In Practice: Reflections from NPs and PAs

Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.

On Sunday morning I went to an early and excruciatingly difficult barre class with a friend, after which we promptly rewarded ourselves with a decadent brunch. While walking home alone in the rain, hood drawn and head tucked down against the wind, I was taken aback when a man reached out and pushed me aside out of his path — doing so by placing his hand on my groin. Truly, it took me a few more strides to feel offended by the placement of his hand — much too personal a place to be used under the guise of avoiding a collision with a stranger. Offended was just the start though — I have spent the last several days stewing.

When someone in a position to influence national discourse (let alone domestic and foreign policy) dismisses conversations about touching women inappropriately as “locker room talk,” when an athlete is caught on tape abusing a partner and continues to play with only minor sanctions, or when a victim of sexual assault feels more vilified by the media than the perpetrator — we send a clear message to women that they are less than, that they are objects, that they do not deserve to control what happens to their bodies. This also sends a message to perpetrators of sexual violence that this behavior will be condoned, and I cannot begin to think of the message it sends children about gender roles, respect, equity, etc.

Some have recently defended this type of discourse as “just words,” but unfortunately all too often talk leads to action. And in thinking about what happened on my walk home on Sunday, I began to feel sad — because the truth is I count myself among a lucky few women whose experience of degradation has been relatively limited, paling in comparison to the type of sexual assault others have known. I have borne witness to the effects of such experiences on my patients. The magnitude and gravity of those experiences stay with me.

I vividly remember the first time I was shocked by a story of domestic violence; it was within the first month of my practice. A woman in her mid 40s came in for a routine physical. She filled out a form indicating that yes, she felt she had been emotionally, verbally, or physically abused by someone in her household. When we asked if she would like to discuss it further, she shared a story of years of abuse at the hands of her husband — who had forced her repeatedly to engage in sexual intercourse with multiple partners while he looked on. She had suffered with depression and anxiety and had never sought care because she hadn’t felt safe to confess the source of her symptoms. Only when her husband had decided to ask for divorce did she find herself able to come forward and ask for help.

A couple of years later, a patient disclosed to me that she had been the patient of a gynecologist who had videotaped her Pap smears for years without her knowledge or consent. The gynecologist went on to be sued by several patients once the abuse was uncovered. Months after that I referred, for the first time, a patient to a gynecologist for a routine Pap smear to be performed under general anesthesia — she had been the victim of such brutal sexual assault that she could not obtain routine care without experiencing significant panic symptoms. Within the last week I have asked a social work colleague to participate in consults for three different woman in their 20s who have experienced post-traumatic stress disorder from sexual assaults that occurred in childhood.

Gender is considered a social determinant of health by the World Health Organization. Being a woman affects health outcomes in that it increases the possibility of violence, restricts access to resources, and correlates to a lower ability to participate in decision-making regarding health. It is reported that approximately 1.3 to 5.3 million women in the US experience intimate partner violence every year — ranging from psychological aggression to rape. Nearly 80% of female rape victims say they were first assaulted before age 25. And approximately 27% of women report that they experience short- or long-term health effects from sexual violence, including physical and mental health conditions — something I have seen over and over again in practice. Injuries reported around the world range from bruises to broken bones to loss of consciousness. Increased mental health diagnoses (such as depression and anxiety), substance use, and suicidal thoughts are also linked to violence experienced by women.

A multi-country study done by the World Health Organization on women’s health and domestic violence against women explicitly stated that the “immediate social context” was a factor in rates of sexual abuse and could either protect women against or increase risk for violence. As providers, it is suggested that we create safe, non-judgmental spaces to provide support and treatment for women who have experienced violence. As a society, we need to change the social context — and it should start by no longer condoning the type of talk that suggests violence against women is acceptable. According to the Chinese proverb, “Women hold up half the sky” — and it’s time we hold them up, respecting them as equals.

Author’s note: This post is related to the specific correlation between sexual violence and effects on women’s health and does not seek to minimize the experience of any other group or individual experiences of sexual violence. It is well known that sexual violence does not discriminate — it has been recognized in all populations, regardless of gender identity, sexual orientation, income level, race or ethnicity. The roots of sexual violence should be examined and strategies must be in place to reduce violence across all populations.