Hi dear friends and random readers (actually I think of you all as friends). Tomorrow I am paying yet another visit to my trusty urogynecologist, to be fitted with a device that may help me out a bit with my pelvic organ prolapse until I can have surgery in a few months. I was thinking I might take the following letter with me to give to her. And I would so appreciate feedback and suggestions. Be honest. It is too antagonizing? Is it too direct? Or too indirect? Should I include something else?
I can also wait and send it to her later, but maybe I should go ahead and give it to her before I chicken out. Appointment is as 10:30am Pacific time, but if you read this later and want to offer suggestions, that’s still wonderful. Thank you all for your help. Here’s the first draft.
February 1, 2016
Dear Dr. XX,
Thank you for taking the extra time to talk me about the details related to my future surgery. I don’t like all the details, but knowing them will help me make a plan to take care of myself emotionally.
While you and [nurse] have both been patient and forthcoming with me about what to expect, I get the sense that you don’t routinely have these talks with patients. So it might seem like I am unusual (or pushy or obsessive) in wanting to have these conversations. (No, you haven’t said anything like that—this is just me imagining what it might feel like on your end.)
I want to tell you a little more about why this matters to me. It’s for my own sake and for the sake of others (presumably 20 to 25 percent of your patients). I write a blog, anonymously, about the sexual abuse I experienced from childhood and into adulthood, what I am learning in therapy, and how I am working to take care of myself. I have written about my gynecological visits, what scares me about them, and what helps make it easier. What I most wanted to tell you about is the way that other women with trauma histories read and respond to my blog. They tell me that they think it’s “brave” of me to speak up to you about it at all. They say they could never bring it up with their doctor, even though it affects their experience with their doctors. Some describe doctors getting frustrated with them because a pap smear makes them break out in tears or because they leap up when a doctor takes a cervical sample for biopsy without telling them what is going to happen. Others say they are not able to go for routine gynecological care because it is too triggering for them.
I don’t know that I think it’s at all “brave” of me to speak up to you about this, but I do know it hasn’t feel easy. It’s not like I go around telling people that oh yeah, I experienced childhood sexual abuse. I didn’t tell my therapist for years, and I didn’t talk about it with my husband until we’d been married about 15 years. It’s just not easy to talk about.
That’s why I think it would be great if you and [nurse] could find a way to bring it up to patients, rather than wait for us to bring it up. Earlier I suggested you might want to use language like, “I see you checked the box about abuse history in your intake form; are there things we should consider in thinking about how we work together?” But even that is hard, because I am only gradually learning what things we need to consider; I wouldn’t have been able to answer that question the first time I saw you. Later I read an article from the American College of Obstetricians and Gynecology (http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Adult-Manifestations-of-Childhood-Sexual-Abuse) and I found they had some suggestions that were better. You may have seen them before but I’d love to share them anyway (and am sharing them with readers of my blog):
“… it is strongly recommended that all women be screened for a history of sexual abuse. Patients overwhelmingly favor universal inquiry about sexual assault because they report a reluctance to initiate a discussion of this subject. Following are some guidelines:
- Make the question “natural.” When physicians routinely incorporate questions about possible sexual abuse, they will develop increased comfort.
- Normalize the experience. Physicians may offer explanatory statements, such as: “About one woman in five was sexually abused as a child. Because these experiences can affect health, I ask all my patients about unwanted sexual experiences in childhood.”
- Give the patient control over disclosure. Ask every patient about childhood abuse and rape trauma, but let her control what she says and when she says it in order to keep her emotional defenses intact.
- If the patient reports childhood sexual abuse, ask whether she has disclosed this in the past or sought professional help. Revelations may be traumatic for the patient. Listening attentively is important because excessive reassurance may negate the patient’s pain. The obstetrician-gynecologist should consider referral to a therapist.
- The examination may be postponed until another visit. Once the patient is ready for an examination, questions about whether any parts of the breast or pelvic examination cause emotional or physical discomfort should be asked.
- If the physician suspects abuse, but the patient does not disclose it, the obstetrician-gynecologist should remain open and reassuring. Patients may bring up the subject at a later visit if they have developed trust in the obstetrician-gynecologist. Not asking about sexual abuse may give tacit support to the survivor’s belief that abuse does not matter or does not have medical relevance and the opportunity for intervention is lost.”
I’m glad I have a couple of months to think and prepare before my surgery. I can already tell you, based on your description the other day, that there are some things about it that set off my emotional alarm bells, including
- Being strapped to the table and being literally paralyzed by the anesthesia
- Having a breathing tube (or anything) stuck down my throat
- Having a catheter or other things inserted inside of me
- Having a lot of gauze inside of me
- Having floor nurses checking/poking at my vagina
- The possibility of having to go home with the catheter and keep it all weekend
- Having anyone do anything to me that I don’t know is coming, particularly anything involving touch to my mouth, vagina, or rectum
I want to have the surgery done, so I will work to cope with all of these challenges the best I can. I very much appreciate your understanding and support. I am especially grateful that you said you could help to communicate my wishes to the hospital staff who will work with me after the surgery. I hope you will find ways to extend that same understanding and support to other patients who might not be ready to tell you how much and why different procedures can freak them out. I am sure it’s hard to figure out what we all need, but I can tell you for sure that we appreciate your efforts.