Trauma-informed management of patients with prior sexual trauma in pelvic health physiotherapy clinical practice

Janine Stirling; Zoe Wallace; Angela James; Rita Shackel; James Elliott

doi:10.1071/CJ24042

RESEARCH ARTICLE (Open Access)

Previous Next Contents Vol 31(1)

Trauma-informed management of patients with prior sexual trauma in pelvic health physiotherapy clinical practice

Janine Stirling ^A ^B ^* , Zoe Wallace ^C ^D , Angela James ^D ^E , Rita Shackel ^F and James Elliott ^A ^G

+ Author Affiliations

- Author Affiliations

^A The University of Sydney, Faculty of Medicine and Health, School of Health Sciences, Camperdown, NSW, Australia.

^B The Sydney Clinic, Bronte, NSW, Australia.

^C Alana Healthcare, Kensington, NSW, Australia.

^D Sydney Pelvic Clinic, Balmain, Bondi Junction, St Leonards and St Vincent’s, NSW, Australia.

^E Melbourne University, Department of Physiotherapy, Parkville, Vic, Australia.

^F The University of Sydney Law School, The University of Sydney, Camperdown, NSW, Australia.

^G The Northern Sydney Local Health District, The Kolling Institute, St Leonards, NSW, Australia.

^* Correspondence to: jwhi6060@uni.sydney.edu.au

Australian and New Zealand Continence Journal 31, CJ24042 https://doi.org/10.1071/CJ24042

Submitted: 17 October 2024 Accepted: 16 January 2025 Published: 11 March 2025

© 2025 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of Continence Health Australia (CHA). This is an open access article distributed under the Creative Commons Attribution 4.0 International License (CC BY)

Abstract

Pelvic health (PH) physiotherapists treat a range of pelvic floor conditions, with more than 20% of those seeking treatment having a prior history of sexual assault or childhood sexual abuse. This Discussion Paper incorporates an integrated case study of a patient who was sexually assaulted as a teenager and went on to develop Genito-Pelvic Pain Penetration Disorder (GPPPD). The authors collectively share multidisciplinary insights in physiotherapy, psychology, psychotherapy, nursing, law and trauma research to advocate for a tailored evidence-based approach to treating patients with sexual trauma. A trauma-informed perspective creating safety, screening and consent will be offered. Graded exposure techniques to facilitate an adaptive and flexible patient response to cues of safety vs threat will be introduced. Empathic responding, being attentive and attuned to a patient’s trauma triggers could translate to improved patient outcomes. Inadvertently, these same qualities may place PH physiotherapists at risk for vicarious trauma. Harmonising this delicate intersection where clinicians are required to flexibly pivot between containing hyper/hypo arousal for the patient with empathic, attuned responding to ensure a safe treatment milieu, is a specific focus. We invite further collaboration from this review article, serving as a catalyst for developing rigorous clinical practice guidelines for PH physiotherapists to be confident and competent when managing patients presenting with history of sexual trauma.

Keywords: childhood sexual abuse, deep brain reorienting, dyspareunia, Genito-pelvic pain penetration disorder, pelvic health physiotherapy, pelvic pain, post-traumatic stress disorder, rape, sexual assault, sexual trauma, somatic experiencing, tonic immobility, trauma-informed care, vaginismus, vicarious trauma.

References

1 Freedman E. Clinical management of patients presenting following a sexual assault. Aust J Gen Pract 2020; 49(7): 406-411.
| Crossref | Google Scholar | PubMed |

2 Lanius RA, Terpou BA, McKinnon MC. The sense of self in the aftermath of trauma: lessons from the default mode network in posttraumatic stress disorder. Eur J Psychotraumatol 2020; 11(1): 1807703.
| Crossref | Google Scholar |

3 Kearney BE, Lanius RA. The brain-body disconnect: a somatic sensory basis for trauma-related disorders. Front Neurosci 2022; 16: 1015749.
| Crossref | Google Scholar |

4 Speckhard Pasque L. The lingering effects of sexual trauma. Mayo Clinic Press Article: Women’s Health website; 2023. Available at https://mcpress.mayoclinic.org/women-health/lingering-effects-of-sexual-trauma/ [cited 16 October 2024]

5 Dworkin ER. Risk for mental disorders associated with sexual assault: a meta-analysis. Trauma Violence Abuse 2020; 21(5): 1011-1028.
| Crossref | Google Scholar |

6 Nöthling J, Abrahams N, Jewkes R, Mhlongo S, Lombard C, Hemmings SMJ, Seedat S. Risk and protective factors affecting the symptom trajectory of posttraumatic stress disorder post-rape. J Affect Disord 2022; 309: 151-164.
| Crossref | Google Scholar |

7 Möller AT, Bäckström T, Söndergaard HP, Helström L. Identifying risk factors for PTSD in women seeking medical help after rape. PLoS ONE 2014; 9(10): e111136.
| Crossref | Google Scholar |

8 American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5-TR. 5th edn. text revision. Washington, DC: American Psychiatric Association Publishing; 2022. Available at https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787 [cited 20 February 2025]

9 Montgomery E, Pope C, Rogers J. The re-enactment of childhood sexual abuse in maternity care: a qualitative study. BMC Pregnancy Childbirth 2015; 15(1): 194.
| Crossref | Google Scholar |

10 TeBockhorst SF, O’Halloran MS, Nyline BN. Tonic immobility among survivors of sexual assault. Psychol Trauma 2015; 7(2): 171-178.
| Crossref | Google Scholar |

11 Troutman M, Chacko S, Petras L, Laufer MR. Informed care for the gynecologic day surgical patient with a history of sexual trauma. J Pediatr Adolesc Gynecol 2022; 35(1): 3-6.
| Crossref | Google Scholar |

12 Crosby SS, Mashour GA, Grodin MA, Jiang Y, Osterman J. Emergence flashback in a patient with posttraumatic stress disorder. Gen Hosp Psychiatry 2007; 29(2): 169-171.
| Crossref | Google Scholar |

13 Porges SW. The polyvagal theory: neurophysiological foundations of emotions, attachment, communication, and self-regulation. 1st edn. W.W. Norton; 2011.

14 Porges SW. Polyvagal theory: a science of safety. Front Integr Neurosci 2022; 16: 871227.
| Crossref | Google Scholar |

15 Better Health Channel. Patient-centred care explained. Victoria State Government: Department of Health; 2024. Available at https://www.betterhealth.vic.gov.au/health/servicesandsupport/patient-centred-care-explained# [cited 16 October 2024]

16 Heywood S, Bunzli S, Dillon M, Bicchi N, Black S, Hemus P, Bogatek E, Setchell J.. Trauma-informed physiotherapy and the principles of safety, trustworthiness, choice, collaboration, and empowerment: a qualitative study. Physiother Theory Pract 2024; 41(1): 153-168.
| Crossref | Google Scholar | PubMed |

17 Kezelman C, Stavropoulos P. Talking about trauma: Guide to conversations, screening and treatment for primary health care providers. Blue Knot Foundation: National Centre of Excellence for Complex Trauma; 2018. Available at https://www.pc.gov.au/__data/assets/pdf_file/0003/241752/sub047-mental-health-attachment3.pdf

18 Chen LP, Murad MH, Paras ML, Colbenson KM, Sattler AL, Goranson EN, Elamin MB, Seime RJ, Shinozaki G, Prokop LJ, Zirakzadeh A. Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis. Mayo Clin Proc 2010; 85(7): 618-629.
| Crossref | Google Scholar |

19 Arditte Hall KA, Healy ET, Galovski TE. The sequelae of sexual assault. In: O’Donohue WT, Schewe PA, editors. Handbook of sexual assault and sexual assault prevention. Springer International Publishing; 2019. pp. 277–292. 10.1007/978-3-030-23645-8_16

20 Lalchandani P, Lisha N, Gibson C, Huang AJ. Early life sexual trauma and later life genitourinary dysfunction and functional disability in women. J Gen Intern Med 2020; 35(11): 3210-3217.
| Crossref | Google Scholar |

21 Paras ML, Murad MH, Chen LP, Goranson EN, Sattler AL, Colbenson KM, Elamin MB, Seime RJ, Prokop LJ, Zirakzadeh A. Sexual abuse and lifetime diagnosis of somatic disorders: a systematic review and meta-analysis. JAMA 2009; 302(5): 550-561.
| Crossref | Google Scholar |

22 Möller A, Sondergaard HP, Helstrom L. Tonic immobility during sexual assault – a common reaction predicting post-traumatic stress disorder and severe depression. Acta Obstet Gynecol Scand 2017; 96(8): 932-938.
| Crossref | Google Scholar |

23 Imhoff LR, Liwanag L, Varma M. Exacerbation of symptom severity of pelvic floor disorders in women who report a history of sexual abuse. Arch Surg 2012; 147(12): 1123-1129.
| Crossref | Google Scholar |

24 Nanavaty N, Thompson CG, Meagher MW, McCord C, Mathur VA. Traumatic life experience and pain sensitization: meta-analysis of laboratory findings. Clin J Pain 2023; 39(1): 15-28.
| Crossref | Google Scholar |

25 Levesque A, Riant T, Ploteau S, Rigaud J, Labat J-J, Convergences PP Network. Clinical criteria of central sensitization in chronic pelvic and perineal pain (Convergences PP Criteria): elaboration of a clinical evaluation tool based on formal expert consensus. Pain Med 2018; 19(10): 2009-2015.
| Crossref | Google Scholar |

26 Woolf CJ. Pain amplification—A perspective on the how, why, when, and where of central sensitization. J Appl Biobehav Res 2018; 23(2): e12124.
| Crossref | Google Scholar |

27 World Health Organization. ICD-11: International classification of diseases (11th revision). WHO; 2022. Available at https://icd.who.int/browse/2024-01/mms/en#1581976053 [cited 16 October 2024]

28 Keay KA, Bandler R. Parallel circuits mediating distinct emotional coping reactions to different types of stress. Neurosci Biobehav Rev 2001; 25(7–8): 669-678.
| Crossref | Google Scholar |

29 Terpou BA, Harricharan S, McKinnon MC, Frewen P, Jetly R, Lanius RA. The effects of trauma on brain and body: a unifying role for the midbrain periaqueductal gray. J Neurosci Res 2019; 97(9): 1110-1140.
| Crossref | Google Scholar |

30 van der Kolk BA, van der Hart O. The intrusive past: the flexibility of memory and the engraving of trauma. American Imago 1991; 48(4): 425-454.
| Google Scholar |

31 Marx BP, Forsyth JP, Gallup GG, Fusé T, Lexington JM. Tonic immobility as an evolved predator defense: implications for sexual assault survivors. Clin Psychol 2008; 15(1): 74-90.
| Crossref | Google Scholar |

32 Kalaf J, Coutinho ESF, Vilete LMP, Luz MP, Berger W, Mendlowicz M, Volchan E, Andreoli SB, Quintana MI, de Jesus Mari J, Figueira I. Sexual trauma is more strongly associated with tonic immobility than other types of trauma – a population based study. J Affect Disord 2017; 215: 71-76.
| Crossref | Google Scholar |

33 Heidt JM, Marx BP, Forsyth JP. Tonic immobility and childhood sexual abuse: a preliminary report evaluating the sequela of rape-induced paralysis. Behav Res Ther 2005; 43(9): 1157-1171.
| Crossref | Google Scholar |

34 Porges SW, Peper E. When not saying NO does not mean yes: psychophysiological factors involved in date rape. Biofeedback 2015; 43(1): 45-48.
| Crossref | Google Scholar |

35 Kearney BE, Terpou BA, Densmore M, Shaw SB, Théberge J, Jetly R, McKinnon MC, Lanius RA. How the body remembers: examining the default mode and sensorimotor networks during moral injury autobiographical memory retrieval in PTSD. Neuroimage Clin 2023; 38: 103426.
| Crossref | Google Scholar |

36 Zhang H, Zhu Z, Ma W-X, Kong L-X, Yuan P-C, Bu L-F, Han J, Huang Z-L, Wang Y-Q. The contribution of periaqueductal gray in the regulation of physiological and pathological behaviors. Front Neurosci 2024; 18: 1380171.
| Crossref | Google Scholar |

37 Kim MC, Fricchione GL, Akeju O. Accidental awareness under general anaesthesia: incidence, risk factors, and psychological management. BJA Educ 2021; 21(4): 154-161.
| Crossref | Google Scholar |

38 van der Kolk BA. The body keeps the score: memory and the evolving psychobiology of posttraumatic stress. Harv Rev Psychiatry 1994; 1(5): 253-265.
| Crossref | Google Scholar |

39 Cusack K, Jonas DE, Forneris CA, Wines C, Sonis J, Middleton JC, Feltner C, Brownley KA, Olmsted KR, Greenblatt A, Weil A, Gaynes BN. Psychological treatments for adults with posttraumatic stress disorder: a systematic review and meta-analysis. Clin Psychol Rev 2016; 43: 128-141.
| Crossref | Google Scholar |

40 Payne P, Levine P, Crane-Godreau MA. Somatic experiencing: using interoception and proprioception as core elements of trauma therapy. Front Psychol 2015; 6: 93.
| Crossref | Google Scholar |

41 Rash JA, Aguirre-Camacho A, Campbell TS. Oxytocin and pain: a systematic review and synthesis of findings. Clin J Pain 2014; 30(5): 453-462.
| Crossref | Google Scholar |

42 Ellingsen D-M, Wessberg J, Chelnokova O, Olausson H, Laeng B, Leknes S. In touch with your emotions: oxytocin and touch change social impressions while others’ facial expressions can alter touch. Psychoneuroendocrinology 2014; 39(1): 11-20.
| Crossref | Google Scholar |

43 Kearney BE, Corrigan FM, Frewen PA, Nevill S, Harricharan S, Andrews K, Jetly R, McKinnon MC, Lanius RA. A randomized controlled trial of Deep Brain Reorienting: a neuroscientifically guided treatment for post-traumatic stress disorder. Eur J Psychotraumatol 2023; 14(2): 2240691.
| Crossref | Google Scholar |

44 Frawley H, Shelly B, Morin M, Bernard S, Bø K, Digesu GA, Dickinson T, Goonewardene S, McClurg D, Rahnama’i MS, Schizas A, Slieker-Ten Hove M, Takahashi S, Voelkl Guevara J. An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment. Neurourol Urodynamics 2021; 40(5): 1217-1260.
| Crossref | Google Scholar |

45 Morris LS, McCall JG, Charney DS, Murrough JW. The role of the locus coeruleus in the generation of pathological anxiety. Brain Neurosci Adv 2020; 4: 239821282093032.
| Crossref | Google Scholar |

46 Benarroch EE. Locus coeruleus. Cell Tissue Res 2018; 373(1): 221-232.
| Crossref | Google Scholar |

47 Rogers CR. The necessary and sufficient conditions of therapeutic personality change. J Consul Clin Psychol 1992; 60(6): 827-832.
| Crossref | Google Scholar |

48 Aces aware: Screen. Treat. Heal. Adverse Childhood Experience Questionnaire for Adults. California Surgeon General’s Clinical Advisory Committee; 2022. Available at https://www.acesaware.org/wp-content/uploads/2022/07/ACE-Questionnaire-for-Adults-Identified-English-rev.7.26.22.pdf [cited 17 October 2024]

49 Weiss DS, Marmar CR. The impact of event scale—revised. In: Wilson JP, Keane TM, editors. Assessing psychological trauma and PTSD. The Guilford Press; 1997. pp. 399–411.

50 Lovibond SH, Lovibond PF. Manual for the depression anxiety stress scales. 2nd edn. Sydney: Psychology Foundation; 1995.

51 Depression, Anxiety, Stress Scales (DASS). Psychology Foundation of Australia; 2023. Available at https://dass.psy.unsw.edu.au [updated 10 October 2024, cited 17 Oct 2024]

52 Mayer TG, Neblett R, Cohen H, Howard KJ, Choi YH, Williams MJ, Perez Y, Gatchel RJ. The development and psychometric validation of the central sensitization inventory. Pain Pract 2012; 12(4): 276-285.
| Crossref | Google Scholar |

53 Rosen CB, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, Ferguson D, D’Agostino R, Jr. The female sexual function index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000; 26(2): 191-208.
| Crossref | Google Scholar |

54 DeRogatis L, Clayton A, Lewis-D’Agostino D, Wunderlich G, Fu Y. Validation of the female sexual distress scale-revised for assessing distress in women with hypoactive sexual desire disorder. J Sex Med 2008; 5(2): 357-364.
| Crossref | Google Scholar |

55 Raja S, Hasnain M, Hoersch M, Gove-Yin S, Rajagopalan C. Trauma informed care in medicine: current knowledge and future research directions. Fam Community Health 2015; 38(3): 216-226.
| Crossref | Google Scholar |

56 Crockett R. How belly breathing benefits your body, mind. Mayo Clinic Q&A: Tribune Content Agency LLC; 2024. Available at https://www.proquest.com/other-sources/how-belly-breathing-benefits-your-body-mind/docview/3031587684/se-2 [cited 17 October 2024]

57 Liu H, Wiedman CM, Lovelace-Chandler V, Gong S, Salem Y. Deep diaphragmatic breathing—anatomical and biomechanical consideration. J Holist Nurs 2024; 42(1): 90-103.
| Crossref | Google Scholar |

58 Forbes R, Elkins MR. Patient education. J Physiother 2024; 70(2): 85-87.
| Crossref | Google Scholar |

59 Weinreb L, Savageau JA, Candib LM, Reed GW, Fletcher KE, Lee Hargraves J. Screening for childhood trauma in adult primary care patients: a cross-sectional survey. Prim Care Companion J Clin Psychiatry 2010; 12(6): PCC.10m00950.
| Crossref | Google Scholar |

60 Gordinier ME, Shields LBE, Davis MH, Cagata S, Lorenz DJ. Impact of screening for sexual trauma in a gynecologic oncology setting. Gynecol Obstet Invest 2021; 86(5): 438-444.
| Crossref | Google Scholar |

61 Information and Privacy Commission New South Wales. Fact Sheet. Consent. Available at https://www.ipc.nsw.gov.au/sites/default/files/2023-06/Fact_Sheet_Consent_June_2023.pdf [cited 16 October 2024]

62 Delany C, Frawley H. A process of informed consent for student learning through peer physical examination in pelvic floor physiotherapy practice. Physiotherapy 2012; 98(1): 33-39.
| Crossref | Google Scholar |

63 Copnell G. Informed consent in physiotherapy practice: it is not what is said but how it is said. Physiotherapy 2018; 104(1): 67-71.
| Crossref | Google Scholar |

64 Padmanabhanunni A, Gqomfa N. “The Ugliness of It Seeps into Me”: experiences of vicarious trauma among female psychologists treating survivors of sexual assault. Int J Environ Res Public Health 2022; 19(7): 3925.
| Crossref | Google Scholar |

65 Quitangon G. Vicarious trauma in clinicians: fostering resilience and preventing burnout. The Psychiatric Times 2019; 36(7): 18-19.
| Google Scholar |

66 Kassam-Adams N. The risks of treating sexual trauma: Stress and secondary trauma in psychotherapists. In: Stamm BH, editor. Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators, Lutherville, MD: Sidran Press; 1995. pp. 37–48.

67 Hallinan S, Shiyko MP, Volpe R, Molnar BE. Reliability and validity of the vicarious trauma organizational readiness guide (VT-ORG). Am J Community Psychol 2019; 64(3–4): 481-493.
| Crossref | Google Scholar |

68 Isobel S, Thomas M. Vicarious trauma and nursing: an integrative review. Int J Ment Health Nurs 2022; 31(2): 247-259.
| Crossref | Google Scholar |

69 Australian Bureau of Statistics. Sexual violence – victimisation. Canberra: ABS; 2021. Available at https://www.abs.gov.au/articles/sexual-violence-victimisation [cited 5 September 2024]

70 Data Pandas. Rape statistics by country. Available at https://www.datapandas.org/ranking/rape-statistics-by-country [cited 17 Ocotober 2024]

71 McGrath RL, Parnell T, Verdon S, Pope R. “We take on people’s emotions”: a qualitative study of physiotherapists’ experiences with patients experiencing psychological distress. Physiother Theory Pract 2024; 40(2): 304-326.
| Crossref | Google Scholar |

72 Cromie JE, Robertson VJ, Best MO. Occupational health and safety in physiotherapy: guidelines for practice. Aust J Physiother 2001; 47(1): 43-51.
| Crossref | Google Scholar |

73 de Castro AB. ‘Hierarchy of controls’: providing a framework for addressing workplace hazards. Am J Nurs 2003; 103(12): 104.
| Crossref | Google Scholar |

74 Guidi J, Lucente M, Sonino N, Fava GA. Allostatic load and its impact on health: a systematic review. Psychother Psychosom 2021; 90(1): 11-27.
| Crossref | Google Scholar |

75 Higginbotham JA, Markovic T, Massaly N, Moron JA. Endogenous opioid systems alterations in pain and opioid use disorder. Front Syst Neurosci 2022; 16: 1014768.
| Crossref | Google Scholar |

76 Pal MM. Glutamate: the master neurotransmitter and its implications in chronic stress and mood disorders. Front Hum Neurosci 2021; 15: 722323.
| Crossref | Google Scholar |

77 Goodall E. Interoception and mental wellbeing in autistic people. National Autistic Society; 2022. Available at https://www.autism.org.uk/advice-and-guidance/professional-practice/interoception-wellbeing#:~:text=Interoception%20is%20an%20internal%20sensory,pulling%20sensation%20in%20their%20abdomen [cited 4 January 2025]

78 Schimmelpfennig J, Topczewski J, Zajkowski W, Jankowiak-Siuda K. The role of the salience network in cognitive and affective deficits. Front Hum Neurosci 2023; 17: 1133367.
| Crossref | Google Scholar |

79 Benarroch E. What are the functions of the superior colliculus and its involvement in neurologic disorders? Neurology 2023; 100(16): 784-790.
| Crossref | Google Scholar |