Do’s and don’ts for taking health history and conducting a physical exam for individuals in the sex trade

Do:

  • Review the details of their history that is already in the medical record. Some individuals have disclosed their trauma history previously, so this avoids the need to re-question the patient about the trauma. 

  • Have patience with survivors. The tasks you need to get done are not as important as displaying empathy and care for your patient during this experience that might be extremely difficult for them.

  • Allow the patient to follow you into the exam room upon arrival, and follow you out at the end. The patient should be “last in, last out” as you transition rooms.

  • Explain principles of confidentiality and medical privacy laws as it is important for reassuring individuals in the sex trade. 

  • Emphasize that the patient has complete control over their medical care. If the patient seems too upset or apprehensive to tolerate an examination, offer the opportunity to complete the physical examination at a later visit. 

  • Ask the patient if there is anything that will make the experience more tolerable when performing a physical examination.

  • Give the option of shifting an item of clothing out of the way rather than putting on a gown when an entire area does not need to be visualized. If a gown is necessary, invite the patient to keep on as much clothing as possible, e.g., underwear and/or shirts. An alternative approach during the physical exam might be to offer the option of a mirror so they can see procedures or examinations that are out of the patient’s visual field.

  • Clearly state that the findings are normal when applicable because a survivor may be worried that their trauma history had negative physical consequences to their body.  

  • Only touch the patients when needed for an exam with clear and ongoing consent. 

  • Respect the rights, choices, and dignity of the patient by maintaining a non-judgmental and sympathetic manner and showing respect for and acceptance of the patient. 

  • Treat all contact with patients as a potential step towards improving their health. Every interaction with a person can have positive or negative effects on their overall health and wellbeing.

  • Give patients space to tell their story and let them take the lead. 

  • Ask the patient to summarize their understanding during the exam to assess whether your explanation is being received. This also highlights ongoing consent. 

  • Use grounding techniques. Grounding techniques help the person feel safe in the here and now. “Put your feet on the floor and feel your presence. You are safe here.”

  • Thank them for their courage in sharing their story, empower them and respond to any dissociation. 

Don’t:

  • Walk behind the patient to the exam room.

  • Stand or sit between the patient and the door of the exam room if it is possible. If not possible due to room configuration, provide support and let the person know that they can leave the appointment at any time. 

  • Touch the patient if you do not have to. Talk through your necessary touches. Limit the exposure of the patient's body as much as possible and explain what is being examined and why. 

  • Use unneeded touch such as a handshake, touching patient’s shoulder, etc. 

  • Call authorities, such as police or immigration services, unless given the consent of the person. Persons may have well founded reasons for avoiding authorities. Attempts should be made to discuss viable options and you must gain consent for actions.

  • Press for information. Ask only relevant questions that are necessary for the assistance being provided. 

  • Ask questions out of simple curiosity.

  • Appear shocked, fearful or disgusted.

  • Show discomfort with silence and hesitation (see table below) (Raja, Hasnain,  Hoersch,  Gove-Yin, Rajagopalan, 2015 & Ades et. al., 2019).

The Patient The Healthcare Provider
Fearful body language:
Refuses exam or touch
Limited or no eye contact
Becomes quiet and distant during procedures

Negative self-talk:
”I was the one who did something wrong”
“This is all my fault”,“No one will love me”
“I know I am crazy”

Signs of trauma or distress:
Crying
Difficulty breathing
Irritable
Flat affect
Withdrawn
Anger
Aggression
Maintain open and accepting body language:
Maintain relaxed body posture, neutral positions with hands at side, and be mindful to keep legs together
Ask permission to make physical contact every time, and explain procedure before making contact

Attitudes:
Don’t stigmatize, victimize, or ask questions that are not pertinent.
Normalize the experience for the patient.
Believe and validate the patient, confront any biases and empathize.

Provide empathetic and empowering statements such as:
“It is normal to feel this way”,“Thank you for sharing with me”
“You are very brave to tell me”
“I am so sorry that this happened to you. No one deserves that”
Use non-judgmental language such as “sex without a condom” vs “risky sex”
Use the term “survivor” vs “victim”

Encourage patient autonomy by saying “Is it okay if I?” instead of “I need to”

Ask “What is the most important thing you need right now?

This table was adapted from An Integrated, Trauma-Informed Care Model for Female Survivors of Sexual Violence: The Engage, Motivate, Protect, Organize, Self-Worth, Educate, Respect (EMPOWER) Clinic. (Ades et. al., 2019).