Patients are often nervous before going under anesthesia, so we put them at ease by chatting with them as they fall asleep. Usually the conversation centers around what beach vacation they will imagine as they nod off or what meal they look forward to once surgery is over. Typically, this prompts talk of Hawaii or double cheeseburgers, but Caroline* was different.
"I was raped. I was just a child. It was someone I trusted. But no one believed me."
The operating room fell silent as Caroline's words settled over us. We reassured her that she was safe, she agreed to proceed with surgery, and within minutes she was asleep.
As a gynecologic surgeon and women's health practitioner, it's not uncommon for patients to disclose a personal history of sexual abuse and assault during clinic visits when detailed histories are reviewed. However, this was the first time such a disclosure was made, unprompted, just minutes before undergoing a major surgery.
Caroline was having her uterus removed due to chronic pelvic pain that had affected her quality of life for years. The surgery was routine and went smoothly, but we grew more concerned about Caroline's words. There are likely many reasons for her surprising disclosure. For some women, removing the reproductive organs elicits fears about sexuality; for others, the disinhibition with anesthetic medications parallels the feeling of loss of control that occurred during prior traumatic events. For some, the vulnerability of being physically exposed on the operating table can be triggering.
However, there may be other explanations for why Caroline and women like her confide in us, and why these traumas might be shared with us in an unexpected manner. Some of these explanations are rooted far outside of the operating room. In the current climate, our country has a heightened sociopolitical consciousness regarding sexual abuse. The #MeToo movement has gained momentum and is at the forefront of news and social media channels. In the midst of abundant media coverage of the recent Senate hearings for the Supreme Court nominee, many women are reliving painful memories of their own experiences of sexual violence, and grappling with the complex feelings around when and how to report abuse and worries about being believed. Perhaps these are questions that had been weighing on Caroline's mind in the days before surgery.
Our nation's health protection agency, the Centers for Disease Control and Prevention (CDC), has an ongoing study of intimate partner violence, sexual violence, and stalking titled the National Intimate Partner and Sexual Violence Survey (NISVS). The most recent data from the NISVS shows that nearly one in three women have been a victim of sexual violence at some point in their lives; among these women, nearly 23 million reported rape or attempted rape as the specific act of sexual violence. Many of these instances occurred at very young ages with nearly 8.5 million women experiencing rape prior to the age of 18. These figures are shocking and disheartening.
Particularly pertinent to women's healthcare providers is that victims of sexual violence may present to our clinic with unexpected medical complaints. Nearly 15 percent of women are affected by a condition called chronic pelvic pain that includes severe menstrual cramping, pain during intercourse, and unprovoked chronic pain. Almost half of the patients with chronic pain report a history of sexual abuse. There is a nearly 1.6-fold increase in the risk of developing chronic pelvic pain if a person has experienced any instance of sexual abuse when compared to those who have not. This statistic further suggests that sexual abuse is an important predisposing psychosocial risk factor for chronic pelvic pain.
Aside from medical consequences that can lead to clinic visits and surgeries, the psychological toll on patients who have experienced abuse is undeniable. Many women will acutely experience shock, denial, fear, confusion, anxiety, withdrawal, shame, guilt, nervousness, and distrust following sexual abuse. Chronic psychological conditions such as major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, diminished sexual interest, and low self-esteem are also very common outcomes.
When surgery was over and Caroline was waking up, we moved her to the recovery room and she again confided in us. "I was raped and I wanted you to know. Do you believe me?" We reassured her that we believed her, and once back in the recovery room, we were able to discuss the issues Caroline had raised further. With the help of our colleagues in Social Work and Psychiatry, we were able to ensure that Caroline had the appropriate supports to address her prior traumas, and to ensure that her surgery experience did not add to her burden. Before she was discharged, I told her that I thought she was brave for sharing her story and that I was happy she was seeking therapy. Privately, we wished she had been believed much earlier in her life.
It is not uncommon for a victim of sexual assault to remain silent due to perceived shame, guilt, and fear of stigmatization. So it comes as no surprise that Dr. Christine Blasey Ford and others like her would need a significant amount of time to cope with their past histories of sexual violence before deciding to speak out, if they are able to speak out at all. It is inconceivable that so many people in this country, including our own president, could so easily dismiss Dr. Blasey Ford's account on the ground that she did not immediately discuss those life-shattering events with anyone.
It took being medicated and on an operating table for Caroline to openly disclose her personal history of abuse. It has taken a national movement for celebrities like Padma Lakshmi, Alyssa Milano, or Lili Reinhart to share their stories of sexual violence. After the recent confirmation of Supreme Court Justice Brett Kavanaugh, despite several accusations of sexual assault, it may take victims even longer to speak out and they may now have increased fear that their friends, family, or the public will not believe them.
For those of us who are unwilling to accept this, we can start by showing the victims of sexual violence that we believe them. As the national consciousness around sexual violence grows, we must be more mindful of the impact that media discourse regarding sexual violence can have on a person's medical and psychological health. We can all do better in supporting victims of sexual assault as they move towards finding safe forums to discuss their experiences, including with their doctors. As physicians, and particularly as providers of women's health care, we stand with women like Caroline and Dr. Blasey Ford. When they share their stories, whether it be in a clinic, on the operating table, or on the Senate floor, we will believe them.
*All names and patient identifiers have been altered or omitted for the purposes of patient discretion in accordance with the HIPPA privacy rule.
Peter Movilla is a physician in the field of Obstetrics-Gynecology, now completing a fellowship in Minimally Invasive Gynecologic Surgery at Newton Wellesley Hospital in Newton, Massachusetts.
Himabindu Reddy is a resident physician in the field of Obstetrics-Gynecology, now completing residency training at Brigham and Women's Hospital – Massachusetts General Hospital Integrated Residency Program.
The opinions expressed in this article are solely those of Drs. Movilla and Reddy, and do not reflect the views or opinions of Newton Wellesley Hospital, Brigham and Women's Hospital, or Massachusetts General Hospital.
References:
- The National Intimate Partner and Sexual Violence Survey (NISVS). Center for Disease Control and Prevention. Atlanta, Georgia.
- Reiter RC, Gambone JC; Demographic and historic variables in women with idiopathic chronic pelvic pain. Obstet Gynecol. 1990 Mar;75(3 Pt 1):428-32.
- Latthe P, Mignini L, Gray R, Hills R, Khan K; Factors predisposing women to chronic pelvic pain: systematic review. BMJ. 2006 Apr 1;332(7544):749-55. Epub 2006 Feb 16.
- Schachter CL, Radomsku NA, Stalker CA, Teram E; Women survivors of child sexual abuse. How can health professionals promote healing? Can Fam Physician. 2004 Mar;50:405-12.
