Intended for healthcare professionals

Practice Clinical Update

Caring for long term health needs in women with a history of sexual trauma

BMJ 2019; 367 doi: (Published 22 October 2019) Cite this as: BMJ 2019;367:l5825
  1. Veronica Ades, associate professor1,
  2. Brian Goddard, medical student2,
  3. Savannah Pearson Ayala, medical student2,
  4. Judy A Greene, clinical assistant professor3
  1. 1NYU School of Medicine, Department of Obstetrics & Gynecology, New York, NY, USA
  2. 2NYU School of Medicine, New York, NY, USA
  3. 3NYU School of Medicine, Department of Psychiatry, New York, NY, USA
  1. Correspondence to
    V Ades Veronica.Ades{at}

What you need to know

  • Trauma focused cognitive behavioural therapy interventions in the acute phase after sexual assault can potentially prevent development of post-traumatic stress disorder

  • Some people are hesitant to disclose a history of sexual trauma and may avoid routine medical care because of fear of retraumatisation

  • Some groups recommend routinely screening women for a history of sexual trauma, but you may individualise this and ask if specific concerns arise during the consultation

  • Exercise additional sensitivity during examination and explain the steps so the patient knows what to expect and can request to defer examination at any point

  • Annual pelvic examination may be avoided in people who express anxiety or discomfort; a thorough review of symptoms may suffice in these patients if they have no related symptoms

Globally, about 30% of women report intimate partner violence (physical, sexual, or both) (95% confidence interval 27.8% to 32.2%) and about 7.2% (95% confidence interval 5.3% to9.1%) of women face non-partner sexual violence in their lifetime.1 Sexual violence in men is less studied. In the United States, the National Intimate Partner and Sexual Violence Survey determined a lifetime prevalence of contact sexual violence (including forced penetration and fondling) of 36.3% (95% confidence interval 35.3% to 37.2%) among women and 17.1% (95% confidence interval 16.3% to 17.9%) among men.2

Experiences of sexual violence negatively affect a person’s long term physical and psychological wellbeing as well as their interaction with the healthcare system.

Most guidelines focus on treatment in the acute setting in the immediate aftermath of sexual assault, and rarely address long term care. Box 1 lists key aspects of acute medical care for people who have experienced sexual violence.

Box 1

Summary of acute care for people who have experienced sexual assault345

  • Access to sexual assault referral centres or a sexual assault forensic examiner, if possible

  • Assault history: location, positioning, timing, mechanisms of injury, coercion used, forms of penetration, ejaculation

  • Physical examination

    • o “Top to toe” skin evaluation

    • o Anogenital examination as indicated by the assault history

  • Emergency contraception if a possible pregnancy is undesired

    • o Progestin-only contraception within 120 hours, 72 hours ideally to increase efficiency

  • Testing for sexually transmitted infection (STI)

    • o Gonorrhoea and chlamydia culture/nucleic acid test

    • o Trichomonas culture

    • o Syphilis, HIV, hepatitis B serologies

  • STI prophylaxis

    • o HIV post-exposure prophylaxis (data on the effectiveness of other forms of STI prophylaxis are limited)

  • Mental health

    • o Patient validation

    • o Provide affirmation that patient is not to blame

    • o Screening for acute stress disorder and early signs of post-traumatic stress disorder

    • o Refer to social worker or crisis counsellor for safety planning and further psychosocial treatment


In this Clinical Update, we discuss long term care for people with a history of sexual trauma. This covers medical care provided months to years after their experience or experiences of sexual violence have passed. We summarise the long term medical and mental health needs in people who have experienced sexual violence and provide recommendations for clinicians to optimise their care. Prevalence of sexual violence is higher among women; therefore we focus on women and briefly discuss specific considerations in men, transgender people, andchildren.

Sources and selection criteria

We searched PubMed, Google Scholar, and the Cochrane Database of Systematic Reviews using search terms such as “sexual violence”, “sexual trauma”, “sexual assault”, and “rape” in conjunction with terms such as “long-term care”, “medical management”, “medical care”, “gynecologic care”, “trauma-informed care”, “mental health services”, and “psychiatric care.” We included only English language articles. Due to a lack of large scale randomised controlled trials pertaining to this topic, most references are cross-sectional, retrospective, or case-control reports. Whenever possible, preference was given to more recent articles with large numbers of enrolled subjects. As this population is not sufficiently studied, this was not always possible. For topics covered in this review for which there is little or no literature on the subject, recommendations are based on the experience of the authors and indicated as such.

What are the long term health effects of sexual violence?

Mental health

People with a history of sexual trauma are at increased risk for chronic mental health conditions, including post-traumatic stress disorder (PTSD), depression, anxiety, and substance abuse disorders.678 Sexual violence is shown to be one of the strongest predictors for the development of PTSD compared with other forms of trauma.910 A recent, well conducted systematic review (39 studies, more than 88 000 participants) reported a lifetime prevalence of PTSD after sexual assault of 36% (95% confidence interval 31% to 41%).11 It can persist for many years, even with treatment.1213 People may experience intrusive memories of the trauma, flashbacks or nightmares, dissociative episodes, avoidance of trauma associated situations, depressed mood, irritability, insomnia, or anxiety.14

Physical health

Most research on long term health effects of sexual violence focuses on psychiatric sequelae; however, data suggest an increased prevalence of negative physical health outcomes as well. A cross-sectional study of more than 16 000 men and women in the United States showed higher rates of asthma, diabetes, irritable bowel syndrome, headaches, sleep disorders, and chronic pain in people who had experienced sexual and intimate partner violence compared with people without such a history.6 Gynaecological symptoms are more common. In a cross-sectional study (730 German women), those with a lifetime history of any form of sexual violence had a higher prevalence of dysmenorrhoea, vaginal infections, urinary tract infections, chronic pelvic pain, and irregular menstrual cycles.15 In a separate small study (191 American women), women who had been subject to sexual assault and/or intimate partner violence were more likely to report dyspareunia, menorrhagia, and a history of one or more sexually transmitted infections compared with women without such a history.16 Due to the cross-sectional design of current research, little can be said about the causality of the relationship between sexual violence and long term physical health outcomes. Some posit that it may be related to harmful coping mechanisms and/or a neurophysiological response to chronic stress.17

What measures can be taken in the acute setting to improve long term outcomes?

Sufficient literature is available only for the prevention of PTSD with interventions in the acute setting after sexual assault. Cochrane systematic reviews of acute psychological interventions after a traumatic event have studied both single-session “psychological debriefs,” which involve a single opportunity for discussion and emotional processing of the event, and multiple-session brief interventions, including cognitive behavioural therapy (CBT), trauma-focused cognitive behavioural therapy, and eye movement desensitisation and reprocessing.1819 These reviews found no evidence for the efficacy of any psychological intervention in preventing the development of PTSD.19

We recommend screening for acute stress disorder within one month of sexual assault to identify people that would benefit from trauma-focused CBT. Acute stress disorder is distinct from PTSD only in that the symptoms have lasted less than one month. Validated screening tools include the Stanford Acute Stress Reaction Questionnaire or the Post-Traumatic Symptom Scale-Self Report.2021 Treatment with trauma-focused CBT within three months of the traumatic experience has been shown to be effective in reducing traumatic stress symptoms in people presenting with acute stress disorder.2223

A Cochrane systematic review of pharmacological interventions to prevent PTSD found moderate quality evidence for the use of hydrocortisone (risk ratio 0.17; 95% confidence interval 0.05 to -0.56; P value=0.004 and number needed to treat = 7-13) (four randomised controlled trials, 165 people).24 It has yet to become a standard of care in psychiatric emergency departments.25

Prevention of sexually transmitted infections (STIs) is important in the acute setting. Test for STIs and consider offering post-exposure prophylaxis for HIV.26

How does a history of sexual trauma influence a person’s healthcare experiences?

Experiences of sexual violence have the potential to influence a person’s medical care in the long term (fig 1). In a small cross-sectional study (61 people), more than 90% of women who had experienced childhood sexual abuse had a fear of medical examinations as a result of their abuse and 64% of respondents reported that this fear caused them to avoid routine healthcare.27 Avoidance of preventive care, such as mammograms and cervical smears, has been noted in people with a history of sexual trauma in moderate sized case-control studies.2829

Fig 1
Fig 1

How a history of sexual trauma can influence a person’s health and healthcare

When people do utilise services, they may report more negative experiences related to their medical care. People with a history of trauma report greater discomfort during the pelvic exam.303132 A case-control study of 85 German women found that a higher percentage of women with a history of childhood sexual abuse reported that a visit to their gynaecologist would be a source of psychological strain, and more than half of participants said their experiences of abuse continued to influence their gynaecological care.33 Dissociation, in which a person becomes detached from their physical surroundings and will often be non-responsive to talk or touch, is a common reaction to the heightened anxiety people with a history of trauma may experience during a gynaecological exam.3435

Should we routinely ask people about history of sexual violence?

Some professionals recommend routine screening to identify people who may have experienced sexual violence to better understand their health needs and provide additional support if needed. The American College of Obstetrics and Gynecology recommends that obstetrician-gynaecologists routinely screen all women for a history of sexual assault.36 However, there is little evidence to show that routine screening actually improves outcomes for, or is desired by, women who have experienced trauma.

Between 6% and 27% of women with a history of sexual violence disclosed it in the healthcare setting, as per a systematic review (23 original studies, with range of participants 103 to 2181).37 More than half of women (over 3000 participants) who did not disclose their history to a provider stated that they did not think it was relevant to their care.38 Indeed, in our experience, many people do not wish to discuss their experiences of sexual trauma with every medical provider.

Given the absence of clear evidence, the decision whether or not to screen should be individualised and will likely depend on the provider’s specific role, area of expertise, and perceived competency in responding to a person’s affirmative response to screening. As an alternative, you could ask about a history of sexual assault when specific concerns arise, such as unusual anxiety during the interview or physical exam, or emotional reactions in discussing gynaecologic history.

How can medical professionals provide sensitive care to people with a history of sexual trauma?

Trauma-informed care involves providing services in a manner that recognises and responds to the unique needs of people who have experienced trauma. Box 2 describes the EMPOWER Clinic approach that we have established in our practice as a particular model of trauma-informed care.

Box 2

The EMPOWER Clinic model

  • The EMPOWER Clinic for people who have experienced sex trafficking and sexual violence, located in New York, provides trauma-informed, long term care for people with a history of sexual trauma39

  • The EMPOWER model consists of an obstetrician/gynaecologist and co-located psychiatrist who work closely together and coordinate care with case managers of referring social service organisations, to holistically address a person’s needs

  • The integrated care model (obstetrician/gynaecologist and psychiatrist) is designed to ensure that both the medical and mental health needs of patients are fully met

  • Providers have training and experience in trauma and have the necessary tools to deliver sensitive care to this population

  • EMPOWER providers

    • allow patients the opportunity to directly discuss their history of sexual trauma and how it may impact their health and experiences

    • evaluate patients’ medical histories and symptoms in the context of the sexual violence they have experienced

    • work collaboratively with patients to deliver medical care that is sensitive to their unique needs


You may not know in advance if a person has a history of trauma. Strive to create a welcoming and safe environment so patients feel safe to disclose a history of sexual violence if they choose to. Consider how a person’s history of trauma could be linked to their presenting symptoms. Ask about their medical history and interactions with the healthcare system.

Adults who have experienced sexual abuse during childhood consistently report feelings of vulnerability and lack of control as important determinants of negative healthcare experiences, as per a systematic review of studies on patients’ perspectives.40 Acknowledge the person’s role in making decisions about their health and modify practices when necessary to meet individual needs. Provide an overview of the steps in the visit, including specific aspects of physical examination. Encourage them to feel as in-control as is possible, and ask what might make them more comfortable.41 Pay particular attention to the patient’s modesty and comfort. This can also help to avoid retraumatisation. Box 3 covers suggestions on how to approach examination in these patients.

Box 3

Tips for physical and gynaecological examination in people with a history of sexual trauma40

  • Exercise additional sensitivity during examination. Touching a person as part of a physical or gynaecological exam can feel more invasive and potentially triggering to some patients

  • Emphasise the person’s agency and control over their body throughout the physical examination. Inform them in advance that they can ask to stop the process at any time. This can help to alleviate stress related to examination

  • Explain the examination steps before performing them so the person knows what to expect and you have their permission

  • Expose only the necessary area of the body at a time during the examination

  • Some people may have particular difficulty with a speculum examination. It is important not to force this aspect of the examination. Attempt to teach the person to voluntarily relax their perineal muscles. You may gently touch the person’s leg, followed by the perineum, and finally the labia majora asking the person to pay attention to how their perineal muscles respond to the touch and then practise voluntarily relaxing them. Proceed with the exam once the person feels that they can successfully do so and can tolerate the exam

  • Avoid behaviours that may be triggering, such as pushing the patient’s legs apart or using language that may have been used during their abuse (eg, “just relax,” “this won’t hurt”)

  • Consider omitting or deferring certain components of the physical exam if it is not particularly relevant to the patient’s chief concern

  • Discontinue examination if a person dissociates. In addition to the legal and ethical issues of performing an invasive examination while the person is effectively unconscious, continuing the exam could retraumatise them


According to the US Preventive Services Task Force, there are currently insufficient data to conclude whether the benefits of an annual pelvic exam outweigh the associated risks in asymptomatic women.42 Given the increased chance of discomfort and retraumatisation for women with a history of sexual trauma, the question of the necessity of an annual exam is especially relevant. A thorough review of systems may suffice in people who describe severe discomfort or anxiety with a pelvic exam. You may defer the pelvic exam if asymptomatic.

How to provide care for patients’ mental health needs

Inquire about the status of a patient’s mental health (for example, by asking if they have had negative thoughts, feelings, or behaviours that are interfering with their daily life) and/or use standardised screening tools (eg, the Patient Health Questionnaire-9 (PHQ-9)) for depression43 to identify common mental health concerns, including PTSD, depression, anxiety, substance abuse disorders, and suicidal ideation. Discuss referral to appropriate mental health services when a psychiatric disorder is identified. Co-location of primary care and mental health services can improve access for this population.44 A combination of psychological and/or pharmacological interventions may be appropriate for PTSD, taking into consideration the person’s preferences.45

Other patient populations

Men who experience sexual violence experience similar long term health effects as women and may have specific medical needs. Men are often less likely to disclose a history of sexual violence, in part due to more negative reactions when they do.46 It is important to be aware of gender biases concerning sexual victimisation and recognise that men can also experience abuse. Some studies note worse outcomes among men and boys who have been subject to sexual violence. In a small cross-sectional study of adults who had experienced sexual assault, men reported higher distress on 8 out of 10 scales of a standardised clinical measure of trauma symptoms compared with women.47 Additional long term psychological problems may be more common among men, including sexuality confusion.48

Transgender people who have faced sexual violence frequently experience discrimination in the medical setting, increased barriers to care, and have a higher prevalence of mental health issues.4950 A thorough review (20 studies, almost 3000 transgender individuals) reported that about half had experienced some form of unwanted sexual activity.51

People who have experienced sexual abuse in childhood may also have unique healthcare needs. Several reviews report a higher probability of adult revictimisation (new experience of sexual violence after a previous experience has ended) in people who have experienced childhood sexual abuse.525354 Psychological and behavioural sequelae of trauma, including PTSD, dissociation, and substance abuse, are assumed to play a role in revictimisation.5354 Adequate psychiatric and behavioural treatment may be important in these people to prevent re-victimisation. Co-location of paediatric primary care and mental health services can improve access to management of post-trauma psychiatric sequelae.55

Education into practice

  • If a patient disclosed a history of sexual trauma, how would you attempt to make their medical appointments more comfortable for them?

  • Are you aware of local resources available to people who have experienced sexual violence—including sexual assault crisis centres and hotlines—where you can refer a patient who discloses a history of sexual violence?

Interview with a patient

In what ways do you think trauma can affect health?

I think it affects health in many ways. It gave me an eating disorder, and gave me a lot of health issues from that eating disorder. It also affected me mentally. I usually get triggered by things, I cry a lot. It makes me feel like I have headaches. I don’t know what the headaches are; they checked me for everything and they couldn’t find anything. I keep thinking about things and I have trouble sleeping at night. That’s probably why I have headaches all the time. It made me anxious and I became antisocial (withdrawn and isolated) from that anxiety.

What kinds of negative healthcare experiences have you had?

I didn’t know I could be in the room with the doctor without someone else being there if I wanted to. I was never told that. My trafficker was always in the room when I saw the doctor. He was basically the one who was doing most of the talking because I couldn’t speak English very well.

When I was pregnant, with everything that was going on, I just didn’t want to eat. They connected me with the nutritionist, and she said, “Do you want to kill yourself and your baby?” She said if I didn’t eat, that’s what was going to happen. I had a stillbirth at 7 months, and …. when the baby died, I thought back on her comment and thought it was my fault.

When I first got pregnant, I went to the gynaecologist’s office. I was very uncomfortable because I was not used to seeing a gynaecologist in my country. I was already nervous because [the gynaecologist] was male. The gynaecologist was explaining the speculum, and said, “Just pretend it’s an African man’s penis.” My trafficker was an African man. The other two people in the room didn’t say anything, they just laughed. After that, I didn’t want to go see a gynaecologist at all.

What made your experience in EMPOWER different?

I just feel more comfortable being open. It was the gynaecologist and the [patient care associate], and both were very nice and friendly. They asked me first if I wanted to do the pelvic exam, and I had never been asked before—it was just like, “You have to have this.” I didn’t know I could say no. It made me feel like I could actually have a say in my care.

I never knew doctors would care about other things that aren’t just health type things. But in EMPOWER, they actually helped me get connected with people who helped me with my mental health, like the psychiatrist. They also connected me with people who helped me with life things, like social service organisations that helped me get a job and housing, and get my education. They are not only helping me with my health, but also helping me with my life.

How can doctors help people who have experienced trauma?

Doctors should always use an interpreter if the patient doesn’t speak English, and not just use a family member. For me, they used my trafficker as my interpreter.

It also helps if doctors can see patients alone. There was a therapist that I saw after the baby died [who] never saw me alone. Thinking back … she should have asked some more questions to figure out why I was scared of [my trafficker]. I would like doctors to pay attention to the small details, to figure out why something may be off.

I think doctors should follow up when a patient doesn’t come back and something might be wrong. They should check for more than just health. In EMPOWER … [if] things aren’t going well, they follow up with someone who can help. When I don’t show up for my appointment, they always call or email to find out why I didn’t show up. It helps with the recovery process because you feel like someone cares, and it makes you more likely to go.

Questions for future research

  • In what ways can providers incorporate trauma-informed care into their practice?

  • What is the role of an annual pelvic exam for asymptomatic women with a history of sexual trauma?

  • Is there a benefit to routinely screening patients for a history of sexual violence?

  • What is the global prevalence of sexual violence among less studied groups, such as men and transgender individuals?

  • What factors mediate the increased likelihood of adult revictimisation of people who have experienced sexual abuse in childhood?

How were patients involved in the creation of this article?

A patient who had been trafficked for sex gave her perspective on how sexual trauma can affect one’s health and medical care; she also described her experiences receiving medical care at the EMPOWER Clinic for Survivors of Sex Trafficking and Sexual Violence. We recorded her thoughts in the box ‘Interview with a patient’

Additional information and resources

For healthcare professionals

  • Clinical management of people who have experienced rape, e-learning programme:

    • Free, downloadable programme created by the World Health Organization and United Nations intended to give healthcare providers information on appropriate and integrated care, in a humanitarian setting, for people who have experienced rape.

  • Further information regarding the foundations and implementations of trauma-focused CBT:

    • Cohen JA, Mannarino AP. Trauma-focused cognitive behaviour therapy for traumatized children and families. Child Adolesc Psychiatr Clin N Am 2015;24:557-70.

For people who have experienced sexual violence

  • Rape, Abuse & Incest National Network

    • Has extensive information and advice for people who have experienced abuse

    • Can assist in connecting patients to a sexual assault service provider (for patients in the US)

    • Has a confidential 24/7 hotline and online messaging services

  • The Polaris Project

    • o Has a confidential 24/7 hotline and messaging for people who have been trafficked

    • o International database of anti-trafficking organisations in more than 145 countries

Key terms (adapted from references)

  • Sexual assault A form of sexual violence in which a physical act is carried out or attempted against the will of the person, regardless of the setting or relationship between the victim and the perpetrator1

  • Childhood sexual abuse Involvement of a child in sexual activity this is beyond their comprehension or level of development, to which they cannot consent. Although the person experiencing abuse is by necessity a child, an adult may still be sexually traumatised by a personal history of childhood sexual abuse2

  • Sexual violence Used in this article as an umbrella term that encompasses many experiences including but not limited to sexual assault, childhood sexual abuse, sex trafficking, and unwanted sexual acts perpetrated by an intimate partner

  • Sexual trauma Lasting, adverse effects on an individual’s functioning and mental, physical, social, emotional, or spiritual wellbeing as a result of sexual violence56

  • History of trauma used to describe a patient exposed to a traumatic event


  • Contributorship Statement and Guarantor All authors contributed to the conception and design of the work, gave final approval of the version to be published, and have agreed to be responsible for all aspects of the work. BG and SPA were responsible for the literature search and drafting of the initial and revised manuscript. VA and JG were responsible for important critical revision and final approval of the manuscript. VA is the guarantor.

  • Competing interestsThe BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none.

  • Further details of The BMJ policy on financial interests are here:

  • Provenance and peer review: commissioned, based on an idea from the author

  • Patient consent obtained.