A doctor-patient relationship based on trust and effective communication is key to successfully managing the physical and mental health of my clients. Obtaining a thorough health history, narrowing down the possible diagnoses, ordering the correct test, stressing compliance with treatment regimens, and emphasis on follow up are routine. Connecting with patients of different ages, races, and walks of life every day however can be challenging. Not only do I enjoy this challenge, but I believe it improves patient compliance and ultimately health outcomes. That's why I knew that on one particular office visit my patient Carla, a 37 year old African American female, was not herself that day. Our exchange of pleasantries did not seem the same, so I simply asked "What's wrong? You seem different." Tears began to flow and the conversation took a tortuous turn that I never saw coming. She was not sleeping well, her job performance was deteriorating, and she was having issues with her boyfriend. Six months previously at her annual physical she was excited about the future and as happy as a clam- new job, new boyfriend, losing weight, exercising regularly and in good health. But she admitted to have been hiding something since childhood which all came out after attending a family reunion. My patient saw the man who raped her from age eight until thirteen. It was her uncle and she had never shared this with anyone until our visit that day.
A sexual assault occurs once every 6.4 minutes in the United States. One out of every six American women has been the victim of an attempted or completed rape in her lifetime and among all victims, about nine out of ten are female. A woman is four times more likely to be assaulted by someone she knows and a significant number of these crimes go unreported. Almost 2/3 of sexual assaults are committed by someone known to the victim. Victims of sexual assault are three times more likely to suffer from depression; six times more likely to suffer from post-traumatic stress disorder; thirteen more times more likely to abuse alcohol; twenty-six more times to abuse drugs; and four times more likely to contemplate suicide. Disclosure of sexual abuse in many situations is often delayed. Children avoid reporting the assault because they are either afraid of a negative reaction from their parents and family or of being threatened or injured by the abuser. They will often delay disclosure until adulthood which was the case with my patient. I asked Carla why she waited so long to tell someone and the answer was not atypical- "I was afraid and I did not want him to get in trouble."
That statement continues to haunt me. She was obviously still scared and very nervous but still wanted to protect her uncle. "Twenty-four years later and it feels like it just happened yesterday", she said. There are many reasons for not reporting sexual assault which include self-blame or guilt; shame or embarrassment; a desire to keep the assault private; humiliation; fear of the perpetrator; fear of others' perceptions; fear of not being believed; fear of being accused of playing a part in the crime; and lack of trust in the criminal justice system.And although there has been some debate about who and when to screen for sexual assault, many physicians believe that because of the lack of reporting, screening for sexual assault in the primary care setting should be routine. I'm a father, brother, son, and soon to be husband and the thought of someone sexually assaulting my loved one is unimaginable. Sexual assault is a tragedy with the potential for long-term medical, psychological, and emotional consequences. Victims of sexual assault who feel that their physician and staff are genuinely concerned and kind in their delivery of care are far more likely to return for follow-up visits, seek counseling as well as treatment. Survivors of sexual assault have the right to medical treatment, to be treated humanely, and the right to report the assault to police. As family physicians, we can stand tall for social change and make a difference by including sexual assault in our history taking of patients who present to our practices; by preparing and familiarizing ourselves with the management of rape victims; knowing the laws that govern the state in which we practice; encouraging victims to report sexual assault; and by knowing available resources to help victims cope with consequences of rape including physical injury, mental health, pregnancy, and sexually transmitted diseases/HIV.
My patient is doing quite well after seeking counseling and discussing the sexual assault with her family. She did however defer any legal action against her uncle. After some research she discovered that he too was a victim of sexual assault as a child, and although she battles with this daily, she wanted to leave that situation in the past. But there is light at the end of this tunnel. I want the men in our society to understand that they can no longer be silent about sexual violence. The women in our society can no longer put off seeking help in a time of need. Until we all understand how common sexual violence is no one will take the issue seriously. I don't understand what these women go through and I could never walk a day in their shoes, but I can raise awareness and speak out loud about attitudes and behaviors that degrade women and promote abuse. ThisOctober on one special night I will stand in high heel shoes with other men from my local community to help raise awareness about sexual trauma/rape. I encourage physicians and other community leaders to find ways to raise awareness as well. I'm a Hunk in Heels! Stand tall with me!