Editor’s note: This article was updated to add a reference for the statistic regarding the number of men who are victims of completed or attempted rape and to renumber the consecutive references.

Sexual assault is a pervasive issue in the United States. Studies show that 1 in 5 women and 1 in 38 men are victims of completed or attempted rape in their lifetime,1,2 and 47% of transgender persons report sexual assault in their lifetime.3 There are no comprehensive statistics about the number of people with cancer who have a history of sexual trauma, but there is likely a large overlap due to high rates of both cancer and sexual assault in the United States.

The Impact of Sexual Trauma

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A history of sexual trauma can have major impacts on a person’s mental and physical health. Those with a history of sexual trauma are more likely to be diagnosed with various mental health disorders, inducing anxiety, depression, post-traumatic stress disorder, and more.4 A meta-analysis of available literature found a moderate association between people who experienced 4 or more adverse childhood experiences (eg, witnessing violence in the home; exposure to neglect or abuse, including sexual abuse) and various physical health problems including heart disease, respiratory disease, and cancer.5 Furthermore, people with sexual trauma are less likely to be screened for cancer: women are 31% less likely to undergo a pap smear and 30% less likely to undergo mammography, and men are 51% less likely to be screened for prostate cancer.6 This may lead to delayed detection of cancer, cancer being at a later stage at diagnosis, and may decrease treatment options.7

Cancer and healthcare interactions can be uniquely triggering to those with a trauma history. Cancer care may lead to re-experiencing feelings that were experienced during or after their trauma, including feelings of powerlessness, lack or loss of control, lack of choice or agency, vulnerability, and feeling out of control. Procedures and healthcare interactions can be challenging, especially being touched by unfamiliar healthcare providers, or having pain inflicted by another — as is the case with surgery or other procedures.8 Aspects of a healthcare interaction may mirror the sexual trauma itself, including the patient being in darkness, immobilized, or silenced during various examinations or treatments.9 It can be especially triggering for patients whose cancer is in a site related to where they may have experienced sexual trauma (such as breast, gynecologic, prostate, colorectal, and anal cancers) as these sites of the body may require frequent exposure or touch during treatment. 

Oncology patients with a history of sexual trauma may exhibit different trauma-related behaviors. These can include missing treatment appointments, having a hard time remembering instructions or integrating information, having fear towards staff, and panic in enclosed or confined spaces.6 There may also be increased interpersonal issues between the patient and the healthcare team. Multiple studies show that patients with a history of sexual abuse are less likely to feel supported by their healthcare teams, and providers are also more likely to identify these patients as more difficult to help.10 Patients may have poorer healthcare outcomes if they miss appointments or do not follow treatment as instructed.

Trauma-Informed Care and How to Help

A history of sexual trauma can greatly impact an oncology patient’s mental and physical health, so implementing trauma-informed care practices in oncology settings is essential. According to the Substance Abuse and Mental Health Services Administration, trauma-informed care involves policy and practice that fosters feelings of safety, trust, support, collaboration, and empowerment amongst patients. Trauma-informed care involves recognizing signs of trauma from patients who are served, and staff understanding the impact that trauma has on patients. Patient behavior is viewed in a trauma-informed lens, and patients are provided support around issues that arise. Policies and practices are put into place to avoid re-traumatizing patients.11

Implementing trauma-informed care involves training staff on the impact of trauma, and how to most effectively communicate and interact in a healthcare setting with patients who have a history of trauma. Sensitive screeners can be implemented to identify patients with a history of sexual trauma, as well as any triggers they may experience in a healthcare setting, so that staff can know how to avoid those triggers and best provide support.12

Healthcare providers and staff should also modify certain aspects of healthcare interactions. These could include offering choice and control to the patient whenever possible. For example, patients should be asked for consent before touching them. Procedures should be explained before they occur, so the patient understands what will happen during the interaction, what they can expect, and what tools may be involved. These types of practices help minimize feelings of vulnerability and help encourage the patient’s sense of partnership and power throughout the healthcare interaction.

Healthcare providers may need to take extra care to clearly communicate instructions, and what to expect in between appointments, including side effects or common symptoms. Encouraging patients to bring someone who can take notes or record interactions with them to appointments may be useful.13 If the patient does not have someone in their life able to fill this role, advocate services offered through the healthcare setting can be a helpful support. Healthcare providers can also connect their patients to a variety of support services, which may include counseling or psychotherapy, psychopharmacology, support groups, peer support, and patient advocacy services.

Allison Duggan is the internship program coordinator for CancerCare.

References

  1. Smith SG, Zhang X, Basile KC, et al; Centers for Disease Control and Prevention; National Center for Injury Prevention and Control; Division of Violence Prevention. The National Intimate Partner and Sexual Violence Survey (NISVS): 2015 Data Brief — Updated Release. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; November 2018. Accessed August 31, 2022. https://www.cdc.gov/violenceprevention/pdf/2015data-brief508.pdf
  2. Centers for Disease Control and Prevention. Intimate partner violence, sexual violence, and stalking among men. Last reviewed June 1, 2020. Accessed September 13, 2022. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/men-ipvsvandstalking.html#:~:text=About%201%20in%2014%20men,victimization%20prior%20to%20age%2025
  3. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. (2016). Executive Summary of the Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; December 2016. Accessed August 31, 2022. https://transequality.org/sites/default/files/docs/usts/USTS-Executive-Summary-Dec17.pdf
  4. Spataro J, Mullen PE, Burgess PM, Wells DL, Moss SA. Impact of child sexual abuse on mental health: prospective study in males and females. Br J Psychiatry., 2004;184(5):416-421. doi:10.1192/bjp.184.5.416
  5. Hughes K, Bellis MA, Hardcastle KA, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health. 2017;2(8):e356–e366. doi:10.1016/S2468-2667(17)30118-4
  6. Alcalá HE, Keim-Malpass J, Mitchell EM. Sexual assault and cancer screening among men and women. J Interpers Violence. 2021;36(11/12):NP6243-NP6259. doi:10.1177/0886260518812797
  7. Coker AL, Garcia LS, Williams CM, Follingstad D, Crawford TN, Bush HM. Association of intimate partner violence and childhood sexual abuse with cancer-related well-being in women. J Womens Health (Larchmt). 2012;21(11):1180-1188. doi:10.1089/jwh.2012.3708
  8. Schnur JB, Dillon MJ, Goldsmith RE, Montgomery GH. Cancer treatment experiences among survivors of childhood sexual abuse: a qualitative investigation of triggers and reactions to cumulative trauma. Palliat Support Care. 2018;16(6):767-776. doi:10.1017/S147895151700075X
  9. Schnur JB, Goldsmith RE. Through her eyes. J Clin Oncol. 2011;29(30):4054-4056. doi:10.1200/JCO.2011.37.2409
  10. Clark L, Beesley H, Holcombe C, Salmon P. The influence of childhood abuse and adult attachment style on clinical relationships in breast cancer care. Gen Hosp Psychiatry. 2011;33(6):579-586. doi:10.1016/j.genhosppsych.2011.07.007
  11. Substance Abuse and Mental Health Services Administration (SAMHSA) Trauma and Justice Strategic Initiative. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Rockville, MD: Office of Policy, Planning and Innovation, Substance Abuse and Mental Health Services Administration; 2014. HHS Publication No. (SMA) 14-4884. Accessed August 31, 2022. https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf
  12. Schnur JB, Chaplin WF, Khurshid K, et al. Development of the healthcare triggering questionnaire in adult sexual abuse survivors. Psychol Trauma. 2017;9(6):714-722. doi:10.1037/tra0000273
  13. Havig K. The health care experiences of adult survivors of child sexual abuse: a systematic review of evidence on sensitive practice. Trauma Violence Abuse. 2008;9(1):19-33. doi:10.1177/1524838007309805

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From CancerCare Intimacy and Sexual Relationships Nurse Communications