The role of the physiotherapist in treating survivors of sexual assault

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Editorial
The role of the physiotherapist in treating survivors of sexual assault
Janine Stirling
a
, K Jane Chalmers
b,c
, Lucy Chipchase
c,d
a
Department of Counselling and Psychotherapy, Australian College of Applied Psychology, Sydney, Australia;
b
IIMPACT in Health Research, Allied Health and Human Performance,
University of South Australia, Adelaide, Australia;
c
School of Health Sciences, Western Sydney University, Sydney, Australia;
d
College of Nursing and Health Sciences, Flinders
University, Adelaide, Australia
In memory of India Eve Chipchase
The Me Too Movement has facilitated an international conversation
on sexual harassment and sexual assault, paving the way for change.
1
This topic –once shrouded in secrecy, silence and shame –is
currently under the spotlight, challenging society in a new and dy-
namic way. With open dialogue and readily accessible information,
the need for healthcare professionals to know more and do more is
compelling. Thus, it is time to reflect on the role that physiotherapists
may play, either explicitly or implicitly, in the management of people
who have undergone sexual assault. The intent of this editorial is to
raise awareness and demonstrate a need for specific skills and
training to meet the complex needs of women who are survivors of
sexual assault trauma. The primary focus is on women’s experiences;
men, however, may be similarly impacted.
In Australia, a population survey conducted in 2016 found that one
in every two women experienced sexual harassment.
2
Sexual
harassment includes a range of unwanted behaviours such as
touching, kissing, fondling and showing or sending sexually offensive
material via text, email or social media.
2,3
Sexual assault, on the other
hand, is an act of a sexual nature that involves threat, intimidation
and physical force, carried out against a person’s will and includes
rape, attempted rape and/or indecent assault.
3
One in six women
have experienced a sexual assault in Australia, although if childhood
sexual abuse is included, this ratio becomes one in four women.
2,3
The terms sexual assault and sexual abuse (often associated with
behaviour toward children, not adults) are often used interchange-
ably in the literature. For the purposes of this paper, the term sexual
assault is used and encompasses rape, sexual abuse and assault.
Sexual assault impacts on a person’s physical, social, emotional
and psychological health. A systematic review of international papers,
including over three million participants, reported that sexual assault
had a significant association with a lifetime diagnosis of depression,
post-traumatic stress disorder, anxiety, eating disorders, sleep disor-
ders and suicide attempts.
4
Similarly, Paras et al
5
found a statistically
significant association between women with a history of rape and a
subsequent diagnosis of fibromyalgia, chronic pelvic pain and
gastrointestinal disorders. Indeed, any exposure to trauma –be it
psychological, emotional, physical or sexual in nature –results in an
individual being 2.7 times more likely to experience a somatic syn-
drome than if they had no exposure to trauma.
6
These last two
studies were systematic reviews and meta-analyses of studies con-
ducted internationally.
5,6
Physiotherapists who work in the Women’s, Men’s and Pelvic
Health subdiscipline of the profession have a role to play with women
who are survivors of sexual assault because they are more likely to
have multiple pelvic floor complaints compared with those without a
history of sexual assault.
7
Similarly, women who have been sexually
assaulted have been found to perceive symptoms of incontinence or
constipation as more severe and life impacting than those without a
sexual assault history.
8
While suitably qualified physiotherapists in
the Women’s, Men’s and Pelvic Health subdiscipline play a funda-
mental role in the management of these pelvic floor conditions, there
are two aspects that require further consideration.
First, given that one in four women have experienced sexual as-
sault, we must consider how this knowledge can be used in practice
to achieve the best possible outcome for women seeking treatment.
This may require physiotherapists, in the process of taking a history,
to use screening tools that address aspects of sexual wellbeing. Sexual
trauma impacts a person’s psychological and physical health, and
treatment effectiveness relies on treating the underlying issues as
well as focusing on presenting symptoms.
9
Thus, one could argue that
it is an ethical duty to screen for sexual trauma and to obtain as much
clinically relevant information as possible to support assessment,
treatment and referral.
9
There are different ways to obtain this in-
formation, either through subjective questioning, or through the use
of more structured assessment tools. For example, the Adverse
Childhood Experience Questionnaire for Adults
10
is a 10-question tick
box tool that can identify exposure to sexual, emotional and physical
adversity in childhood (Box 1). Alternatively, the American College of
Obstetricians and Gynecologists suggests five screening questions
that can be asked to screen women for sexual assault (Box 2).
11
The
American College of Obstetricians and Gynecologists suggests that
healthcare practitioners screen those presenting with pelvic pain,
sexual dysfunction or dysmenorrhoea.
11
The numerous health im-
plications associated with sexual assault means that it is highly
probable that all physiotherapists will encounter patients with a
history of sexual assault in their practice, whether explicitly identified
or not. Training in conducting a subjective assessment and use of the
aforementioned assessment tools is important to ensure that phys-
iotherapists are competent in dealing with the possible responses to
the screening questions, while remaining sensitive to the needs of the
patient throughout the process.
12
A second aspect for physiotherapists to consider when treating a
patient presenting with a history of sexual assault is the survival
response and sequelae. Approximately 70% of women report tonic
immobility during a sexual assault.
13
Tonic immobility is a profound,
global motor inhibition where the skeletal muscles tense rigidly and
are unable to be moved voluntarily.
13,14
Not only is voluntary move-
ment affected, but vocal capacity is also diminished.
14,15
These motor
inhibitions mean that key survival-based actions of screaming and
movements of fighting or running away, which ordinarily protect the
body during a sympathetic response to threat, are not available.
15
Women who experience tonic immobility during sexual assault are
Journal of Physiotherapy -(2020) -–-
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1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
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twice as likely to develop post-traumatic stress disorder and are three
times more likely to have severe depression 6 months after sexual
assault.
13
Women describe the experience of tonic immobility as
leaving them vulnerable to the feeling that immobility may occur in
other stressful life situations that involve sexual contact, or when
they feel afraid, out of control, angry or disregarded.
15
It is plausible
that when physiotherapists treat women with a history of sexual
assault that involuntary reflexive responses relating to the assault
may be elicited during the course of treatment. This is particularly
likely if a woman is seeking help for a distressing pelvic condition
that requires an internal examination and related treatment.
To date, one case study has been published addressing how a
patient who received physiotherapy management of lower back pain
later developed symptoms associated with a prior history of sexual
assault.
16
In this case study, a number of physiological signs and
symptoms were observed in the patient after 10 weeks of treatment,
including sweating, shaking, suppressed breathing, freezing, hyper-
vigilance, an inability to focus, and outbursts of anger.
16
The patient
then disclosed experiencing flashbacks of her sexual assault 40 years
prior and was subsequently diagnosed with post-traumatic stress
disorder. This report of delayed-onset post-traumatic stress disorder
during physiotherapy sessions draws into focus a number of key
questions that require investigation. For example, how many women
experience similar somatic symptoms during visits to physiothera-
pists? Are physiotherapists equipped to detect and manage these
uncomfortable somatic experiences? To what degree does a fear of
uncomfortable somatic experiences interfere with a woman’s
willingness to access physiotherapy services? If a patient does access
physiotherapy and vestiges of the survival response arise, what
conditions are necessary to promote a positive treatment outcome?
A trauma-informed approach is recommended when treating a
patient who presents with a history of any type of trauma.
17
The five
core principles of trauma-informed care include: providing emotional
and physical safety by attuning to a patient’s needs; being trustworthy;
offering choices to patients; collaborating with them; and empowering
them.
10,17
In a qualitative study involving 27 survivors of childhood
sexual abuse who received or were referred to physiotherapy, a need
for safety was considered the prevailing theme when discussing how
health professionals can practise with more sensitivity to their needs.
18
Safety was impacted if patients perceived a lack of control. They valued
accepting environments where the physiotherapist respected them,
was informed about how trauma impacts the bodyand was attentive to
their personal boundaries. Survivors also expressed a need to work in
partnership with a healthcare team consisting of a physiotherapist,
psychotherapist and general practitioner.
18
A similar approach was
documented by Dunleavy and Slowik in the physiotherapy manage-
ment of a patient with low back pain and a history of sexual assault 40
years prior.
16
With collaborative identification of stress responses and
triggers, management of hyperarousal, and a slow, graded exposure to
triggering stimuli, the patient reported positive outcomes in her back
pain after 2 years and an improvement in post-traumatic stress disor-
der symptoms over 4 years.
16
With very little available research to address how physiotherapists
can work with women who have been sexually assaulted, we must
consider how to build capacity within the profession to ensure that
women who are survivors of sexual assault receive the care and support
they require. This editorial is a first step that has aimed to highlight gaps
in research and in clinical practice. There is a strong need for: good
screening of sexual assault history and subsequent psychological illness
in women; a requirement for future research to provide more detailed
approaches to delivering trauma-informed pelvic healthcare to women
who are survivors of sexual assault; and competency-based training for
physiotherapists so that they can deal with the issues that may arise
from screening. This is a callto action to further ourprofession’s capacity
to help the one in four women who have experienced sexual assault.
Ethics approval: Nil.
Competing interests: Nil.
Source(s) of support: Nil.
Acknowledgements: Nil.
Provenance: Not invited. Peer reviewed.
Correspondence: Lucy Chipchase, Flinders University, Adelaide,
Australia. Email: lucy.chipchase@flinders.edu.au
References
1. Lore G, et al. Policy Options Politiques. 2020. https://policyoptions.irpp.org/
magazines/february-2020/sup port-services- still-lacking-for-survivors-of-sexual-
assault/. Accessed 9 September, 2020.
2. Australian Bureau of Statistics. Personal Safety. Canberra: ABS; 2017. https://
www.abs.gov.au/auss tats/abs@.nsf/Lookup/ by%20Subject/4906.0w2016wMain%
20FeatureswAbout%20the% 20Personal%2 0Safety%20Survey%20w2. Accessed 9
September, 2020.
3. Australian Bureau of Statistics. Personal Safety. Canberra: ABS; 2012. https://
www.abs.gov.au/ausstats/abs@.nsf/Lookup/4906.0Chapter5002012. Accessed 9
September, 2020.
4. Chen LP, et al. Mayo Clin Proc. 2010;85:618–629.
5. Paras ML, et al. JAMA. 2009;302:550–561.
6. Afari N, et al. Psychosom Med. 2014;76:2–11.
7. Beck JJ, et al. J Sexual Med. 2009;6:193–198 .
8. Imhoff LR, et al. Arch Surg. 2012;147:1123–112 9.
9. Probst DR, et al. J Aggress Maltreatment Trauma. 2011;20:199–226.
10. Provider Toolkit. Screening and Responding to the Impact of ACE’s and Toxic Stress.
May 2020. https://www.acesaware.org/wp-content/uploads/2020/05/ACEs-Aware-
Provider-Toolkit-5.21.20.pdf. Accessed 9 September, 2020.
11. Floyd S, Anderson J. Obstet Gynecol. 2019;133:e296–e301.
12. Frawley HC, et al. Physiother Theory Pract. 2019;35:1117–113 0.
13. Moller A, et al. Acta Obstet Gynecol Scand. 2017;96:932–938.
14. de Kleine RA, et al. Psychiatry Res. 2018;270:1105–1109 .
15. TeBockhorst SF, et al. Psychol Trauma. 2015;7:171–178.
16. Dunleavy K, Slowik AK. Phys Ther. 2012;92:339–351.
17. Kezelman C, Stavropoulos P. Blue Knot Foundation. 2018;1–147.
18. Schachter CL, et al. Can Fam Physician. 2004;50:405–412.
Box 1. Adverse Childhood Experience Questionnaire for
Adults.
10
Did you feel that you didn’t have enough to eat, had to wear
dirty clothes, or had no one to protect or take care of you?
Did you lose a parent through divorce, abandonment, death, or
other reason?
Did you live with anyone who was depressed, mentally ill, or
attempted suicide?
Did you live with anyone who had a problem with drinking or
using drugs, including prescription drugs?
Did your parents or adults in your home ever hit, punch, beat or
threaten to harm each other?
Did you live with anyone who went to jail or prison?
Did a parent or adult in your home ever swear at you, insult
you, or put you down?
Did a parent or adult in your home ever hit, beat, kick or
physically hurt you in any way?
Did you feel that no one in your family loved you or thought you
were special?
Did you experience unwanted sexual contact (such as fondling
or oral/anal/vaginal intercourse/penetration)?
Box 2. American College of Obstetricians and Gynecologists
sexual assault screening questions.
11
Has anyone ever touched you against your will or without your
consent?
Have you ever been forced or pressured to engage in sexual
activities when you did not want to?
Have you ever had unwanted sex while under the influence of
alcohol or drugs?
Do you feel that you have control over your sexual relationships
and will be listened to if you say ‘no’to sexual activities?
Is your visit today because of a sexual experience you did not
want to happen?
Floyd S, Anderson J. American College of Obstetricians and
Gynecologists Committee Opinion Number 777: Sexual Assault.
Obstet Gynecol. 2019;133:e296–e301.
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