Paula J. Adams Hillard, MD

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Sexual violence continues to be a major public health problem affecting millions of adults and children in the United States. Medical consequences of sexual assault include sexually transmitted infections; mental health conditions, including posttraumatic stress disorder; and risk of unintended pregnancy in reproductive-aged survivors of sexual assault. Obstetrician-gynecologists and other women’s health care providers play a key role in the evaluation and management of sexual assault survivors and should screen routinely for a history of sexual assault. When sexual violence is identified, individuals should receive appropriate and timely care. A clinician who examines sexual assault survivors in the acute-care setting has a responsibility to comply with state and local statutory or policy requirements for the use of evidence-gathering kits. This document has been updated to include model screening protocols and questions, relevant guidelines from other medical associations, trauma-informed care, and additional guidance regarding acute evaluation of survivors and evidence-gathering kits.

Why and how to perform trauma-informed care

Violence against women, including intimate partner violence and sexual violence, has been characterized by the World Health Organization (

) as a major public health problem, and a violation of women’s human rights.

 The Committee on Health Care for Underserved Women of the American College of Obstetricians and Gynecologists (

 This document recognizes the frequency of sexual assault as a public health problem, exhorts ob/gyns and other women’s health care clinicians to screen all women for a history of sexual assault, addresses the issues that must be addressed in the acute evaluation of survivors, highlights the short- and long-term health consequences of sexual assault, and emphasizes the need to provide trauma-informed care when assessing the needs of sexual assault survivors.  

Because sexual assault is so common (nearly one in five US women have been victims of a completed or attempted rape during their lifetime), all of us as ob/gyns will see women who have been sexually assaulted, even if this event occurred in the distant past.

 Thus it is imperative that we be familiar with the issues addressed in this Committee Opinion. The acute consequences of sexual assault include acute traumatic injuries that may be severe and life-threatening, as well as pregnancy and sexually transmitted infections.  

In today’s world, myths about women’s reproductive health abound and are being perpetuated by misinformed politicians and others with a political agenda. It has been inaccurately claimed that “legitimate rapes” (whatever that hot-button term means) don’t result in pregnancies. The statistics from a longitudinal study on the prevalence and incidence of rape found the national rape-related pregnancy rate to be 5.0% per rape among victims of reproductive age, with approximately 32,000 pregnancies yearly in the United States resulting from rape.

 It really should go without saying that we must counter this misinformation at every turn.  

The long-term health consequences of sexual assault can include physical symptoms, decreased social functioning, changes in health perception, and decreased quality of life. Many women with a history of sexual assault may not volunteer this history, but may present with chronic pelvic pain, dysmenorrhea, and sexual dysfunction. The psychological and mental health sequelae of sexual assault can be profound, from an acute disorganization phase to delayed symptoms such as nightmares, flashbacks, phobias, somatic symptoms, and post-traumatic stress disorder (PTSD), characterized by a re-experience of the trauma, avoidance, and hyper-arousal. Women with substance use disorders have very high rates of a history of rape or sexual assault, and thus it is particularly important to screen for this history when we detect substance use disorders, and conversely, when a history of sexual assault is elicited, to screen for substance use disorders that may result as a mechanism for coping with the history of trauma.   

ACOG recommends screening all women for a history of sexual assault by asking direct questions in a nonjudgmental manner, validating the patient, as well as providing appropriate referrals. The Committee Opinion provides examples of appropriate screening questions. When a history of sexual abuse is disclosed, medical procedures including pelvic, rectal, and breast exams, as well as transvaginal ultrasound exams, may be triggering and associated with PTSD. Women with a history of sexual assault are at increased risk for PTSD and depression after childbirth.

Trauma-informed care is essential for all women with a history of sexual assault, but I would suggest that we approach ALL women with these principles, including acknowledging the effects of trauma, recognizing its signs and symptoms, and practicing so as to avoid retraumatizing. To that end, we need to ensure every woman’s physical and emotional safety, assure patients of our trustworthiness, prioritize individual choice and control during examinations, and seek to empower individuals. We should also encourage peer support, including during gynecologic exams. I would suggest that we treat all women in this manner, given that women may not feel comfortable acknowledging a difficult past history of sexual assault. In addition, we must avoid doing exams that themselves can be traumatizing or triggering. Our performance of the gynecologic exam should be predicated on the principles of “catalyzing women’s empowerment,” as described by Wijma and Siwe.

Many hospitals today have implemented programs whereby acute medical exams for sexual assault victims are performed by Sexual Assault Nurse Examiners (

). When I was an intern, many moons ago, I learned how to assess the appropriate medical issues for sexual assault survivors, and to collect forensic evidence using a “rape kit,” which fortunately included a checklist of the appropriate steps and required documentation. The Committee Opinion lists a website that facilitates localization of a specialized sexual assault examiner, because for an assault victim, being examined by such an expert is much preferable to being in the hands of someone who is inexperienced. Today, many fewer residents in ob/gyn do these evaluations, which is likely preferable for individual survivors of sexual assault, but which means that many clinicians today have never done such exams. The ACOG document acknowledges that in some locations or situations, the ob/gyn may remain responsible for the acute exam. A detailed protocol for sexual assault medical forensic examinations is available online from the U.S. Department of Justice’s Office of Violence Against Women at 

https://www.justice.gov/ovw/sexual-assault

. ACOG has other resources on this topic, available at 

. When we do provide acute care for survivors of sexual assault, it is important to provide instructions in writing, and also critically important to arrange for both clinical and psychologic follow-up.  

As ob/gyns, it is our responsibility to screen all patients for physical and sexual violence, and to provide compassionate trauma-informed care for all women. This ACOG Committee Opinion provides basic information that can inform that care. 

The author reports no potential conflicts of interest with regard to this article

World Health Organization. RESPECT women: preventing violence against women. Available at 

https://www.who.int/reproductivehealth/topics/violence/respect-women-framework/en/

Sexual assault. ACOG  Committee Opinion No. 777. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2019;133:e296-302.

Breiding MJ, Smith SG, Basile KC, Walters ML, Chen J, Merrick MT. Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization--national intimate partner and sexual violence survey, United States, 2011. MMWR Surveill Summ. 2014;63(8):1-18.

Holmes MM, Resnick HS, Kilpatrick DG, Best CL. Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women. Am J Obstet Gynecol. 1996;175(2):320-324; discussion 324-325.

Soderquist J, Wijma B, Thorbert G, Wijma K. Risk factors in pregnancy for post-traumatic stress and depression after childbirth. BJOG. 2009;116(5):672-680.

Wijma B, Siwe K. Examiner’s unique possibilities to catalyze women’s empowerment during a pelvic examination. Acta Obstet Gynecol Scand. 2004;83(12):1102-1103.

Articles

Commentary on ACOG Committee Opinion 777: Sexual Assault, which discusses the role of the ob/gyn in caring for sexual assault survivors and includes information on screening.

ACOG Guidelines at a Glance: Sexual Assault

I know you’ve been there. Someone, somewhere, wanting to make conversation, asks you what type of work you do. Typically, I’ll answer that I’m a physician, and we all know that reply can trigger a long story from the questioner about their own latest encounter with the medical profession. Sometimes, if they are curious and ask for more information, “what type of doctor?”, I’ll respond that I’m a gynecologist. Before volunteering even this limited information, I’ll try to gauge their interest. If my questioner is a man, the conversation may quickly to turn another subject. This is certainly not always the case, and a man may choose to pursue a discussion, just as the subject may change when I am speaking with a woman. But more often than not, when speaking with a woman, the topic of gynecology or obstetrics leads to further discussion.

The conversation may then evolve to a discussion of my gynecology practice that no longer includes adult women, but which focuses on pediatric and adolescent gynecology (PAG). Here’s where I often see a puzzled look, and some variation on the question, “What on earth is pediatric and adolescent gynecology?”

 Many people are surprised that PAG is a “thing.” I may describe some of what I do as “preventive obstetrics,” which typically brings a smile or a chuckle, albeit often with a bit of lag time. 

Preventing unintended pregnancies in adolescents is indeed a major focus of my practice, but my practice is much broader than just contraception. I see girls, adolescents, and young adult women in my practice at the Lucile Packard Stanford Children’s Hospital in Palo Alto, California. My patients come from all around the San Francisco bay area, as well as from much further afield in California and other parts of the western United States. I care for these individuals with problems ranging from abnormal menstrual bleeding, abnormal puberty (too early, or too late), vulvar and vaginal symptoms, pelvic/ovarian masses, pelvic pain, differences of sex development, concerns about sexually transmitted infections, congenital utero-vaginal variants, and much more. 

I regularly provide preventive guidance to teens (and their parents), address anxieties about fertility and future reproductive health, encourage preventive services including human papillomavirus vaccinations, and talk about the benefits and risks of hormone therapies including oral contraceptives and hormonal intrauterine devices not only for contraception, but also for managing menstrual pain, irregular bleeding, or heavy menstrual bleeding. I talk about condoms, safe sex, responsible sex, abstinence, self-esteem, bullying, and uncover never-before-disclosed sexual abuse. I answer questions about normal anatomy-breasts of different sizes, or labia that may not look like the idealized images of porn stars on the Internet. Once you earn their trust with honest answers and sincerity, teens will confide a lot-including their hopes, dreams, fears, and foibles. And if I’m lucky and have the privilege of seeing an individual weather her teen years into young adulthood, I’m often witness to the amazing transformation of adolescent development. 

If you practice general obstetrics and gynecology, and if you enjoy taking care of teens, you likely do some or all of these things in your ob/gyn practice. I just do them every day. If you don’t like taking care of adolescents (and if you’re the parent of a teen, you’ll understand that they can be prickly at times, and that eye-rolling is par for the course), then you probably shouldn’t do much of it. Most teens are pretty discerning, and it’s hard to fake sincerity. But if you remember how hard it was to BE a teen, and how much you would have appreciated a caring physician who addressed your concerns about growing up (including menstrual concerns, if you identify as female), you may want to learn more about PAG and include more adolescents in your practice. I have no doubt that if you want to do this, and you start to ask your adult patients about their adolescent daughters, you will begin to build a practice that includes adolescents. The American College of Obstetricians and Gynecologists recommends that the initial visit for screening and provision of preventive health care services should take place between ages 13 and 15, and the Committee Opinion on 

provides guidance and resources for that visit.

 Most moms of teens are unaware of this recommendation-YOU may even be unaware of this recommendation.

The CREOG educational objectives include topics on pediatric and adolescent gynecology,

 and more and more residency training programs have faculty with expertise and experience in dealing with girls and adolescent young women, so that current residents are better prepared than ever before to care for this underserved population. For residency programs without PAG-trained faculty, or for individuals in practice who want to learn more PAG, two publications (dubbed the Short and the Long curriculum) provide a standard curriculum with resources and guidance for self-learning.

 The American Board of Obstetrics and Gynecology (ABOG) includes articles on PAG among the lifelong learning papers for Maintenance of Certification (MOC).

 For the first time, in 2018, ABOG offered an examination and focused practice designation in PAG. The North American Society for Pediatric and Adolescent Gynecology (NASPAG) website offers resources for clinicians, patient handouts, and the annual clinical and research meeting each May is a wonderful Continuing Medical Education (CME) opportunity for learning more about caring for young girls’ and teens’ gynecologic needs.

 The next NASPAG meeting will be held in New Orleans on April 11-13, 2019.  

 since 1992, and I am passionate about the clinically relevant articles that you and I read on a regular basis. 

 has published a number of excellent reviews of PAG topics, including eating disorders,

 heavy menstrual bleeding in adolescents,

 These reviews are great places to start reading if you want to become more familiar with care of adolescents and young girls. I thank Charly Lockwood for his leadership as Editor-in-Chief of 

, as well as my fellow editorial board members for their dedication to this publication. I’m grateful that they have allowed me this forum to be an evangelist for Pediatric and Adolescent Gynecology. My PAG practice is never boring. I would encourage you to add care for more adolescents and young girls to your practice of general obstetrics and gynecology. It is gratifying, and much appreciated by the girls and their mothers.

The author reports no potential conflicts of interest with regard to this editorial.

Adams Hillard PJ. What is pediatric and adolescent gynecology? 

ACOG Committee Opinion no. 598: Committee on Adolescent Health Care: The initial reproductive health visit. 

American College of Obstetricians and Gynecologists. CREOG 11

 edition of educational objectives. Available at 

https://www.acog.org/About-ACOG/ACOG-Departments/CREOG/CREOG-Search/CREOG-11th-Edition-of-Educational-Objectives

Fleming N, Amies Oelschlager AM, Browner-Elhanan KJ, et al. Resident education curriculum in pediatric and adolescent gynecology: the short curriculum. 

Loveless M, Amies Oelschlager AM, Browner-Elhanan KJ, et al. Long curriculum in resident education. 

American Board of Obstetrics and Gynecology. Why is MOC important? Available at 

https://www.abog.org/new/information.aspx?cat=moc&id=1

North American Society for Pediatric and Adolescent Gynecology. 

Snyder B. Eating disorders in adolescents and young adult women: Implications for reproductive health. 

http://www.contemporaryobgyn.net/obstetrics-gynecology-womens-health/eating-disorders-adolescents-and-young-adult-women-implications-reproductive-health

Heavy menstrual bleeding in adolescents. 

http://www.contemporaryobgyn.net/modern-medicine-news/heavy-menstrual-bleeding-adolescents

. 2013. http://www.contemporaryobgyn.net/endometriosis/pelvic-pain-adolescent 

Talking with patients about their daughters is one way to build a practice focused on caring for girls, adolescents, and young adults.

What is pediatric and adolescent gynecology?

 when I was a resident and for more than 30 years, the Technology issue has always been one of my favorites. Why the tech issue?   

No doubt my father, an electrical engineer, helped forge my love of gadgets, sparking my interest at a young age. I remember him coming home from an out-of-town meeting with a large cardboard box about 30×30×15 inches in size. He said someday this would be the size of something that would be called a "personal computer." His excitement at this prospect was infectious and at that point, it was clear to me that future technologic developments would benefit our lives. My laptop computer, my cell phone, and my PDA-my "accessory brains"-have certainly proven that to be the case. 

Of course, technology has not just contributed to our personal lives. The free online encyclopedia 

), one of my current favorite sources of information, indicates that medical technology "refers to the diagnostic or therapeutic application of science and technology to improve the management of health conditions." The 

 entry goes on to state that "technologies may encompass any means of identifying the nature of conditions to allow intervention with devices, pharmacologic, biologic or other methods to increase life span and/or improve the quality of life." As clinicians who care for women, we rely on technologic developments to benefit our patients.  

But it's not always easy for physicians to keep up with and evaluate the latest technologies. In this issue, 

 experts provide unbiased reviews that allow us busy clinicians to figure out when a given technologic development is "ready for prime time," and to incorporate new devices and technologies into our practices, based on evidence and science rather than marketing or hype. The article by Drs. Matthew Guile and Robert Bristow on "New tools for preventing surgery-related adhesions and excessive bleeding" discusses several ready for prime time technologic advances. The article by Drs. Willard Cates and Zeda Rosenberg, on the other hand, gives us a glimpse into the future by summing up the research on vaginal microbicides now in the pipeline. And finally, Drs. Michelle Isley and Paul Blumenthal provide a concise summary of the latest treatment protocols for women who are seeking a medical alternative to surgical abortion.  

How will you use this information in daily practice? That depends in part on your attitude toward technology. Adopters of new technologies have been categorized as innovators, early adopters, early majority, late majority, or laggards. Most readers fall somewhere along this continuum. But whether you are an early, mid- or late-adopter, evidence, science, and insights from distinguished experts will help you to assess which technologies will benefit the women for whom you provide medical care. As clinicians, it's our duty to critically and carefully assess new technologic developments. I believe that this issue of the journal will help you do just that.  

, Issue Editor, is Professor, Department of Obstetrics and Gynecology, Chief, Division of Gynecologic Specialties, Stanford University Medical Center, Stanford, CA. 

Technology has transformed medicine; to keep up with these advances requires access to unbiased clinical reviews, which are provided in this special issue.

Author | Paula J. Adams Hillard, MD

Articles

ACOG Guidelines at a Glance: Sexual Assault

What is pediatric and adolescent gynecology?

Opinion: I admit it, I'm a technophile