Every Saturday The CSPH highlights news or recent research in the field of human sexuality. This week we’re discussing research from the Netherlands that looks at how Dutch gastroenterologists consider or address sexual assault in routine interactions with their patients.
Many would not automatically see the connection between sexual assault and gastrointestinal (GI) illness; however, the authors of this study—urologists, gastroenterologists, and surgeons from a variety of Dutch medical centers—found this subject to be quite significant. As they report in the introduction to their paper, between 30 to 50% of GI patients are survivors of past sexual abuse, and many sexual abuses contribute to pelvic floor or pelvic region dysfunctions. Thus, the researchers sought to understand how often the subject of assault was actually addressed by gastroenterologist (GE) practitioners, as they are uniquely placed to intervene in an aspect of health that many patients might not connect to their abuse history and may never properly address.
In this study, the researchers contacted all Dutch GEs and fellows-in-training with an anonymous questionnaire that looked at GE-patient interactions around discussing sexual assault, GE impressions of their patients’ disorders and assault backgrounds, and the reasons GEs might not discuss sexual assault with their patients. One hundred and sixty nine were deemed usable (returned at least 90% complete) and incorporated into the analysis. Of these, 70% were GEs and 30% were fellows; 60% were male, 34% female, and 9% did not report their gender; and the ages of those participating in the study ranged from 23 to 64, with the median age at 41 years old.
Of this population, a small number reported always asking about sexual assault prior to a physical examination (for 5% of female patients and 0.6% of male patients). This number increased, however, to 71.4% of female patients and 31.3% of males if patients reported specific complaints, such as chronic abdominal pain or constipation.
While asking about sexual assault was not an altogether common practice, the majority of practitioners did not consider asking about sexual assault to be unimportant; although, again, there was a persistent gender disparity, as asking about sexual assault with female patients was deemed unimportant by 7.5% of practitioners versus 29.9% for males. When asked why they did not ask about sexual assault, about a quarter of those surveyed reported that asking about sexual assault was difficult (similar for both males and females), and a number also reported that they did not know what to do if a patient had a history of sexual assault. And when asked about the prevalence of sexual assault in their patient populations, they estimated 10.5% of females and 3.6% of males were survivors, while the true rates were about two to five times that for females and two to seven times that for males.
What was most remarkable in these results is the disparity between how GEs think about and discuss sexual assault with their male versus female patients. Male patients were less likely to be asked about assault histories or to be considered survivors of abuse, and practitioners were much less likely to think asking them about sexual assault was important. Such a difference in beliefs and practices indicates the cultural stereotyping that exists over what a sexual assault survivor looks like or what body or gender comes to mind when thinking about who might have experienced a sexual assault.
Another important point mentioned by the authors was how infrequently patients were asked about their sexual assault histories before a physical examination or colonoscopy (only 2.5% for female patients and 0.6% for males). As they noted, because sexual assault often includes anal penetration, examining the rectum can be a highly triggering or threatening event. This is an especially discouraging and disappointing statistic, to see that here, where the intersection of gastroenterology and sexual abuse is perhaps the most relevant, there is no consideration of the pain that can be caused by neglecting to ask about sexual assault. A suggestion offered by the researchers was to mandate an intake form that addresses sexual assault before beginning outpatient visits with a GE practitioner. Such an idea could be a simple and effective measure of not only combating the gender disparities in asking about sexual assault, but also ensuring that the issue gets routinely addressed so that treatments can be effectively targeted and accommodations made for the patients who might be survivors.
Even while we consider the impacts of this study—truly the first of its kind—in understanding doctor-patient relations around sexuality and sexual abuse, it is important to note its specific context. It would be difficult to extrapolate many of its findings to the United States. The healthcare system in the Netherlands is much more financially accessible, as health insurance is universal. Similarly, their relatively open and free sexual culture, as compared to the US, likely means that the results of this study are more encouraging than we would find on this side of the Atlantic. Performing a study closer to home is the first step towards understanding the important connections between sexual assault and gastroenterological practice in U.S. cultures. These practitioners, so often working with survivor populations, are an important tool for the holistic health of sexual assault survivors in a way that so rarely gets discussed. It is necessary to keep them a part of the conversation, and to do that, we must keep them conversing with their patients—of all genders—about their sexual and sexual assault histories.