How can GPs help with historical trauma following child sexual abuse?

Chris Hogan

6/06/2019 2:50:58 PM

Dr Chris Hogan reflects on how GPs can help survivors of sexual abuse who may be triggered by media reports of crimes against children.

Distressed man
Dr Hogan said it is important GPs be aware of the fact they may be hearing something a person has never previously discussed – with anyone.

Court cases played out in the public eye can significantly affect those who are survivors of childhood sexual abuse themselves, or who are close to a survivor.
How common is childhood sexual abuse?
In short, it is too common.
As a registrar 40 years ago, I was taught that serial anonymous surveys showed one person in 10 will have had an unwanted sexual experience before the age of 13. Of these, 80% will be female and 20% male.
In all of my subsequent years in practice, I have never had any reason to doubt those figures.

The idea of ‘stranger danger’ is essentially irrelevant. Almost all offenders – usually, but not exclusively, male – are very well known to the family. They usually initially delight in seduction, rather than assault.

Over the last 40 years, I have noticed patients report a sickening uniformity of actions and language used by their persecutors. Even before the proliferation of the internet, they have had to be in regular communication.
It is very easy to recognise the victims of childhood sexual abuse by their body language, as they are usually ambivalent in their relationships with authority figures (such as doctors) – needing help but afraid to trust. They can be anxious, over-protective of their children to an extreme extent, and have difficulties with relationships and intimacy. They often have issues with medications or substances that block the recall of past traumas, such as alcohol and benzodiazepines among others.

I have detected very few recent victims. Most have presented as adults when their offenders were long dead.
What are the traps for GPs in raising the issue?
Suspecting childhood sexual abuse is one thing, but it is vital that a GP never comes straight out and ask directly if a patient has been the victim of a paedophile.
As I have said, these offenders are in communication and they often lay a very nasty trap for therapists, a scenario I have encountered far, far too often.
‘I found you because you are evil and look evil – and others can see that, too.’
This is the standard line, but there are variations.
It is incredibly cruel. If the victim goes to a therapist and is immediately identified, that simply serves to confirm to the victim that they are, in fact, evil and not worth saving. They then abandon treatment.
What can we do?
Let them talk.
These patients have come to you in distress and want to tell you, but they are afraid. Afraid of being rejected as evil or dirty, of not being believed, of bring up something so painful that is has often been deeply buried.
They are often in greater distress than they should be for a minor or medium problem. In counselling, this is referred to as the ‘ticket of entry’, a plausible but insignificant excuse given to justify a consultation.
Often, as the excuse is dealt with, the patient will say those words dreaded by time-poor GPs: ‘Oh, by the way, Doctor …’

Settle in, let them talk, and acknowledge their distress and the significance of their concerns. It is important to be aware that you may be hearing something this patient has never previously discussed, and not even mentioned to intimate partners, friends or family.
Do not waste the opportunity.

If you are unable to deal with the issue straight away, get the patient to come back as soon as possible. Give them access to the relevant counselling and emergency services.
It is also important that you, as a GP and a person, seek advice and assistance for yourself.
This type of presentation is messy, confronting, vital and disruptive. The first time, I found I was overwhelmed with anger and despair. It is beneficial to speak to a colleague.

Support the patient with regular meetings as they work their way through the therapeutic maze.
Inevitably, many who read this article will have endured childhood sexual abuse. I urge you to seek assistance from a trusted colleague if you have not already. Truly, you are not alone and you will be believed.

childhood sexual abuse trauma

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Dr Oliver Kirland Weir   7/06/2019 7:08:33 AM

Great piece Chris. For further training on treatment of survivors of trauma see Blue Knot Foundation.
Dr Ollie Weir GP / Addiction Medicine

Prof Max Kamien, AM   7/06/2019 7:57:59 AM

Words of wisdom about this important task of the conscientious GP. Medicare economics, 10-minute consultations, form filling and other bureaucratic nonsense should not get in the way of doing what we have been educated and trained to do.

Dr Catherine Belinda Brooker   7/06/2019 11:02:59 AM

After many stumbles early in my career I have learned the signs that you describe above and many more (obesity often being a flag). My skills at counselling in this area have been overstretched as frequently a woman who has divulged to me then refuses to see a counsellor - not wanting to divulge to anyone else. My efforts now centre around getting patients to counsellors BEFORE they divulge to me, often very successfully, so that the first person they tell is really well trained to hold them.

Christine Troy   7/06/2019 12:32:12 PM

Well written Chris, sometimes they present flighty and overanxious as you said, because of their history. I agree with Max, Medicare needs to support the difficult job of doing it right and not encourage fast referral consultations, as if GP's have no secondary skills.