Someone’s emotional state after an assault or in relation to sexual violence they have experienced in their lifetime. The emotional states most commonly cited as barriers are shame, embarrassment or humiliation, guilt, and self-blame.
The Ottawa Rape Crisis Centre (ORCC) works directly with women* sixteen years old and over who are survivors of sexual violence/abuse (childhood sexual abuse, sexual assault, sexual harassment, sexual assault in the context of intimate relationships, etc.), offering various frontline supports such as free counselling (crisis, on-going, and groups), a 24-hour crisis line, individual advocacy and accompaniment. We also do public education work to empower our community as well as work towards strengthening support networks of survivors of sexual violence/abuse, offering guidance to friends, partners and families.
About the author: The Ottawa Rape Crisis Centre (ORCC)
The Ottawa Rape Crisis Centre (ORCC) is a pro-active, anti-racist, feminist organization. We counsel and support women*, educate for change and work to create a safe and equitable community. Focusing on education, empowerment and promoting justice and respect, the ORCC works to rally voices in the community around issues of sexual violence and feminism.
We work directly with women sixteen years old and over who are survivors of sexual violence/abuse (childhood sexual abuse, sexual assault, sexual harassment, sexual assault in the context of intimate relationships, etc.), offering various frontline supports such as free counselling (crisis, on-going, and groups), a 24-hour crisis line, individual advocacy and accompaniment. We also do public education work to empower our community as well as work towards strengthening support networks of survivors of sexual violence/abuse, offering guidance to friends, partners and families.
We also take a stand in the public sphere and participate in important conversations about sexual violence. In the same vein, we provide public education opportunities, trainings and professional development for the community, schools and universities, social service organizations, and policy-makers.
* We serve all self-identified women, gender non-conforming and genderqueer survivors. We also serve self-identified men in helping them find inclusive services for male survivors but we don’t do long-term counseling with them since it’s not our area of expertise. But we do see them if they need help supporting a loved one who is a survivor.
Join the Conversation
Health service providers can (regardless of intentions) contribute to the shaming, blaming, stigmatizing, endangering, or triggering of people who have experienced sexual violence when they access health care services, be it in the context of emergency care after an assault, or when accessing routine care. By sharing feedback from our community and collaborating on building skills around what facilitates or hinders caring for survivors of sexual violence, we strive to see access to comprehensive health care increase and the trust between sexual assault survivors and their medical supports increase.
Barriers to health
Sexual violence is a pervasive problem and affects a high percentage of people in our communities. Due to stigma and/or discomfort in sharing what many consider to be a “private matter”, it is also an underreported crime, a reality that impacts what supports are made available and people’s perception about the issue.
Experiencing sexual violence (defined as any unwanted act of a sexual nature that is imposed on another person) can cause severe psychological trauma. In addition to psychological harm, sexual assault survivors can experience physical consequences such as bodily injury, sexually transmitted infections (STIs), and pregnancy. Survivors are more likely than the average person to attempt suicide. Numerous physical problems occur with greater frequency among people with sexual assault histories. Despite all these potential health risks, a major gap exists between the reported rates of sexual assault and the rates of comprehensive post-assault care offered as well as the level of knowledge of health care providers when it comes to providing routine care to people who have experienced sexual violence in their lifetime. Why is that?
Barriers that survivors of sexual violence face
Survivors of sexual violence encounter many barriers that can jeopardize their access to care they need and deserve. This is true for people seeking medical attention following violence or sexual assault/abuse, someone who has historically experienced sexual abuse, a childhood sexual assault survivor, or survivors of ritualistic abuse and torture.
These barriers can stem from both personal and environmental factors.
On a personal level, what can get in the way of survivors of sexual violence accessing quality health care and supports?
Fear of external exposure, including bad treatment by the criminal justice system, not being believed, lack of confidentiality and going to trial which can be linked to public exposure.
The fear of facing stigma.
The fear of facing repercussions, including the fear of child apprehension (in connection to intimate partner abuse, especially for marginalized populations), the fear of having their confidentiality compromised, or the threat of criminalization (for example, if someone is assaulted in a situation where they would be found in breach of release conditions, in the context of criminalized work, when they are in a precarious immigration situation, etc.)
Fears related to the assailant, including fear of retaliation and/or of the possibility of jail for the assailant if the survivor has some type of relationship with them.
The fear of not being believed or being dismissed when sharing sensitive and intimate information due to a culture of disbelief when it comes to sexual violence, particularly when it is directed at people from marginalized groups such as immigrants, LGBTQ individuals, persons with disabilities, and people of color.
Lack of knowledge of available services in the community.
Lack of services (primary-care providers, housing/shelter beds, long-term counselling, etc.) or long waiting lists to access existing services.
Reluctance to engage strangers or third-parties in “private” matters.
Fear of losing control over processes and outcomes. For example, being pushed to report, or discouraged to report.
Fear of facing triggering situations, for example when bodily autonomy is compromised, lack of control is experienced, limitations are placed on personal movement, internal exams or touch are required, and situations where shaming/blaming/judgmental perspectives are felt during the interactions.
The belief that the assault is not serious enough to warrant the use of services. Or that it has happened too long ago to bring it up. There still are stereotypic views of what defines sexual assault and unwanted sexual incidents and they make it harder for people to make sense of certain experiences when they fall out of typical narratives.
Barriers to comprehensive care also include factors related to how services are accessed. Structural/organization barriers can play a large role in jeopardizing the access to care for survivors of sexual violence. This is in addition to the perpetuation of rape myths by society which is certainly a factor in preventing sexual violence survivors from accessing care.
What are some of these environmental barriers?
Insufficient funding for resources and supports for survivors of sexual violence.
Heath care providers having inadequate time to spend with survivors, personal discomfort, and inexperience in treating sexual assault survivors.
A lack of training and awareness about how to best work with survivors, for example, a lack of knowledge or skills around supporting disclosure, safety planning, how to make physical exams more comfortable, or how to support someone reporting a sexual assault to the police, etc. Or how to work with people who have experienced sexual violence to increase their comfort during a forensic or pelvic exam (directly after an assault or during routine care).
Health care providers adopting directive or problematic approaches to issues of sexual and reproductive health (including a lack of support for pregnancy options)
Health care provider feeling uncomfortable engaging patients around issues of violence against women, intimate partners abuse and sexual violence. Not knowing how to broach the topic or what to say to initiate such conversations.
Interventionist approaches that do not recognize the complex nature of reporting sexual violence.
Lack of inclusivity in resources and services for survivors of sexual violence, including lack of visible representation of equity-seeking groups and lack of inclusive language when speaking about sexual violence, invisibilizing certain populations.
Language barriers, including for Francophone communities and those whose first language is neither French nor English.
Barriers faced by people because of mental-health issues, precarious immigration status, language, disability, criminality, racial or ethnic biases, poverty, etc. which can compound the difficulty of disclosing sexual violence and accessing health care.
Systems that are already beyond capacity makes it challenging to build community knowledge and cross-sector competence.
Societal myths about sexual violence can inform a health care provider’s practice and can also combine with, or inform, discriminatory or insensitive institutional policies and practices.
Perceptions of who is a “legitimate victim” or who can even be a victim of sexual violence. These perceptions are linked to biases related to race, gender, disability, sexual orientation, and class.
Differential treatment related to the amount of blame that can be assigned to people who do not fit into stereotypical narratives of the ‘legitimate victim’.
Perceptions about the prevalence or nature of sexual violence. This can look like health care providers who, unless told explicitly, assume they are not treating people who have experienced sexual violence. Alternatively, sexual violence not being on health care providers’ radar.
Doubts about the validity of sexual violence accusations or the seriousness of the incident. This can look like brushing people off, dismissing experiences or interpretations, of fears, etc.
Stigma and judgment about femininity, women’s roles, gender expression and sexual orientation.
The perception that survivors would returned to partners who perpetrated assaults.
Myths about sexual violence
- It is not really rape if a weapon or physical violence was not used or if someone didn’t fight it/wasn’t hysterical Most sexual assaults are perpetrated by an acquaintance, who is more likely to use tricks, verbal pressure, threats or mild force (twisting an arm or gripping) rather than a weapon or severe beating. A person who has been assaulted may be hysterical, but the more common reaction is one of shock or disbelief, and people may present themselves as calm and collected.
- People “ask for it” by how they dress or act – or at least, they could have helped prevent it by acting/dressing appropriately No one asks to be degraded or hurt. Sexual assault is the only crime where the victim is seen to be more responsible for the crime than the offender. Sexual assault victims are often asked why they acted in a certain way, or said certain things, this blames the victim and protects the offender. This is called ‘Victim Blaming’.
- Rape usually occurs in a dark, isolated location, such as an alley or parking lot Most sexual assaults occur in someone’s home. The next most common location is in someone’s car.
- Rapists are crazed, sex starved strangers Sexual assault is a crime of power, control, and violence. It is not caused by being sexually starved. Studies reveal that “rapists” are ordinary “normal” people. Most people are sexually assaulted by people they know, including intimate partners, friends, acquaintances, friends of friends, dates, etc.
- People lie about sexual assault Such incidents are rare. False rape accusations are estimated to occur at the low rate of two percent – similar to the rate of false accusations for other violent crimes. Most people do not report being sexually assaulted. In the rare cases when they do, conviction rates are low.
- Only young attractive women get raped People of any age, gender, race, class, lifestyle, or physical attributes may potentially be sexually assaulted.
- Sexual Assault doesn’t happen often Sexual assault happens everyday at home, at work, at school, or on the street and a high percentage of us will experience at least one incident of sexual violence in our lifetime. The most detailed information on sexual assault is available from the 1993 national Violence Against Women Survey. At that time, 39% of Canadian adult women reported having had at least one experience of sexual assault since the age of 16
- It is only sexual assault if someone has visible injuries Sexual assault is any unwanted act of a sexual nature that one person imposes on another. A weapon and visible physical injuries do not have to be present in order for a woman’s experience to be sexual assault.
- Unless they are physically harmed, a person who has been sexually assaulted will not suffer any long-term effects Many people report emotional effect when they experience sexual violence. That said, it is also important to remember that, although reactions like anger, mistrust, and sadness are common, not all people experience the same emotions or express them in the same way. Because someone does not feel or act a certain way does not mean that an experience of sexual assault is not legitimate.
- People cannot be assaulted by their partners Legally, people have the right to say no, to any form of sex with anyone, including their spouse or the person they are dating.
- If someone has had many sexual partners then they cannot be sexually assaulted The number of partners someone has had has no bearing on them being assaulted or not. Consent must be freely given each time two people are intimate with each other. This is also true for people in the sex trade.
- You can tell if someone has really been sexually assaulted by the way they act There is no one way to react to a sexual assault and none of them is more legitimate then another.
What can you do?
Considering that a significant number of people who come through health care services have experienced sexual violence, it is fundamental to be mindful of how we can best care for patients with such experiences or histories. Here are some things to keep in mind:
People who have experienced sexual trauma can certainly be triggered in the medical setting, especially if they feel strong emotional reactions such as terror, surprise, shame, or helplessness, or feeling trapped or exposed. Several aspect of medical care can increase the likelihood of feeling these things, such as certain types of procedures, including some that are part of yearly physicals, gastrointestinal exams, and gynecological exams). In particular, procedures involving the insertion of fingers or instruments, like pelvic exams, colonoscopies or endoscopies, can be challenging.
Health care providers should also be mindful that seemingly commonplace interactions or dynamics can be difficult for some patients, like being touched, feeling the power differential between patient and provider, the removal or absence of clothing, or the focus on bodily pain or disorder.
Because sexual violence survivors may anticipate these difficulties, they may repeatedly cancel appointments for exams or avoid telling their health care providers about symptoms, like blood in their stools, pelvic pain, etc. that might lead to invasive tests.
Practical tips during exams
Manage the power differential between you and your patient. Simplify medical talk, engage them in conversation, and ask questions to understand people’s circumstances.
Greet the patient in your office (not exam room) while they are still fully dressed. Leave the room for them to get undressed, make sure to give them time and notice of your return.
Give the patient as much control as possible over how exams may proceed. For example, some people may find it easier to go through an internal exam if the back of the table is raised and they can sit more upright during it.
Provide health education materials so people feel informed about what will happen during appointments.
View the patient as experts about themselves. Ask them what might help reduce their stress during the exam or make going through an exam more comfortable. Trust what they tell you about their bodies.
Ask them to predict what will be the most difficult parts of a procedure. Work with them on figuring out ways to ease their anxiety about these moments.
Take breaks during the exam if necessary. Ask them how they are doing, if they need to stop.
Provide patients with as much choice as possible about how an exam can be conducted.
Engage in dialogue throughout exam and explain everything you will do in advance and as you do it.
Give positive feedback if possible, “you are doing well”, “we are going to take care of you”, “let me know…” “I am on your side”.
Stay grounded and do not interpret reluctance to engage personally, this will be key to developing trust with a person who likely reads these cues before establishing any rapport with a person.
Listen carefully to any concerns. Be responsive to any concerns raised. Answer questions carefully and patiently. Providing validation and communicating in supportive and non-judgemental ways matters for all interactions: from a PAP smear, to an ER visit, to a labour and delivery.
Check in regularly throughout the exam about the patient’s level of anxiety.
Remind the person of why you are performing this exam.
Plan and allow extra time. Schedule patients you know may have a harder time going through exams or medical appointments for slower days or late appointments.
Be prepared and willing to reschedule the exam if necessary.
Talk with the patient about other topics of interest to them in order to distract them from the exam.
If they are not doing well, here are some grounding techniques
Speak in a calm, matter of fact voice and avoid sudden movements.
Reassure your patient that everything is okay.
Continue to explain what you’re doing.
If possible, stop the procedure.
Ask (or remind) the patient where they are.
Offer a drink of water, an extra gown, if possible, a blanket, or a warm or cold washcloth for their face. If needed, leave the room with them to change environment.
Greet people warmly and not in an overly familiar way if there are no pre-existing relationship. Names are not necessary if in a public or crowded space.
Tell people where they are going next and if that space is private. Do not summarize why they are there in front of others unless necessary.
If there is an opportunity, do find sensitive ways to inquire about history of sexual trauma. Do not make assumptions about who can/can’t have experienced sexual violence. Health care providers do have a responsibility to understand their patients’ histories and their healthcare needs so it is important to work towards building relationships that are conducive to trust building and disclosure of sensitive information.
Keep your face and body language neutral or calmly reassuring without patronizing or infantilizing people. Stigma, judgement and shame are communicated through non-verbal cues and so, be mindful of how you react to someone’s story. Shock, surprise, pity, dismay, disbelief, doubt or discomfort can be easily perceived and can shut down conversations.
When possible, keep your space comfortable and private. Keep conversations minimal in common areas. Choose features that reduce ‘clinical’ or ‘institutional’ feel.
Add a check box to your intake about the desire to speak confidentially
Offer a short summary of the expectations people can have about privacy and confidentiality.
Be upfront about your duty to report, be clear about processes and inform them if you need to take steps to share information they gave you.
Be mindful of your own assumptions.
Look into resources in the community that can flatten language barriers, like interpretation services, including ASL.
Build your knowledge and capacity
Get trained on how to provide trauma-informed care.
Inform yourself on reproductive coercion, STI testing and treatment, pregnancy options and other issues that may come up when offering comprehensive reproductive and sexual health care.
Train yourself or staff on how to address survivors’ emotional and medical needs while performing high-quality evidence collection.
Access trainings on the intersections of violence against women and sexual and reproductive health and reproductive coercion.
Increase inter-agency partnerships and knowledge-sharing. Build a list of resources for referrals.
Cross-agency crisis debriefing can sometimes be very useful, and help to reduce some providers’ fears and feeling of isolation in raising and responding to issues of violence.
Inform yourself on the processes to report violence, including sexual violence to better support patients who may choose to report a sexual assault. Ensure that people stay in control during the process, discuss potential risks and outcomes.
If there are risks of criminalization or risks of control being taken away (non-voluntary hospitalization, police involvement, etc.), it should be disclosed as soon as possible. Any need for restraints should be explained and avoided if possible. Offer to call a support person known to them. Have a list of advocates/support person who may be available through the hospital or community organizations.
Once you have the necessary resources at hand, inform people about the available resources and recommended care after a sexual assault as it can help mitigate personal barriers to care.
Be an advocate for change when it comes to societal attitudes about sexual violence.
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