Why this matters
One in four girls and one in thirteen boys in the United States experiences sexual abuse before age 18, and the vast majority of those survivors will at some point sit in front of a clinician for a reason unrelated to the abuse. Most of them will not tell you about it. Some of them will not have told anyone. The pelvic exam you are about to do is going to be the third or the thirtieth pelvic exam they have had, and every prior encounter has either reinforced the bodily violation or interrupted it. You are about to do one of those.
Trauma-informed care is not about being nicer. Every provider I have ever met thinks they are nice to their patients. Trauma-informed care is a structural redesign of the clinical encounter so that survivors can use the encounter — for the medical thing they came in for — without the encounter itself becoming the next event their nervous system has to recover from. It is workflow. It is what you say before you touch a patient, the order in which you do things, who is in the room, how the room is configured, and how you respond when something lands hard. The Epstein files include, in the contemporaneous record, clinical encounters with adolescent survivors that were not trauma-informed. The girls were treated as bodies the system was using. We can do better than that. We owe better than that. And the literature on how to do better has existed in our specialty journals for the better part of a decade.
What the evidence says
The American College of Obstetricians and Gynecologists has now published two current Committee Opinions that together constitute the canonical OB/GYN guidance on trauma-informed clinical care. Committee Opinion 825 (April 2021), Caring for Patients Who Have Experienced Trauma, defines trauma-informed care as a framework that recognizes the prevalence of trauma in patient populations, anticipates its impact on engagement with care, and structures the clinical encounter to minimize retraumatization while supporting recovery. Committee Opinion 777 (April 2019, reaffirmed), Sexual Assault, supplies the model screening protocols, forensic-care framework, and referral structure for survivors of sexual violence and references trauma-informed care throughout. Both opinions remain current as of June 2026.
The ACE (Adverse Childhood Experiences) literature, originating with the Felitti et al. 1998 study and now reinforced by three decades of replication, documents the dose-response relationship between childhood sexual abuse and adult health outcomes. Survivors carry significantly elevated risk for cardiovascular disease, autoimmune disease, depression, anxiety, substance use disorder, chronic pelvic pain, hyperemesis in pregnancy, postpartum depression and PTSD, sexual dysfunction, and pelvic floor disorders. These are not psychiatric epiphenomena. They are physiologic sequelae of chronic stress exposure during developmental neurodevelopment. The cardiology visit, the GI visit, and the autoimmune workup are all CSA-survivor encounters whether the patient discloses the history or not.
The literature also documents that trauma-informed encounter design measurably improves clinical outcomes for survivors — engagement with prenatal care, adherence to follow-up, successful completion of necessary procedures, reduced rates of trauma-symptom exacerbation post-visit. This is not a quality-of-experience metric. It is a clinical-effectiveness metric.
The six principles, operationalized
SAMHSA's framework names six principles of trauma-informed care: safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment and choice, and cultural/historical/gender awareness. The principles are the right principles. They are also abstractions, and abstractions do not change clinical practice. What changes clinical practice is a list of behaviors you can implement on Monday.
What to do differently in the room
- Knock and wait. Do not enter an exam room without an explicit "come in" from the patient. Survivors of sexual abuse experience unexpected entry by an authority figure as a body-memory event. The knock-and-wait costs you two seconds and prevents a fight-or-flight cascade you were not planning to trigger.
- Sit before you speak. Standing over a patient, even briefly, replicates the power dynamic of an assault. Sit. Make eye contact. Introduce yourself by first name if your context permits it.
- Narrate before you touch. "I am going to put my hand on your wrist to take your pulse" before you put your hand on her wrist. "I am going to listen to your heart" before you place the stethoscope. "I am going to start the exam by checking your belly; you can tell me to stop at any time" before you begin. Every transition narrated, every time.
- Drape generously. Survivors often experience the gown-only encounter as exposure. Add a sheet. Offer it. Let her decline it if she wants. Do not require her to be more uncovered than the exam requires.
- Pause for pelvic and breast exams. Before initiating a pelvic exam: "I am going to do an exam of your pelvic organs now. I am going to tell you each step before I do it. If you need me to stop at any point, tell me to stop and I will stop. Stopping does not change anything else about your care." Then do it.
- Offer choice where choice exists. Stirrups or no stirrups for the pap if both are clinically reasonable. Self-insertion of the speculum where appropriate. Position of the support person. Order of exam components. The point is not to negotiate every detail — it is to communicate that the patient is the person whose body this is.
- Watch for the signs of dissociation. Sudden silence. Fixed gaze. Slowed responses. Body becoming rigid. If you see them, pause. Bring the patient back: "I am going to stop for a minute. Can you tell me three things you can see in this room?" Then check in: "How are you doing? Do you want to keep going or take a break?"
- End by re-orienting. "We are done. You can sit up when you are ready. Take whatever time you need. I will be back in a few minutes to talk about the plan." Survivors often dissociate during the exam and the moment of being told "we are done" is a re-entry moment. Give it room.
The OB/GYN encounter specifically
For survivors of childhood sexual abuse, the pelvic exam is the highest-stakes routine medical event in their lives. Every survivor I have seen who has had a difficult pelvic exam tells the same story: it was not the discomfort. It was the loss of control. The provider was kind, but the exam happened to her, not with her. She came out of the room shaking and could not say why.
The protocol I use, and the one I teach residents:
The phrasing matters. "Have you been sexually assaulted" is a closed question that asks the patient to self-identify with a label many survivors reject. "Have you had experiences where someone touched your body in a way you did not want" is open, behaviorally specific, and does not require her to perform a victim identity to access better care. The "I am asking because" phrase tells her why I want to know — which gives her permission to disclose for an instrumental reason rather than for an emotional one. The "yes, no, or I do not want to answer" phrase explicitly permits non-disclosure without judgment.
If she says yes: "Thank you for telling me. Here is what I would like to do." Then you do the protocol above — narrating, pacing, offering choice — and you do not require her to explain or elaborate. If she says no: same protocol. You do not need a positive history to provide trauma-informed care. You provide it by default.
The first time I really understood what trauma-informed pelvic care meant, I was a resident and I had a patient in for an annual exam who, two questions into the visit, started crying and could not stop. I asked her what was happening. She said: I do not know. I have been to four annuals in eight years and every time I get into the gown I cannot breathe and I do not know why.
I did not do the exam that day. I sat with her. I told her we did not have to do the exam at this visit; we could do it next time, or in a different position, or with her partner in the room, or with me narrating each step, or not at all. I asked if she had a history that might be related. She did. She was forty-one years old and no one had ever asked.
The exam she eventually came in for, six months later, took an hour. We did the questions; we did the protocol; she self-inserted the speculum because that was the choice she wanted; her shoulders never came up to her ears. It was a complete exam. We caught a low-grade lesion that ended up being early cervical dysplasia. She was treated. The visit that did not happen the first time — the trauma-informed one we built together — is the visit that found the lesion.
That is what I tell residents about why this matters. It is not just about being a person who is kind. The trauma-informed visit is the visit where the medicine works.
Language: what to say, what not to say
When and how to refer
The disclosure visit is not the place to deliver a full mental-health referral. A survivor who has just disclosed for the first time is in an acute window where the wrong referral — too clinical, too forward, too many phone numbers — can shut down further engagement. The visit-level referral is small, specific, and uses the patient's own language.
In the visit: "There are some resources I want to put in front of you, but I do not want you to feel like you have to use any of them today. The one I would want you to know about is the RAINN hotline — 1-800-656-HOPE. They are 24/7, confidential, and you do not have to give them your name. Some patients want to call right away; some want to know it exists for later. You can decide. I am also going to give you the name of a trauma therapist I refer patients to — you can call them when you are ready, or never."
After the visit: If the patient is open to a warm handoff, call the receiving clinician before the patient leaves and introduce the referral. Document who you referred to and why. Schedule a follow-up visit within four weeks — not because you are providing trauma therapy at that visit, but because the act of the follow-up communicates to the patient that the disclosure has not ended the clinical relationship.
The full referral framework — to trauma-informed therapists, advocacy organizations, population-specific resources (LGBTQ+, Black, Native, Spanish-speaking survivors), and crisis services — is housed in R1 — Resource Directory. Use it. Hand the patient a one-page printout. Survivors who leave the visit with a paper resource in hand engage at higher rates than survivors who leave with a verbal recommendation alone.
For your own care
Secondary trauma is real, it is cumulative, and providers who do this work and do not name it eventually leave the work. The leaving is not a personal failure. It is what happens when you absorb the pain of survivors at the rate you encounter them and do not have an exhaust mechanism. The exhaust mechanism is the work you do for yourself. It is part of the job. It is not extra.
I want to say one thing that is harder to say. Some disclosures will land hard because they are clinically difficult; some will land hard because they touch your own history. Providers who are themselves CSA survivors are over-represented in trauma-focused fields, and that is part of why the work gets done well. It is also why some visits will leave you not just sad but activated — body memory, somatic re-experiencing, the day after. That is not a sign you are unfit for the work. It is a sign you are human and that the work has done something to you. The response is the same response you would give a colleague: name it, get support, do not isolate, and do not pretend you are fine when you are not.
What I tell residents who come to me after a difficult disclosure is the same thing I tell myself. The patient does not need you to be unmarked by what she told you. She needs you to be steady. Steady is not the same as unaffected. Steady means you can hold what she said without flinching, without minimizing, without rushing her through it, and without falling apart in front of her. The flinch and the falling-apart you do later, with another clinician who knows the work, after the visit is done. Not in the room. After.
The practice I use, and have used for years, is a five-minute walk between hard visits. I do not chart immediately. I do not pick up the phone. I walk down a hallway, drink some water, breathe, and let my own nervous system come down from where the patient's nervous system put it. Then I chart. Then I see the next patient. The five minutes are not extra. They are how I do not bring the last visit into the next one. Without them I am a worse clinician for the patient who walks in next.
I do this in the obstetric units too, after a loss. It is the same nervous system. The same physiology. The same need to land.