Health care for female trauma survivors (with posttraumatic stress disorder or similarly severe symptoms)

INTRODUCTION — Women presenting for health care may have experienced trauma in the forms of sexual or physical abuse (childhood or adult), emotional abuse, violence (including intimate partner violence), neglect, accidents, disaster, war, death, and medical events such as traumatic birth, having been an intensive care unit (ICU) patient, or being a health care provider during a pandemic [1]. These events may be directly experienced or witnessed. For women exposed to traumatic events, resultant posttraumatic stress disorder (PTSD) appears to develop more commonly compared with trauma-exposed men. Thus, providers of health services must understand the impact of trauma (especially directly experienced physical or sexual trauma) and PTSD (or similar symptoms) on women and female-bodied patients as well as the unique needs of trauma survivors who access reproductive and general health care.

This topic will review health care issues specific to women and female-bodied patients with trauma exposure (with or without PTSD); challenges in providing health care, including obstetric and gynecologic care for this population; and techniques to reduce retraumatization (ie, trauma-informed care). As the available study data are limited, the information in this topic comes largely from the clinical experience of health care providers, including family medicine clinicians, obstetrician-gynecologists, psychiatrists, psychologists, and social workers who have broad experience in this field.

Topics on PTSD and its management are presented separately:

●(See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis".)

●(See "Posttraumatic stress disorder in adults: Treatment overview".)

●(See "Dissociative aspects of posttraumatic stress disorder: Epidemiology, clinical manifestations, assessment, and diagnosis".)

In this topic, we will use the terms "women" or "patient" to describe those with pelvic anatomy that may include a vagina, a uterus, ovaries, and/or fallopian tubes. However, we recognize that not all people with such anatomy identify as women, and we encourage the reader to consider the specific care and counseling needs of transgender and gender nonbinary individuals.

TRAUMA, PTSD, AND TRAUMA-INFORMED CARE

Definitions — The American Psychiatric Association defines trauma as "exposure to actual or threatened death, serious injury, or sexual violence in one or more ways" [2]. The traumatic event can be experienced directly, witnessed, experienced by a family member or close friend, or result from repetitive exposure to aversive details related to a traumatic event. Traumatic events are unfortunately not uncommon. The United States Agency for Healthcare Research and Quality reports "nearly one in three adult women report at least one physical assault by a partner, and one out of every six American women report being the victim of attempted or completed rape" [3]. The National Survey of Family Growth noted that one in five women between 18 and 44 years of age reported forced sexual intercourse by a male [4]. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis".)

●Presenting symptoms and diagnosis – PTSD is a diagnosis that is applied when the traumatic event or events result in a constellation of symptoms: negative changes in cognition and mood, intrusion (unwanted memories or thoughts), avoidance, and a state of hyperarousal [2]. Not all survivors of trauma have a memory of the traumatic event, though they may manifest symptoms and signs of trauma with or without PTSD. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis", section on 'Clinical manifestations'.)

●Complex PTSD – Complex PTSD is a diagnosis that captures a more pervasive level of symptoms seen in survivors of long-term abuse and captivity, particularly those who experienced trauma in childhood [5,6]. Individuals who have been held hostage in concentration camps, prostitution brothels, prisoner of war camps, or child exploitation rings and individuals who have been subject to long-term domestic violence or childhood physical or sexual abuse all may have more severe symptoms, compared with survivors of other types of traumatic experiences, that interfere with gaining necessary health care [7-9]. Specifically, these individuals may have extreme difficulty in regulating emotions, as well as guilt, shame, and an ongoing sense of being different from others. They may have altered beliefs about the perpetrator as being all powerful and a total lack of meaning in their lives [10]. Finally, relationships with others are often severely compromised by a lack of trust or a need to find someone to rescue them. These symptoms are in addition to the symptoms of PTSD outlined above [7-10]. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis", section on 'Subtypes'.)

●Trauma-informed care – Trauma-informed care is a conceptual framework that considers a patient's previous experiences with trauma and informs providers' interactions with patients. This is done through realizing the devastating effects of trauma yet the possibility of recovery, recognizing symptoms and signs of trauma, responding knowledgeably with policies, practice, and procedures to signs of trauma in real time, and working to decrease the potential to retraumatize patients [11]. A discussion of trauma-informed care is presented in detail elsewhere. (See "Human trafficking: Identification and evaluation in the health care setting", section on 'Trauma-informed care'.)

●Resilience – Resilience, the ability to cope after traumatic events, is a complex mechanism mediated by personal, social, and genetic factors [12]. If a patient reports a history of trauma with symptoms of PTSD or complex PTSD, it is important to inquire about safe relationships in their life (both past and present). Suggesting a patient visualize a positive relational moment can be effective in countering the potential retraumatization of a necessary, intrusive medical encounter [13-15].

Prevalence of PTSD in women — Global variation in PTSD prevalence rates likely reflects variations in education about the issue, other factors relating to an individual's knowledge of PTSD symptoms and desire for professional help, and the setting in which disclosure is requested. Examples of the degree and range of trauma include:

●The World Health Organization (WHO) estimated in 2021 that approximately one-third of women globally had been "subjected to either physical and/or sexual intimate partner violence or nonpartner sexual violence in their lifetime" [16].

●Estimates of PTSD prevalence for women in the United States range from 12 to 20 percent over a lifetime and 5 to 8 percent for PTSD within the past six months [17,18].

●Survey studies have reported lifetime trauma exposure rates of 70 to 90 percent and that approximately one in four women presenting for primary or gynecologic care has a history of trauma that has resulted in intense emotional reaction [18-20].

The age of the victim appears to impact the risk of developing PTSD in response to trauma. In the National Comorbidity Survey Replication Adolescent Supplement, up to 40 percent of children who experienced sexual or physical abuse developed PTSD [21]. In addition to varying by age of exposure, the prevalence of PTSD varies with the trauma exposure rate of the population and therefore is higher in regions of disaster, conflict, and war [22-24]. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis", section on 'PTSD prevalence'.)

Pathophysiology — Information on the pathophysiology of trauma and PTSD is presented in detail separately. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis", section on 'Pathophysiology'.)

Briefly, traumatic experiences cause physiologic stress reactions and neurochemical changes in the central nervous system. These biochemical changes can result in profound psychological changes that in turn impact behavior. Trauma survivors with PTSD express dysregulation in the stress response in addition to physical changes within the brain. These changes include an overactive amygdala causing an enhanced fear response and an underactive prefrontal cortex that cannot effectively modulate the overactive amygdala [25]. As a result of these biochemical and neuroanatomical changes, triggers encountered later in life can cause parts of the brain to react as if the past trauma is currently happening and simultaneously inactivate centers that regulate the proper processing of the frightening information [25,26]. Genetic polymorphisms likely play a role in gene expression and how a lack of resilience can result in the development of PTSD [12,27].

IDENTIFICATION OF TRAUMA AND PTSD — Identification of trauma survivors is important because these individuals may have specific health care needs resulting from their trauma and because health care providers, from lack of education and/or sensitivity, may unwittingly retraumatize patients with their language or conduct [28]. Clinicians who care for survivors of sexual trafficking and trauma advise asking patients four specific questions to best elicit and document the trauma history, including [29]:

●When the trauma occurred

●Timing and duration of trauma

●The perpetrator, and whether or not the patient remains in contact with the perpetrator

●Whether or not the patient is currently safe.

This information should be documented in the social history section of the medical record succinctly with the patient's permission. Reading it back to her for her approval can be very validating for the patient. Knowing if a patient has a history of trauma can lead to the provision of trauma-informed care.

Identification and PTSD screening tools — Identification of the patient with a history of trauma can come in many forms: clinician referral, self-acknowledgment, disclosure during medical history taking, or nondisclosed and revealed during the examination or on review of prior medical records. Providing care through a trauma-informed lens is always important when working with patients, as some patients will never disclose a history of trauma, and some may not know what their triggers are or want to disclose them. As women can become victims of violence at any point in their lives [30], we believe it is important to screen for trauma when it is clinically relevant, such as when discussing the patient's mental health history or current relationships, prior to a physical examination, such as a gynecologic or breast examination, or at yearly visits. In those who disclose a history of trauma or ongoing mental health symptoms such as anxiety, depression, or insomnia, we find using a PTSD screening tool can be helpful to guide next steps. Several screening tools exist to help identify patients who should be referred for further evaluation of PTSD. The Primary Care PTSD Screen is a validated four-question checklist with yes/no responses that may open the conversation and possibly assist in identifying such patients (table 1) [31,32]. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis", section on 'Assessment'.)

The clinician should be sensitive to the possibility that the patient may continue to be a victim of ongoing trauma, such as with intimate partner violence or trafficking, but unwilling to disclose for fear of the abuser. Since a trauma history may not be disclosed at the first visit, we inquire about possible exposure to physical or sexual trauma at subsequent visits. An environment of trust, safety, and confidentiality is essential in helping patients to feel comfortable disclosing. Victim and survivor identification is presented in more detail separately. (See "Human trafficking: Identification and evaluation in the health care setting", section on 'Approach to assessment'.)

Clinical warning signs — Not every patient will want to or be able to disclose a history of trauma to their health care provider. Furthermore, survivors of trauma historically have been underserved or under-recognized by health care providers [33]. Therefore, health care providers should be alert to warning signs of possible prior trauma and/or PTSD or complex PTSD, including [2,31,32]:

●Physiologic reaction of distress, such as a startle response to loud sounds

●Negative alterations in cognition and mood, such as flat or angry affect, that can arise unpredictably or with subtle triggers

●Somatic symptoms including headache, insomnia, weight loss, abdominal pain, and sexual dysfunction

●Avoidance behavior of any sensory reminders of the traumatic event

●Hyperarousability, hypervigilance, and/or increased anxiety

●Dissociation

●Extreme distrust or dislike of the provider or others in positions of power

●Unexplained recurrent injuries or bruising

Potential indications that the patient is a victim of sex trafficking include [34]:

●Recurrent sexually transmitted infections

●Frequent pregnancies

●Frequent abortions

●Delayed presentation for care

●Companion who tries to speak for the patient and refuses to leave

●Discrepancies in the history

SPECIFIC HEALTH CARE ISSUES

Delay in seeking care — Missed opportunities for preventive health care can arise if patients avoid health care encounters because they do not want to disclose or discuss their experiences or because such visits can potentially trigger PTSD symptoms [35]. In addition, women may avoid health care because of prior negative experiences with health care delivery or with components of the physical examination. Examination of the breast, pelvis, rectum, and oropharynx, as well as procedures such as colposcopy or transvaginal ultrasound, can be triggering for trauma survivors. Examples include:

●A 2004 survey study of over 6000 US women reported that individuals with safety concerns (primarily a history of intimate partner violence) were less likely to have had cervical cancer screening within the prior 12 months, clinical breast examination, or mammography [36].

●A 2021 survey study of Indian women aged 15 to 49 years reported that over one quarter of women experienced some form of intimate partner violence (IPV) in the past year and that exposure to IPV was associated with a lower antenatal care utilization in multivariate analysis (adjusted odds ratio 0.90, 95% CI 0.84-0.97) [37].

Dissociation — Dissociation is an alteration in the usually integrated functions of consciousness, memory, identity, or awareness of body, self, or environment. In this psychological state, the patient becomes mentally removed from the immediate reality and begins to relive the previous traumatic experiences or becomes flooded with feelings about this event. While in a dissociative state, the patient's voice may change and revert to the voice she had at the time of the trauma. Other dissociative symptoms seen in patients with PTSD or similar symptoms include decreased responsiveness to external stimuli ("shutting down"), impaired memory (ie, dissociative amnesia), and disturbances of identity and awareness (eg, depersonalization and derealization). (See "Dissociative aspects of posttraumatic stress disorder: Epidemiology, clinical manifestations, assessment, and diagnosis", section on 'Concepts and definitions'.)

Patients with a history of trauma may dissociate at any time during examinations or procedures. Therefore, the clinician should be alert to these symptoms and respond accordingly. (See 'Managing patient dissociation' below.)

Comorbidities — PTSD can have long-lasting consequences on physical and mental health, including increasing risks of major depressive disorder, bipolar disorder [38], alcohol addiction, substance abuse, anxiety [39], and urinary tract dysfunction [40]. The impact of PTSD on cardiac disease is less clear as the available data conflict [41,42].

Thus, women who present with co-occurring chronic health issues, especially regarding major depressive disorder, substance abuse, and mental health, may warrant screening for PTSD. Studies report that women who are trauma survivors, compared with those not trauma exposed, have higher rates of obesity [43], metabolic syndrome, cardiovascular disease [44], irritable bowel syndrome [45], endometriosis, interstitial cystitis, migraines, fibromyalgia, and chronic fatigue syndrome [46]. Tobacco use, substance abuse, and alcohol abuse are also more prevalent among trauma survivors than in the general population [47-49]. (See "Dissociative aspects of posttraumatic stress disorder: Epidemiology, clinical manifestations, assessment, and diagnosis", section on 'Substance use disorder'.)

Sexual health dysfunction — In addition to traditional medical comorbidities, sexual function is often altered in trauma survivors, particularly those with PTSD. A history of trauma can result in avoidance of intimate relationships from lack of trust, blunted emotions, and fear of touching different zones of the body related to where and how the trauma occurred [50]. In addition, sexual health dysfunctions are prevalent, such as lack of libido (hypoactive sexual desire disorder), anorgasmia, lack of arousal, dyspareunia, and vaginismus [51,52]. Problems with menstruation and increased rates of pelvic inflammatory disease and endometriosis have also been reported [53]. Conversely, patients with trauma histories (especially youth) may also exhibit sexually inappropriate behavior and sexual compulsivity [54]. Again, this type of sexually explicit behavior can be a flag to the health care provider to screen further about trauma. (See "Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation".)

PROVIDER PREPAREDNESS

Staff and clinician education

●Use of trauma-informed care – A trauma-informed approach should be applied to all patient encounters, including on the phone and in the reception area where patients first interface with medical staff. Awareness that a patient may be a survivor of trauma, be subject to ongoing trauma, or have PTSD or related symptoms can help all staff recognize possible warning signs and communicate and interact appropriately with trauma-exposed individuals. The Substance Abuse and Mental Health Services Administration provides guidance for clinical staff on the four Rs of trauma-informed care (realize, recognize, respond, and resist retraumatization) as well as detailed information on the trauma-informed approach and trauma-specific interventions [55]. Additional information on trauma-informed care is presented separately. (See "Human trafficking: Identification and evaluation in the health care setting", section on 'Trauma-informed care'.)

●Avoid retraumatization – Retraumatization refers to the state of reexperiencing the traumatic event in the form of memories, nightmares, intrusive thoughts, or flashbacks. These can be triggered by various stimuli such as the slamming of a door, attitude or tone of voice of health care providers, or touching a patient without asking and receiving permission. Avoiding retraumatization is key to fostering and maintaining a trusting relationship with the patient. Health care providers can learn how to recognize and intervene to prevent retriggering and refer to appropriate resources as indicated.

Clinical considerations — If the patient is referred and described as having a trauma history, document who the referring health care provider is, their qualifications, contact information, and whether or not care is ongoing. However, a patient's history of trauma is often not disclosed or detected until the visit itself. If a history of trauma is disclosed, we ask the following:

●Does the patient currently feel safe? Patients who disclose that they are not safe are then treated according to guidelines for each office practice. If no such protocol exists, the clinician and patient should discuss local resources that are available to the patient. While the following table is specific to pregnant women, much of the information can apply to all patients (table 2). These issues are presented in detail separately. (See "Intimate partner violence: Diagnosis and screening" and "Intimate partner violence: Intervention and patient management".)

●Do they have anyone in their life that they have talked to about this, or would they like behavioral health resources?

●Would the patient feel more comfortable deferring an examination or procedures to a future appointment?

●Does the patient have any known triggers that we can actively work to avoid?

●Does the patient have any specific request(s) pertaining to the examination or future visits?

Lastly, it can be helpful to ask about previous positive experiences in a health care setting: What type of support was helpful to make an examination or procedure more comfortable for them?

The manner in which all of the staff involved in a patient's care communicates is important. Clinicians focused on care of survivors of sexual trauma have compiled a list of actions for consideration when caring for these individuals (table 3) [29].

Office protocol — We advise implementing an office-based protocol that allows scheduling of longer appointments for trauma survivors who may need more time for examination or office-based procedures (table 4). In our experience, these patients can benefit from additional time (possibly double), the presence of a chaperone/medical assistant, the presence of a support person, and the use of the first or last appointment of the day (to reduce possible anxiety associated with waiting). In addition, we offer that patients complete all intake forms and paperwork in advance so the information can be completed in a nonthreatening environment and potentially shorten their office wait time.

If the history of trauma and/or PTSD is known in advance, we ask the referring provider to reassure the patient that the first appointment will be a consultation only (ie, without examination) to discuss the medical issues, establish rapport, and build trust. If physical examination cannot be deferred to a later visit, we try to book a longer appointment to ensure that we have the time required to make the examination as minimally traumatizing as possible. We also request that the referring clinician not premedicate the patient for the first appointment. Premedicating for a subsequent visit, particularly for examination or procedure, can be helpful. (See 'Patient pretreatment for anxiety' below.)

Patient pretreatment for anxiety — For women who find the prospect of a physical examination or procedure extremely anxiety-inducing, pretreatment with an anxiolytic can be beneficial. While there is no standard approach, we find lorazepam 0.5 mg taken orally approximately one hour prior to the visit, and the night before the visit if needed, to be helpful. Benzodiazepines can also work as a mild muscle relaxer, which can further aid in decreasing discomfort from an examination. For women who exhibit symptoms of complex PTSD, it is important to ask if medication was used in abuse rituals prior to recommending an anxiolytic. We ask patients who are taking anxiolytic medication not to drive themselves to or from the visit. (See "Acute procedural anxiety and specific phobia of clinical procedures in adults: Treatment overview".)

For women who are unable to tolerate pelvic examination or procedures while awake, the clinician can schedule an examination or procedure (eg, intrauterine device insertion or endometrial biopsy) under anesthesia instead (table 4). (See "Pelvic examination under anesthesia".)

Support person and other strategies — We encourage the patient to bring a support person, such as a partner, friend, or therapist, to examination or procedure visits if they would find this helpful. Some women benefit from bringing a support object that can be held or seen during the visit to orient them to the present. Additional strategies include the use of music, such as from a patient's phone; focused visualization; breathing exercises; and meditation apps available on smart phones. There is a growing movement for trauma survivors to have emotional support pets. If this is acceptable to the provider, a support animal can often help the patient feel safe. If no outside support person is present, we ask patients if they would like a clinical staff member to provide support during a procedure.

We ask our patients if the provider's gender triggers symptoms. If so, we attempt to arrange providers of the preferred gender. Knowing that much of the time trauma history is not disclosed until later in the visit, we try to meet our patients first while they are clothed to increase a patient's sense of safety and ability to talk openly. If a history of trauma is known beforehand, it can be helpful to obtain the medical history in a consult space rather than an examination room. In addition, we try to void using phrases such as "just relax" or "you're ok" as assailants may have used these on the victim.

HISTORY AND PHYSICAL EXAMINATION — For all patients, but particularly for victims and survivors of trauma, health care providers need to acquire the skills to conduct a history and examination in an atmosphere of safety and trust while keeping the patient as psychologically and physically comfortable as possible. Strategies that we have found helpful are listed in the table (table 5).

Managing patient dissociation — While patients with a history of trauma may dissociate at any time, times of particular risk include physical examination, procedures, the perioperative period, and childbirth [56].

●If dissociation occurs during an examination or procedure, we stop and reorient the patient to the present time and place by using language such as the following: "I am Dr. (Name). You are in my office. It is (date and year), and you are completely safe. Can you hear me?" We repeat this information as necessary until the patient is grounded in the present.

●If a patient is not able to become grounded with reorientation to the present, another strategy would be to focus on one of the five senses. For example, the clinician could give a client an ice cube or ice bag to hold or even some cold water to drink. Strong physical sensations can help the grounding process.

●After such an event, the patient may need some time alone, or with her support person, before she is comfortable enough to either continue the visit or leave the office.

If a dissociative episode has occurred, and after the patient has been reoriented and recovered, the clinician and patient should decide together whether or not to proceed with the visit. Our patients have emphasized that having the choice to continue or reschedule the visit and having the control of the decision are very important to reduce both stress and the sense of failure. For women who choose to continue the visit, completing the examination can generate feelings of survivorship and authority over her life. For women who are unable to complete the visit, we support their decision and help them make follow-up plans. We also contact them in one or two days to check in, continue to offer support, and discuss next plans.

Approach to physical examination — We have found the following techniques, which can be used for all women, helpful in establishing trust and maximizing patient comfort (table 5):

●Supportive language – During the examination, we aim to use language that is reassuring and reinforces that the woman is in control of the experience. We ask her if she is ready for the examination and wait for her response, obtain her permission for each step of the examination, and reassure her when each step is complete. We also remind the patient that she can stop or pause the examination at any time.

●Special populations – It is important to keep in mind that transgender male and gender nonbinary patients need Pap smears and may need other gynecologic procedures as well, and some may disclose a history of trauma. Ask which pronouns they use and ask about the language they use for their body as this will demonstrate your sensitivity and understanding of their unique needs. (See "Transgender men: Evaluation and management".)

●Role of chaperone – We advise clinicians to have a medical assistant present for any examination or procedure if the patient consents. In addition to assisting the clinician, the medical assistant is a chaperone, witness, and hand to hold, if the patient chooses. We ask the medical assistant to stand by the patient's side to ensure the patient's privacy. Some patients prefer not to have the medical assistant but will allow the support person of her choice, such as partner, friend, or therapist, to be in the examination room.

●Clothing coverage – We try to keep the patient as covered as possible during the examination. As an example, the clinician can perform breast palpation under a drape that covers the breasts and then ask to look briefly and discretely at the skin for any signs of lesions, dimpling, etc. We make sure to drape patients as much as possible, and let them know they can also keep shoes or socks on if this would be helpful. For patients who are comfortable wearing a skirt or dress, we discuss wearing this type of clothing to the examination visit so the patient can simply remove her underwear and remain clothed during the examination, rather than wearing an examination gown.

Performing pelvic examination — For women with a history of trauma or PTSD, any touching of the patient can trigger a negative emotional response from the patient (eg, assisting the patient onto the examining table). To limit such response, we describe the planned examination and rationale for performing it, ask permission prior to touching a patient, and minimize unnecessary physical contact (table 5). Throughout the physical examination, it is important that the provider describes both the normal and the abnormal findings with the patient in clear concise language. (See "The gynecologic history and pelvic examination", section on 'Pelvic examination'.)

●Patient positioning – Pelvic examinations are typically performed in dorso-lithotomy or side-lying positions. We ask the woman which is preferable for her. In addition, we ask if she would be more comfortable with the head of the table elevated as much as possible. We ensure that she can make eye contact with the provider performing the examination.

●Examination of external genitalia – We ask the woman's permission prior to inspecting her external anatomy. Components of the external examination are reviewed separately. (See "The gynecologic history and pelvic examination", section on 'External genitalia'.)

●Speculum and bimanual examination – Prior to performing the speculum and bimanual examination, we obtain the patient's permission and offer the patient a mirror so she can view the examination, if desired. Once the patient has given consent, we proceed with the speculum examination. (See "The gynecologic history and pelvic examination", section on 'Speculum examination' and "The gynecologic history and pelvic examination", section on 'Bimanual examination'.)

We find having a range of speculum sizes helpful. As examples, the Pederson extra narrow speculum, 1.5 cm width and 11.5 cm length, or the Pederson medium speculum, 2.5 cm width and 10 cm length, are helpful [57]. We ask the woman if she prefers the speculum insertion to be slow and stepwise or performed as gently yet rapidly as possible. For some patients who are having difficulty with the speculum examination, it can be helpful to ask if they would like to insert the speculum themselves. Self-insertion of the speculum can give the patient a sense of empowerment over this component of the examination.

Speculums can be moistened with a small amount of a water-based lubricant without compromising cytology. The speculum blades should be inserted so that the widest diameter is oblique to avoid urethral pressure. We apply gentle pressure posteriorly at the fourchette until the cervix is visualized. We ask the woman to let us know if the examination is painful so we can pause and adjust the speculum. In addition, we remind her that she can request we stop the examination at any time. For women who are unable to tolerate speculum examination but will permit single finger bimanual examination, we obtain cytology, and human papillomavirus testing as indicated, blindly using the broom device. If available, the broom requires passage of only one instrument, while use of the spatula and endocervical brush involves two devices. The edges may need to be trimmed to facilitate insertion. Lastly, we review the findings at the completion of the examination.

TESTS, PROCEDURES, AND SURGERY — In our practice, we have found the following suggestions helpful when arranging tests, procedures, or surgery for women with a history of trauma (table 4):

●Avoid retraumatization whenever possible – Transvaginal tests and procedures, such as transvaginal ultrasound, can be extremely difficult for women with PTSD, particularly abuse survivors. Whenever possible, we request a transabdominal rather than transvaginal ultrasound. Alternately, transperineal ultrasound may be possible in some cases. When a transvaginal approach is optimal, we ask the woman if she will allow the examination and would feel more in control if she inserted the ultrasound probe herself. In our experience, traumatized patients may not be able to articulate their fear of transvaginal examination or decline insistence by the radiologist or technician. Performing transvaginal examination without explicit permission is traumatizing and may trigger dissociation. Complying with the patient's request to forego the vaginal probe can instill trust that enables the woman to allow transvaginal approach in the future.

●Engage the woman in her care – For example, we explain the indication for, and nature of, all tests and procedures to the patient in advance. This approach allows the woman to discuss components that may be difficult for her and to identify an alternate solution with her care provider.

●Have a support person, pet, object, or music – As with the physical examination, we suggest the patient bring a support person or object with her to the test or procedure.

●Communicate with other team members – We share, discreetly and confidentially, with essential care providers that the woman has PTSD, and thus components of care that are typically routine may be problematic (eg, venipuncture).

●Allow the patient to position herself – For physical examination and certain tests, such as mammography, the woman's body position and tissue requires handling and positioning. When appropriate, we ask the patient to position herself or ask her permission for us to guide her.

●Premedicate when appropriate – As with physical examination, some patients will benefit from pretreatment with anxiolytic medication. Imaging studies, such as magnetic resonance imaging and computed tomography, can induce claustrophobia or fear. Discussion of the test in advance and use of anxiolytic drugs can enable the patient to complete the test or procedure. One caveat to premedication is that women who have had prolonged abuse or trauma may have been medicated by the perpetrator to insure compliance; we specifically ask the woman if she experienced such harm before we prescribe anxiolytic drugs or other premedications.

OBSTETRIC CARE ISSUES

Impact of PTSD on obstetric outcomes — While PTSD has been associated with poor obstetric outcomes, particularly preterm delivery, there are no data-driven recommendations specific to this population. However, a qualitative interview study of 20 trauma survivors who described their experience with childbirth contributed some guidance regarding the importance of having a birth plan, sharing their history of trauma with the obstetric team, and suggesting that providers use language around examinations to avoid triggering [58]. We assess each woman's risk and manage her care on a case-by-case basis.

●Preterm delivery – PTSD is associated with an increased risk of preterm delivery (ie, birth at less than 37 weeks of gestation). The mechanism is not known, but stress may play a role. In a retrospective cohort study, women with active PTSD, when compared with women with no or historical PTSD, had a 35 percent increased risk of preterm delivery in the adjusted analysis (adjusted odds ratio [OR] 1.35, 95% CI 1.14-1.61) [59]. In a prospective cohort study of over 2600 women recruited prior to 17 weeks of gestation, the risk of preterm birth increased by 1 to 2 percent for each additional point on the Modified PTSD Symptom Scale (range 0 to 110) [60]. Women with both major depression and PTSD had a fourfold increased risk of preterm birth. In a study of the World Trade Center Health Registry, women with probable PTSD had a nearly 2.5 increased risk of preterm delivery in the year following the terrorist attacks compared with births to women who did not have PTSD [61]. (See "Preterm labor: Clinical findings, diagnostic evaluation, and initial treatment".)

●Lower birth weight – Stress, trauma, and PTSD have been associated with lower birth weight infants in some studies. In a questionnaire-based cohort study, the mean birth weight of babies born to women with PTSD was 283 g less than infants born to trauma-exposed women without PTSD and 221 g less than babies born to nonexposed women [62]. In a study comparing 47 women exposed to life-threatening rocket attacks during the second trimester of pregnancy with 78 unexposed women, the trauma-exposed women had more low birth weight infants (15 versus 3 percent) [63]. In the above study of the World Trade Center Health Registry, the risk of preterm birth in the week after the attacks on the World Trade Center was significantly increased compared with the two prior years (adjusted OR 1.44 for births <1500 g and 1.76 for births 1500 to 1999 g) [61].

●Hyperemesis gravidarum – It is unclear if PTSD is associated with hyperemesis gravidarum (HG, or excessive vomiting during pregnancy). One study postulated that a trauma-related type of HG exists that is mediated by high levels of oxytocin [64]. A different study comparing women with recurrent HG with those whose HG did not recur did not report a difference in preexisting psychiatric diagnoses (anxiety, depression, bipolar disorder, panic, or eating disorders) between the groups [65]. The experience of having HG itself can result in PTSD [66]. More studies are needed to elucidate a possible relationship between the two illnesses. (See "Nausea and vomiting of pregnancy: Treatment and outcome", section on 'Management of vomiting with hypovolemia'.)

Antepartum — Eliciting a trauma history, especially childhood sexual abuse or later sexual trauma, during pregnancy can alert the obstetrician to the need to modify language and care (table 2). The pregnancy itself, obstetric procedures, and pregnancy-related complications can retraumatize the patient during the current pregnancy and potentially impact future pregnancies. To mitigate stress, we discuss the woman's plan for labor support person(s) (eg, partner, friend, family member, and/or doula) during her antenatal care. Knowing in advance who will be present to support the patient can be beneficial.

Issues that can be particularly important to address for trauma-exposed women include:

●Fear of childbirth – "Tocophobia," the fear of childbirth, may predate the first pregnancy or arise after a traumatic birth [67]. One in 20 pregnant women experience great fear of giving birth, sometimes for fear of the pain itself or for the baby's health [68]. Extreme fear of childbirth is linked to request for elective cesarean section delivery [69]. If high levels of anxiety or fear are observed in a pregnant patient, we screen for PTSD and depression and refer women with a positive screening test to a behavioral health provider for further support and counseling.

●Fear of pain – Many women have a fear of childbirth-associated pain, which can be exacerbated in women with a history of trauma. We discuss the patient's expectations of the discomfort associated with labor, coping strategies, and options for pharmacologic pain management. An antenatal consultation with the obstetric anesthesia team can be helpful if available. (See "Preparation for childbirth" and "Nonpharmacologic approaches to management of labor pain" and "Pharmacologic management of pain during labor and delivery".)

●Retraumatization – Experiences specific to prenatal care, such as repetitive cervical examinations or transvaginal ultrasound, can trigger PTSD symptoms in some women. In an interview study of nine postpartum women, all survivors of childhood sexual abuse, the women reported that events ranging from labor pain to breastfeeding retriggered physical or emotional symptoms related to their prior abuse [70]. We raise these issues with trauma-exposed patients, ask them to guide us in ways to make the experience minimally traumatic (eg, presence of a support provider), and postpone nonessential examinations and studies until trust is established and patient consent is freely given.

●Substance use – While we screen all pregnant women for problematic substance use, we remain vigilant to the high rates of substance use in survivors of trauma. In the 2011 National Epidemiologic Survey on Alcohol and Related Conditions, nearly half of the participants who met the criteria for PTSD also had a substance use disorder [47]. Women with a history of both childhood and adult abuse are at particularly high risk for tobacco and substance use compared with women without an abuse history or women abused in only one of those time periods [48]. (See "Substance use disorders: Clinical assessment".)

●Depression – The prevalence of depression in pregnancy appears to correlate with the extent of abuse endured by the patient [48,71]. In a survey study of 1200 pregnant women, the rates of current depression were 9 percent (no abuse), 14 percent (abuse as adult only), 17 percent (abuse as a child only), and 32 percent (abuse both as child and adult) [48]. While all women are screened for depression during antenatal and postpartum care, we ask abuse victims and survivors about depressive symptoms at every visit. (See "Unipolar major depression during pregnancy: Epidemiology, clinical features, assessment, and diagnosis".)

Intrapartum — The intrapartum experience can be inherently stressful. Women with a history of childhood sexual abuse have significant rates of dissociation during childbirth, subsequent difficulty with bonding with the child, and potential long-term consequences to the child's development [56]. As noted above, we encourage women to identify the individuals who will support them through the labor and delivery experience prior to the onset of labor.

Maneuvers such as fetal scalp electrode placement, cervical assessment, and assisted delivery; complications such as umbilical cord prolapse, postpartum hemorrhage, and perineal lacerations; unplanned cesarean section; and transfer of the baby to the neonatal intensive care unit (NICU) can all induce extreme stress and sometimes flashbacks. Whenever possible, we encourage clinicians to explain any examinations or procedures to the patient in advance. During delivery, involuntary micturition or defecation can be humiliating and trigger PTSD symptoms.

To help minimize stress, we advise having a consistent and limited number of care providers during labor. Ideally, cervical examination is performed by the same provider, who is already known by the patient. We attempt to limit the number of care providers in the delivery room, especially during examination. We also inform the patient of the role of each person. We explain what will be done and the purpose of the examination and ask for her verbal permission. We also review with the patient the need for additional staff in the event of a fetal deceleration or emergency.

Postpartum — There are limited data on how the postpartum experience may be different for women with a history of trauma with PTSD. A systematic review of 21 studies that examined the relationship between perinatal PTSD and birth outcomes reported contradictory findings regarding an association between PTSD and the mother-infant interaction, mother-infant relationship, or child development [72].

It appears that prior depression or depressive symptoms may worsen PTSD symptoms after delivery. In a meta-analysis of 50 studies, risk factors for birth-related PTSD were depression in pregnancy, fear of childbirth, poor health or medical complications during pregnancy, a history of PTSD, and prior counseling for pregnancy- or birth-related issues [73]. A different study that assessed posttraumatic stress symptoms at several time points postpartum reported that use of antidepressant medication in the 10 years prior to birth was associated with higher symptom screening scores six weeks after delivery [74]. As these studies focused on the risk of developing de novo PTSD, more data are needed on the impact of delivery on women with preexisting PTSD.

Pregnancy loss or termination — The impact of pregnancy loss or abortion on women with prior trauma with PTSD, or similarly severe symptoms, is not known. De novo PTSD can occur in response to spontaneous pregnancy loss, ectopic pregnancy, or pregnancy termination [75-78]. Pregnancy termination is not necessarily traumatizing; however, when termination is chosen because of fetal anomalies, it may result in trauma-exposure symptoms. In a questionnaire study of women who terminated a pregnancy because of fetal anomalies, pathological symptoms consistent with PTSD were reported by 46 percent of women at 4 months of follow-up and 21 percent at 16 months [79].

MEDICAL RECORD DOCUMENTATION — Issues regarding medical record documentation, legal obligations, and mandatory reporting are reviewed separately. (See "Intimate partner violence: Intervention and patient management", section on 'Legal issues'.)

RESOURCES FOR PATIENTS AND CLINICIANS

●National Center for PTSD – Provides information for both patients and clinicians, including training videos.

●Substance Abuse and Mental Health Services Administration – Provides information on trauma and violence.

●American College of Obstetricians and Gynecologists (ACOG) Committee Opinion Number 518, Intimate Partner Violence, and Number 825, Caring for Patients Who Have Experienced Trauma.

●Rellini H. The treatment of sexual dysfunctions in survivors of sexual abuse. In: Principles and Practice of Sex Therapy, 5^th ed, Binik Y, Hall K (Eds), Guilford, New York 2014. p.375.

SUMMARY AND RECOMMENDATIONS

●To help direct clinical care, definitions of trauma, posttraumatic stress disorder (PTSD), complex PTSD, and trauma-informed care have been established (see 'Definitions' above):

•The American Psychiatric Association defines trauma as "exposure to actual or threatened death, serious injury, or sexual violence in one or more ways." The traumatic event can be experienced directly, witnessed, experienced by a family member or close friend, or result from repetitive exposure to aversive details related to a traumatic event.

•PTSD is a diagnosis that is applied when the traumatic event(s) results in a constellation of symptoms including negative changes in cognition and mood, intrusion (unwanted memories or thoughts), avoidance, and a state of hyperarousal. Not all trauma results in PTSD.

•In addition to standard PTSD symptoms, complex PTSD results in severe relational disturbances including distortion of the perpetrator, extreme guilt and shame, and either severe isolation or dependence on others. Complex PTSD is found in women who have had long-standing physically or sexually traumatic experiences in childhood or who have been held captive as a prisoner of war or as a sex worker.

•Trauma-informed care is a conceptual framework that takes into account a patient's previous experiences with trauma and informs providers' interactions with patients. This is done through recognizing signs of trauma, responding to signs of trauma in real time, and working to decrease the potential to retraumatize patients.

●Women with a history of trauma, PTSD, or complex PTSD may access care less often because they do not want to disclose or discuss their experiences with trauma or because such visits can potentially trigger PTSD symptoms. In addition, women may avoid health care because of prior negative experiences with health care delivery or with components of the physical examination. Women with significant dissociation may not seek care because they are so disconnected from their bodies. This avoidance can lead to decreased preventive health screenings and increased morbidity over time. (See 'Specific health care issues' above.)

●Survivors of trauma historically have been underserved or under-recognized by health care providers. Identification of trauma survivors is important because these individuals may have specific health care needs resulting from their trauma and because health care providers, from lack of education and/or sensitivity, may unwittingly retraumatize patients with their language or conduct. The Primary Care PTSD Screen is a four-question checklist with yes/no responses that may open the conversation and possibly assist in identifying such patients (table 1). Other screening tools are also available. (See 'Identification and PTSD screening tools' above.)

●A trauma-informed approach should be applied to all patient encounters, including initial interactions (eg, phone and reception area encounters). This trauma-informed approach helps all staff recognize possible warning signs and communicate and interact appropriately with trauma-exposed individuals. The Substance Abuse and Mental Health Services Administration provides guidance for clinical staff on the four Rs of trauma-informed care (realize, recognize, respond, and resist retraumatization). (See 'Provider preparedness' above.)

●For all patients, but particularly for victims and survivors of trauma, clinicians need to acquire the skills to conduct a history and examination in an atmosphere of safety and trust while keeping the patient as emotionally and physically comfortable as possible. Strategies that we have found helpful are listed in the table (table 5). Asking patients about potential triggers, as well as previous positive experiences with examinations or procedures, can help clinicians to avoid triggers and reduce their patient's discomfort. (See 'History and physical examination' above.)

●For physical examinations and procedures, we remind the patient that she is in control of whether or not the examination or procedure occurs, is completed, or is terminated partway through. We believe this approach enhances patient confidence in the provider. Additionally, the care provider must be prepared to manage a dissociative event should it occur. (See 'Approach to physical examination' above and 'Performing pelvic examination' above.)

●Pregnancy and childbirth can be particularly challenging for women with trauma exposure and PTSD or similarly severe symptoms. Clinicians caring for women who have experienced trauma need to be able to screen and refer for appropriate behavioral health care, discuss triggers as well as potential modifications so that triggers can be avoided, maintain patient privacy, and help the patient engage in safety planning (table 2). (See 'Obstetric care issues' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Alexis Drutchas, MD, who contributed to an earlier version of this topic review.