Caring for long term health needs in women with a history of sexual traumaBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l5825 (Published 22 October 2019) Cite this as: BMJ 2019;367:l5825
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Ades et al outline the ways to care for women with long term health needs resulting from sexual trauma. Whilst the educational focus of the article is vital for ensuring that women with a history of sexual trauma are not marginalised from the clinical setting, it is also important to include a nuanced conceptual and critical approach to the framing of such women’s long term health needs.
By situating the discourse of treating long term health needs in women with a history of sexual trauma, there is the risk of prescribing pathology to the woman; a pathology that has been fundamentally shaped by systemic and structural forms of violence and injustice. A woman who is suffering from the burdens of psychological trauma is reacting and responding to the recognition that her integrity and agency have been violated. Trauma-focused cognitive behaviour therapy interventions in the acute phase after sexual assault to potentially prevent the development of post-traumatic stress disorder are a misnomer. The pathology is not within the woman, but constructed by societal-cultural factors. Reducing a woman to her own suffering negates the ways that she has been subjected to pathological forces in her surrounding world. Rather, we should be encouraging and creating spaces for a woman to suffer her suffering.
As a researcher and expert witness to asylum cases related to gender-based violence, the long-term impact of sexual trauma cannot be neatly packed into a linear narrative such as identifying critical window periods in which to implement preventative trauma therapeutic interventions; similarly, the notion of re-traumatisation is questionable. The complexity of sexual trauma means that often there is no respite between the lived experience of its aftermath; that there is no separation of traumatisation, therefore there are no (re)traumatisations, only new traumas. My experience with research in Afghanistan (Mannell, Ahmad, and Ahmad 2018) and in developing a trauma therapeutic intervention using traditional storytelling in Kashmir (www.shaercircle.com) reveals women’s narratives where violence is continually threaded throughout their lives. Women’s lives are part of collective histories, not just an individual case-history, and violence is contained on a continuum whether that is as part of war or conflict, or more localised sources such as within a family or cultural belief-systems. It is therefore essential to recognise the importance of not divorcing events from experience; in other words, a history of sexual trauma is a temporal observation when in reality the event is ahistorical because the sexual trauma alters the space that a woman embodies within her own body and mind, and in her respective society or societies. Clinical responses to caring for long term health needs in women with a history of sexual trauma must be rooted in context and challenge positivitic tendencies in the way that violence is viewed, which otherwise can reduce women to unnecessary victims and as pathological vessels.
Mannell, J., Ahmad, L. and Ahmad, A., 2018. Narrative storytelling as mental health support for women experiencing gender-based violence in Afghanistan. Social Science & Medicine, 214, pp.91-98.
Competing interests: No competing interests
According to Ades and co-workers , clinical practice with women who experienced sexual violence requires multidisciplinary trauma-informed care addressing patients’ medical and psychological needs, either short- or long-term . In line with these key points, at the Sexual and Domestic Violence Service of the Ospedale Maggiore Policlinico, Milan, Italy, we adopt an integrated multidisciplinary approach to assist victims, with a team including gynaecologists, psychologists, social workers, forensics, sexologists, lawyers, and, when needed, paediatricians .
The correct analysis, documentation and interpretation of genital and extragenital lesions and the appropriate reporting to the judicial authority, constitute additional important aspects of the care of a sexual violence victim. Attention to health issues (including psychological aspects related to trauma as post-traumatic stress disorder), as well as an empathetic and non-judgmental approach, are crucial factors that may impact on long-term outcomes. Moreover, besides medical and psychological assistance, meticulous examination, interpretation and documentation of genital and extragenital lesions, as well as correct evidence collection—e.g., DNA swabs, sperm slides, blood and urine samples to test for drug-facilitated rape—are fundamental, as they may affect possible legal proceedings. These practices entail high levels of specialization and an efficient collaboration between all the professionals involved. At the same time, physical examination and evidence collection should be conducted in full respect of women’s dignity, which is an important component of victims’ perception of justice . Lack of thoughtfulness during these procedures may intensify psychological trauma by re-exposing women to objectification, in the sense of feeling treated like a body of evidence rather than a person of worth.
Based on our experience, collecting data for the judicial system is as important as clinical assistance, as we have observed that an appropriate and qualified management of forensic evidence, and at times even the condemnation of the perpetrator, may significantly improve the victim’s psychological outcome and quality of life. Such a model requires appropriate training and continuity between different services (i.e., medical, social, and legal), as well as facilities to guarantee women free access to the anti-violence service at any time. Indeed, clinical forensic activity is not only for “prosecution” but is a fundamental tool as the first step towards protecting the victim and society.
Securing justice for victims of sexual violence is a complex process that should not be considered as exclusively aimed at convicting the perpetrators. Providing patient-centred care, characterised by sensitivity, empathy and attention, is a fundamental component of restoring justice.
1) Ades V, Goddard SB, Ayala P, Greene JA. Caring for long term health needs in women with a history of sexual trauma. BMJ 2019;367:l5825 doi: 10.1136/bmj.l5825 (Published 22 October 2019).
2) Barbara G, Collini F, Cattaneo C, Facchin F, Vercellini P, Chiappa L and Kustermann A. Sexual violence against adolescent girls: labelling it to avoid normalization. J Womens Health 2017;26:1146-1149. doi: 10.1089/jwh.2016.6161.
3) McGlynn C, Westmarland N. Kaleidoscopic justice: sexual violence and victim-survivors’ perceptions of justice. Soc Leg Stud 2019;28:179-201. doi: 10.1177/0964663918761200.
Competing interests: No competing interests