A staggering number of individuals have experienced sexual trauma. According to WHO (1), an estimated one in four women in some countries may experience sexual violence, and almost a third of young women report that their very first sexual encounter was forced. Rates of sexual abuse in children range from 6% to 62% in girls and 3% to 34% in boys; children who have been abused sexually often have also experienced physical abuse and neglect, often from a trusted family member or friend (1).

Despite the prevalence of sexual trauma, it is underrecognized. Indeed, studies suggest that only 3%–26% of sexual assaults are reported to the proper authorities (2). Experts speculate that victims underreport sexual assault for many reasons. Not only do rape victims fear that they will not be believed, but they also worry that their experiences in the judicial system will be retraumatizing (3). Although most who experience sexual violence are female, males are also deeply affected by sexual abuse. According to the National Violence Against Women Survey (4), 78% of sexual assault victims are women, and 22% are men. Most perpetrators (against both women and men) are male.

Many physicians feel ill-equipped to initiate discussions about sexual trauma with their patients because of discomfort with the topic and lack of knowledge about available treatments. Because the experience of sexual trauma is common and those affected may have significant medical and psychiatric sequelae, it is essential that clinicians feel comfortable addressing sexual violence during routine medical and psychiatric care. In this review, we outline the ways in which sexual trauma and abuse have lasting consequences of importance to the health and well-being of our patients and suggest how these issues may be addressed in physician education. We describe how we can more effectively train residents and provide continuing medical education for physicians to hone their communication skills, gain insight into their personal experiences that affect their comfort level discussing sensitive issues, and update their medical knowledge regarding evidence-based treatments for conditions associated with a history of sexual violence.

Sexual trauma has significant and far-reaching effects. Individuals may experience adverse health effects as well as diminished occupational and relational functioning. In the acute setting, assault survivors often report feeling numb and dazed and may feel too vulnerable to consent to a medical evaluation. Immediately after a traumatic event, individuals may experience pain, emotional dysregulation, and severe insomnia (5). Clinicians with special training and previous experience working with assault victims are important resources in the acute setting, particularly when gathering forensic evidence (e.g., the “rape kit”). Medical providers should be sure to provide prophylaxis against pregnancy and sexually transmitted illness and offer support and referrals for counseling. To optimize chances of follow through, it is a good idea to have a firm follow-up plan in place before the victim leaves the acute care setting (5).

In the aftermath of sexual assault or abuse, individuals often experience ill-defined or atypical physical symptoms without a satisfying physiologic explanation, such as headaches, functional abdominal pain, pelvic pain, or musculoskeletal pain syndromes. Physicians must be sensitive to the fact that medical examinations, particularly pelvic and genital examinations, may be traumatic for individuals who have been sexually violated. A number of case reports in the urology literature describe traumatized male patients presenting with hypersexuality, socially inappropriate sexual behavior, excessive urologic procedures, genital mutilation, or autocastration (6). A study of female veterans with chronic pain syndromes (7) demonstrated that those with a history of sexual trauma tended to have greater pain intensity and pain-related interference than those who had not experienced sexual violence. In a study of girls and adolescent females (8), a diagnosis of posttraumatic stress disorder (PTSD) (from any trauma, not just sexual violence) was associated with adverse health outcomes, including increased likelihood of sexually transmitted infection. Because of shame or the belief that one should be able to “move on” from such experiences, patients may be reluctant to share their history with providers. As a result, physicians may order tests and perform interventions that are costly and unnecessary, often with disappointing results.

In addition to problems with general physical health, those who have experienced sexual abuse or assault may experience difficulties with normal sexual function. Intimate activity may trigger traumatic flashbacks, which may lead to emotional dysregulation, dissociation, and avoidance. Those who develop PTSD are thought to have more severe sexual dysfunction than those who are sexually assaulted but do not develop PTSD symptoms (9). PTSD (from any traumatic event) is associated with diminished libido, anorgasmia, and erectile dysfunction (10). Individuals may also experience vaginismus and dyspareunia (11). A study of female veterans with PTSD (12) (93% experiencing sexual trauma) showed that sexual dysfunction abated as PTSD symptoms diminished. Often individuals resist sharing their history with their partners, which may lead to the misperception that they are not interested in sexual activity (5). Decreased sexual interest and avoidance of intimate activity may cause tension in romantic relationships. Furthermore, those with PTSD also appear to be at risk of impulsive and potentially dangerous sexual behavior, which, in turn, leads to increased risk of unintended pregnancy and sexually transmitted infections (7).

Sexual trauma may also be associated with comorbid psychiatric conditions. As with exposure to any life-threatening event, symptoms of acute stress disorder may be present in the initial days and weeks following the trauma. Common presentations include numbing, avoidance, increased arousal, or hypervigilance, reexperiencing the event, and nightmares. When symptoms persist beyond the 1-month mark, a PTSD diagnosis becomes appropriate (13). In addition to PTSD, individuals are prone to developing mood disorders, additional anxiety disorders, substance use disorders, and eating disorders. Particularly when the event occurs early in life, sexual trauma can be associated with personality disorders. Delayed identification of a past trauma can be costly, because it may lead to inaccurate diagnoses, ineffective treatment strategies, and an unnecessarily prolonged course of suffering.

Clearly, the experience of sexual violence places patients at increased risk for both physical and psychiatric sequelae. It is important that medical providers identify a past traumatic event in a timely manner—clinicians can share countless anecdotes of patients who struggled for years with severe symptoms but recovered dramatically once the history was elicited and the appropriate treatment was undertaken. Of course, providers must take caution not to pressure the patient to disclose a trauma history before he or she feels adequately prepared to do so. It is also important to remember that not every patient with a chronic pain condition or complicated psychiatric history has been traumatized or abused.

Clinical experience has shown us that patients are hesitant to discuss sensitive topics unless they feel comfortable that their physician will competently address their concerns in an empathic, nonjudgmental, and professional manner. The same is true of discussing sexual violence in a medical setting. A key task of medical education is to prepare and support physicians to work effectively in this very sensitive and difficult area. The physician needs to convey that he or she has the medical knowledge necessary to accurately assess and treat the patient while also maintaining professional boundaries and creating a safe space to discuss the issue. Personal history, cultural background, knowledge base, communication skills, and clinical experience influence a clinician’s ability to set the stage for a therapeutic discussion. It is important for providers to have insight into personal qualities that may help or hinder them as they discuss sensitive issues with their patients (14). Furthermore, the provider must have an updated understanding of best practices in the medical and psychiatric care of sexually traumatized individuals to approach care calmly and confidently. Regular medical monitoring visits for somatic symptoms; psychotherapeutic interventions, such as trauma-focused cognitive behavior therapy (15, 16) and dialectical behavioral therapy (17); and psychopharmacologic treatments, such as serotonin reuptake inhibitors (18) and alpha agonists (19), can all be helpful.

Clinicians can increase the likelihood that their patients will be willing to share their experiences with sexual trauma or abuse by introducing the topic in an open and nonjudgmental manner during routine medical care. It can be helpful to acknowledge that such topics are sensitive and possibly difficult to discuss, especially early in the treatment relationship. (e.g., “I know that we have not been working together very long, and I want to be respectful of your comfort level, so please let me know if this topic of conversation does not feel comfortable.”) Despite the fact that the conversation might be awkward, the physician can emphasize the importance of sharing sensitive information, while leaving the door open for future discussion. (e.g., “I understand that these sensitive issues can be hard to talk about, but I have found that I can take better care of your medical issues if I am aware of any experiences in your past that have had a significant effect on you. Examples might be a bad accident, the loss of a relationship, or a personal history of physical abuse or unwanted sexual activity.”) It is also important to reassure the patient that any conversations about past trauma or abuse will be kept private and confidential, unless the physician believes that there is current risk to a child or elder that would prompt a mandated report to the proper authorities. In addition, providers should be aware of the need to document only essential information in the medical record in an accurate, complete, yet neutral manner, in the event that records are subpoenaed for future legal action. It may be helpful for the provider to seek consultation to ensure that this is done correctly.

When a patient discloses a history of sexual trauma, it is important to explore whether the individual is currently living in a safe situation and whether there is any acute risk. Discussing sexual violence can bring up a lot of emotion, so it is also necessary to evaluate the patient’s ability to cope, and a full safety assessment, including evaluation of suicidal ideation, homicidal ideation, and impulses to self-injure, may be necessary. Providers should be ready to help develop a safety plan or make an urgent referral for intensive psychiatric care.

We can help residents and fellows feel more comfortable initiating conversations about trauma by modeling a sensitive, nonjudgmental, empathic approach to screening when precepting patient care in the clinical setting. We should be sure to consider the possibility of a previous sexual trauma when helping trainees construct a differential diagnosis or biopsychosocial formulation during supervision. In addition, we must be sure to include didactic instruction in the epidemiology of sexual violence and conditions often associated with a history of trauma, such as substance use disorders, eating disorders, borderline personality disorder, dissociative identity disorder, and PTSD. Learners at all levels must be exposed to the different therapeutic modalities used to treat traumatized individuals so that they feel comfortable building a multidisciplinary treatment plan and making referrals to the appropriate providers. Residents and fellows can be given constructive feedback on communication skills and interviewing techniques in the context of the Clinical Skills Verification exams that all training programs are implementing.

Instruction in sexual violence can be seamlessly integrated into a number of settings, including didactic seminars, medical interviewing groups, outpatient evaluations and follow-up visits, inpatient medical and psychiatric experiences, and consultation-liaison work. Discrete, structured courses explicitly designed to teach clinicians to feel more comfortable discussing sexual issues may also be valuable for trainees and established physicians seeking continuing medical education. The proposed syllabus (see Appendix 1) for teaching sexual violence is based on curricula proposed for teaching about general sexual dysfunction found in the September-October 2010 issue (20, 21). Given the paucity of time available to teach everything required by the Accreditation Council for Graduate Medical Education (ACGME) (Table 1), it may be prudent for program directors to incorporate several related topics into a combined human sexuality curriculum.

As we think about how best to educate medical students, residents, fellows, and attending physicians about human sexuality, we need to remember to include instruction in sexual violence and the evidence-based treatments for traumatized individuals. Psychiatrists can model best practice interventions in clinical teaching settings in addition to providing more structured educational experiences that include didactic instruction, practice in clinical interviewing, and objective assessment of knowledge and skills. Unfortunately, the experience of coercive sexual activity is a common, and important, factor in the development of sexual concerns and chronic medical and psychiatric conditions. As we clinicians become more comfortable eliciting this sensitive information, we can feel confident that our patients will benefit from more timely therapeutic interventions and better health outcomes.

At the time of submission, Dr. Derenne reported no competing interests. Disclosures of editors are published in each January issue.