The Endoscopy Patient With a History of Sexual Abuse:
Strategies for Compassionate Care
Elizabeth Davy, RN, CGRN
A past history of sexual abuse may put a patient at risk of developing physical and psychological sequelae including fear of medical procedures. Invasive procedures such as endoscopy and colonoscopy may exacerbate fears and provoke stress reactions.
In a 90 to 120 minute visit, Endoscopy team members must create rapport, establish a trustworthy relationship, prepare the patient for the procedure, complete the procedure, and then provide post-procedure care and follow-up. The process can be made even more difficult when a history of sexual abuse becomes apparent during the intake, assessment, or procedure. This is not an excuse to abandon the principles of comprehensive care; in fact, it becomes a mandate to do more for the patient and provide the additional resources needed for care and healing. This article reviews the need for careful assessment and intervention during endoscopy procedures for patients with a past history of abuse. Guidelines for compassionate care and follow-up are discussed.
A history of sexual and physical abuse, resultant feelings of anxiety and fear, and a lack of understanding from healthcare providers may prevent people from seeking medical care and lead them particularly to avoid endoscopic procedures such as colonoscopy (Tudiver, McClure, Heinonen, Kreklwitz, & Scurfield, 2000). The percentage of women and men in the United States with sexual abuse histories ranges from 6% to as high as 74% (Drossman, Talley, Leserman, Olden, & Barreiro, 1995). Because only a small number of patients freely acknowledge their abuse histories, it is incumbent upon healthcare providers to elicit and attend to this factor to improve the patient’s clinical outcome (Drossman et al., 1995). As renowned physician Sir William Osler said, “It is much more important to know what sort of patient has a disease than what sort of disease the patient has.”
Failing to screen for a past history of abuse may empower the abuse situation, contribute to feelings of isolation, and convey the impression that it is irrelevant to current issues or symptoms (Seng & Petersen, 1995). Some sexual abuse victims may have experienced a single episode whereas others may have been victimized multiple times over many years. The severity of an individual’s response does not always correlate with the type and duration of the abuse (Hudson, Jones, & Weber, 1999).
A 55-year-old woman who was sexually abused by her father and brothers after her mother gave her enemas to clean her for them spoke with her physician about her fears of having a colonoscopy. He shared the information with the procedure nurse who introduced herself to the patient and acknowledged having been informed of the patient’s abuse history. Because the nurse had been previously acquainted with the patient outside of the medical setting, and the patient remembered her, the nurse offered the option of having someone else as the endoscopy procedure nurse; the patient declined. The colonoscopy was completed successfully.
As illustrated, when a physician has obtained information from a patient regarding a history of sexual abuse, the knowledge should be shared with the other team members involved to provide for the completion of the procedure with the least amount of stress for the patient. Having this knowledge provides an opening for either the admitting or recovery nurse to ask, “What can I do to make today’s procedure easier for you?” Ideally, it is best if this question is asked while the patient is still fully dressed. Asking this question allows patients to decide whether they wish to disclose further details and affords insights into practical ways to ease their care (Tudiver et al., 2000).
An effective screen is to ask, “Are you a victim of abuse?” If the patient answers ‘yes,’ then one should ask, “What kind of abuse?” Because often patients are living with their abusers or are otherwise enmeshed in the relationship and may need assistance to get out of the situation and/or referral to an agency or counselor for support, patients also should be asked if their abuser was a known person (family member, friend, acquaintance, health care provider, counselor, clergy member, etc.) or someone unknown. More often, people who have been raped by a stranger have received help, whereas those who have been or are currently being abused by a family member, pastor, or healthcare provider are much less likely to talk about their experience and thus less likely to receive help.
Even if a patient initially denies abuse, he or she may still disclose an abuse history at any time during the intake. Many patients will not verbally disclose their history of abuse but may provide nonverbal cues. A patient may be extremely anxious, avoid eye contact, or may even shake or cry. Patients may also exhibit feelings of vulnerability and a sense of helplessness. An intense sense of helplessness may drive the patient’s fear. It is important that providers recognize these feelings and find ways to help diffuse that fear (David M. Reiss, MD, personal communication).
No matter when or how the information is obtained, the reaction to the disclosure of a sexual abuse history must be calm and nonjudgmental. Most patients respond well to hearing the words, “I understand. “ If a negative message is conveyed at the time of disclosure, the patient’s feelings of betrayal, stigmatization, and powerlessness resulting from the abuse may be replicated (Weaver, Varvaro, Connors, & Regan-Kubinski, 1994).
Patients must be given opportunities to explain what they would find most helpful to get through the procedure. Likewise, it is necessary to explain to the patient in advance everything that will be done and continue to explain what is taking place as the procedure progresses.
Some patients may request same-sex providers. This request should be accommodated whenever possible. Currently in Portland, Maine, where the author’s practice is located, there are no female gastroenterologists. There is, however, a female surgeon who performs colonoscopies; we have had occasions to refer patients to her. Similarly, when a male patient requested that there be no women present during his colonscopy, the procedure was scheduled at a hospital where there is a male endoscopy nurse. Whenever possible, a patient’s request should be honored in whatever way that allows the patient to be comfortable and satisfied.
During the Procedure
A male patient in his 60s was very quiet when he came into the procedure room. He was somewhat unkempt and quite angry. His anger was directed towards his girlfriend and his physician, the people who had pushed him to have the procedure. When the doctor performed a rectal exam prior to inserting the colonoscope, the patient stated “things might not be right back there” because of what had happened to him while he was in jail. This included abuse with broomsticks. He cried silently throughout the procedure. The nurse coached the patient during the procedure, telling him what a good job he was doing and where he was in terms of the procedure. Upon discharge, the patient was very appreciative of the support and understanding he received.
Colonoscopies, endoscopies, and other procedures that involve placing an instrument into a body orifice may be sufficiently reminiscent of a person’s sexual trauma to evoke a posttraumatic reaction. Although invasive procedures are the most dramatic examples of trigger events that occur in the medical setting, a number of other aspects of medical treatment also may evoke trauma reminders. These include being touched in what would otherwise be a non-threatening place or manner, awareness of the power differential between the patient and the provider, the removal or absence of clothing during an examination, and the focus on body pain or disorder (Sharkansky, 2005). The feel of an automatic blood pressure cuff may be experienced as grabbing of the arm. Some patients resist being placed in a horizontal position and are afraid of having objects placed over or near the face, experiencing severe gagging in response, and involuntarily turn away from the provider (Willumsen, 2004). Some patients do not react until the instrument is inserted. Others may respond by pulling the sheets over their faces or heads, crying, pushing providers away, or asking for the procedure to be stopped.
A woman in her mid-40s was having an esophagogastroduodenoscopy, a procedure to view the esophagus and stomach, for persistent pain and nausea. When the gastroscope was inserted following sedation, the patient began to scream, cried, and pushed the doctor away. He removed the scope, and the patient apologized. The patient was told she did not need to complete the procedure at that time, but she insisted that she wanted answers for her symptoms. After additional sedation, the procedure was completed. Throughout the procedure, the nurse continuously reminded her of where she was and what she was doing. Subsequently, the team learned that she had a past history of abuse and had been forced to perform oral sex for her abuser.
It is important to orient the patient to the procedure and place, continuously provide reassurance that things are going well, speak in a calm and reassuring manner, and determine if more medication is needed. If possible, it can be helpful to take a break during the procedure. Distracting conversations about family, job, or hobbies can also help orient the patient to the present. Facilitating support during the procedures involves being empathetic, knowledgeable, nonjudgmental, honest, and empowering (Glaister & Abel, 2001).
When the patient’s emotional reaction is extreme, it may be necessary to suggest stopping the procedure, but this should be discussed with the patient. It is essential to provide the patient with as much choice as possible (Sharkansky, 2005). In many cases, the patient may feel that the worst is over and want to finish the procedure so as not to face a second invasive event.
Some sedatives used during colonoscopy are associated with a high incidence of partial or complete impairment of recall for several hours after administration. Data from the manufacturers of these drugs indicate that 71% of adult patients in endoscopy studies have no recall of introduction of the endoscope; 82% of the patients have no recall of withdrawal of the endoscope (Rx List, 2004). This may be helpful for patients with a sexual abuse history; however, the medical team should never promise amnesia to anyone, as it may not occur.
Pharmacodynamic and pharmacokinetic properties of the medications, particularly rapid recovery of awareness and lowering of inhibition, also should be recognized. Case reports have documented that patients have had sexual hallucinations during minor surgical procedures; these often involve female patients with male providers (Martinez Villar, d’Este Gonzalez, & Aren Frontera, 2000). Other cases have identified patients who have become hostile and violent rather than tranquil (Weinbroum, Szold, Ogorek, & Flaishon, 2001). Although specific cases involving endoscopic procedures, sexual abuse, and reaction to medication could not be identified in the literature, it must be kept in mind that the medications used during the procedure could precipitate an untoward reaction based on a past history of sexual abuse. Deep sedation or analgesia with the use of Propofol might be indicated for some of these patients. The author’s practice is to offer this alternative for a select group of patients as recommended by their physicians.
After the Procedure
Following the procedure, it is necessary to check with the patient to assess how he or she is doing and determine their reactions to the experience. Patients should be asked about the effects of the medication and assessed if they are amnesic. Patients may have memories, and if so, it is important to provide support during recovery. Patients should be praised for what they have accomplished. It is also important to ask what might have been done differently that would have been more helpful.
The day following a difficult procedure, a nurse talked to a patient and mentioned the experience had apparently brought back some bad memories. The patient responded that she thought that was all gone. The nurse explained this type of trauma is never all gone and encouraged the patient to visit the counselor she had previously seen. The patient was also advised to share this history with healthcare workers, especially when having an invasive procedure or surgery. The patient called several months later to thank the nurse and update her on the patient’s response to counseling.
A follow-up phone call should be made within 24 hours to all patients. This provides an opportunity to make a referral to an abuse counselor. It is also helpful to provide the patient with written information about available agencies or support groups. The need of the patient to share the past history with healthcare providers should be reinforced, especially when having an invasive procedure or surgery. It is appropriate to advise the patient that the primary care provider and the referring physician should be informed of the past history and its details. If the patient is not comfortable conveying this information, a member of the endoscopy team may be offered to do so.
With 25 years of endoscopy nursing experience, the author is always open to what her patients have to say, verbally and nonverbally. The greatest satisfaction is helping patients get through the procedure successfully, especially those who are unfortunate enough to have a history of sexual abuse. The interventions described here are evidence- based and have proven to be effective in practice. Understanding of the sequelae of abuse by an endoscopy team that is caring and supportive can help patients have a successful procedure and, at the same time, an experience healing their past history.
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