suggests discomfort
General approach Use task-specific inquiry to identify difficulties; problem-solve together to increase
comfort
Monitor body language and follow up on signs of distress
Explain why positions for patient and clinician are necessary
Touch Describe what is involved before and during the exam or treatment
Seek consent before beginning and when shifting from one part of the body to another
Encourage individuals to ask you to pause, slow down, or stop the examination or
treatment at any time to lessen their discomfort or anxiety
When a presenting problem necessitates examination of areas of the body other than the
site of the symptoms, explain the rationale
Genital, rectal Acknowledge discomfort
exams and Offer a running commentary about what you are doing
procedures Minimize time the patient must remain in a subordinate position
Drape parts of the body not being examined
108
Oral and facial Agree on hand signals so that the patient can give instant feedback when verbal
health care communication is not possible
Problem-solve with the patient around difficulties with smell/feel of gloves, dental dam,
body position, other task-specific difficulties
Ensure that your comments to the patients about their oral health and behaviour during
the appointment are offered in a nonjudgmental way
Keep the length of appointments as short as possible; consider doing longer procedures
over two or more appointments
Challenges in encounters
Pain & Assess pain in systematic, nonjudgmental manner
disconnection Work with client to set realistic goals and determine appropriate referrals
from body Repeatedly invite individuals to focus on their bodies
Provide clear verbal and written instructions that the patient understands
Suggest a range of strategies to increase self-awareness
Non-adherence to Explore all types of barriers with the patient and problem solve to identify workable
treatment solutions
Adapt treatment to fit patient
Create a “same-day” appointment for patients who frequently cancel appointments
whenever possible
SAVE the situation Stop what you are doing and focus fully on the present situation
Appreciate and understand the person’s situation
Validate the person’s experience
Explore the next steps with the patient
Triggers and Examine list of common triggers and consider what can be avoided/accommodated
dissociation Become familiar with signs of a ‘fight or flight’ response
Work with patients who have been triggered to ground and reorient them
Normalize the experience
Ensure adequate follow-up
Anger and Pay attention to personal safety
agitation Adopt non-threatening body language
Negotiate and assure patients of your interest and concern
Disclosure
Responding Upon hearing a disclosure of past abuse:
effectively Accept the information
Express empathy and caring
Clarify confidentiality
Normalize the experience by acknowledging the prevalence of abuse
Validate the disclosure and offer reassurance to counter feelings of vulnerability
Address time limitations
Collaborate with the survivor to develop an immediate plan for self care
Recognize that action is not always required
Ask whether it is a first disclosure
At the time of disclosure or in a future interaction:
Discuss the implications of the abuse history for future health care and interactions with
clinician
Inquire about social support around abuse issues
109

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Handbook on Sensitive

Practice for Health Care

This publication may be provided in alternate formats upon request.

For further information on family violence issues please contact:

Telephone: 1-800-267-1291 or (613) 957-2938

Researched and Written by...

Candice L. Schachter, DPT, PhD

Carol A. Stalker, PhD, RSW

Eli Teram, PhD

Gerri C. Lasiuk, RN, PhD

Alanna Danilkewich, MD, FCFP

Acknowledgments ................................................................................................................ vii

– A male survivor of childhood sexual abuse –

2.1 Definitions on an unwilling human victim, committed by

In females, a history of childhood sexual abuse or a range of childhood traumas including

3.1 Gender socialization: A female abuse survivor may also be mistrustful

Helping any client prepare The presence of a support

Restraint or entrapment in bed by

Section 6.3 – Task-specific inquiry 6.13 After any physical

Survivors may or may not be aware of their Pallor or flushing;

After hearing a disclosure of past abuse, the clinician should:

9.1 Clinicians’ contributions perspective. While the Handbook includes

9.2 Sensitive Practice and So, what we have is a relationship of ...

Characteristic Dynamics Possible Manifestations

Acute Stress Disorder (ASD) D. Marked avoidance of stimuli that arouse

(2) recurrent distressing dreams of the event. (4) hypervigilance

C. Persistent avoidance of stimuli associated Disorders of Extreme Stress not Otherwise

Suggestions for clients at out-patient physical therapy facilities

Consent Form for Examination and Treatment by a Physical Therapist

I am about to be examined and treated by a physical therapist and her/his assistants.

My signature below indicates that I understand all of the above information.

Childhood sexual abuse and trauma: Websites

Ritual abuse: Readings

Sexual abuse in sport: Readings

Critical cultural perspective: Readings

Aboriginal Peoples: Readings

Aboriginal Peoples: Websites

Plain Language: Readings

Plain Language: Websites

Pregnancy, labour, and postpartum

The therapeutic relationship, boundaries, and managing challenging situations: Readings

Aboriginal individuals, working with, 82 Legal obligations, 68

Sharing Information, 19 Dissociation, 13

Summary, 107 Distrust of authority figues, 12

Taking Time, 18 Fear and anxiety, 13

Understanding nonlinear healing, 22 Physical pain, 14

Proximity of practitioner, 41 Self-harm, 15

Questions about sexuality and sexual orientation, 15 Triggers, 13, 52

Rapport, 19 Support persons, 27

Reflective practice, questions, 24, 46, 70 Task-specific inquiry, 33

Residential school legacy, 83 Terminology, 3

Responding to difficult interactions with patients, 51 Third party observer, 27

Responses to avoid after a disclosure, 67 Time, 18, 37

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