| Environment |
Aim: To enable a safer sensation during treatment, ensuring an appropriate environment. Tools: Local ambience. Orientation: It is important that the place where the sensitive practice will be carried out resembles a safe,10 calm place. Providing a calming ambience, silent or with relaxing songs, can help your patient to calm down or feel protected. Avoid places where sound from other people or rooms can be heard, or where your patient feels no privacy. Mind your moves and dispersive talking, as slower movements from the health professional might help to reduce anxiety whereas faster and excessive movements may trigger the patient’s anxiety. Both excessive talking and silence can feel uncomfortable to your patient. Although there is no clear rule, try to read the physical signs and adjust accordingly. Look at your patient’s eyes whenever possible. If possible, keep the backrest of the examining table high so the patient can see you. |
| Rapport |
Aim: To enable a safer sensation and trust during treatment. Tools: Confidentiality, empathy, active listening and paying attention. Orientation: Rapport is essential to facilitate feelings of safety. This process requires time and patience. Women described confidentiality, sensitivity and respect as decisive components when choosing to initiate the treatment.10,19 Examples include affirmative response as I believe you; It’s not your fault or non-verbal communication as eye contact. |
| Sexual trauma education |
Aim: To validate symptoms reported by the patient and reduce muscular tension. Tools: Instructions on body control, breathing exercises and vaginal penetration. Orientation: Information on prevalence along with effects of sexual violence on mind and body might be discussed after the patient’s report of sexual trauma history. You may propose to patients to notice their own body. Exercises for perception of each part of the body in sequence are well suited. With the purpose of leading patients to self-consciousness, you might ask: Do you think you frequently hold your breath, or make rapid and shallow breathing? Can you perceive your vaginal muscle contracting ‘on its own’ during the day? Diaphragmatic breathing exercises can be taught. This is an important resource to reduce anxiety and deal with hypervigilance, by enabling the autonomous nervous system to reduce the fight and flight reaction. At this point, a non-relaxing pelvic floor muscle (PFM) is usually perceived during the physical exam. This is a frequent sign of hypervigilance,7 and it is important that the patient knows this to progressively increase their awareness of the PFM and improve its control. Along with self-report of perceived PFM tension, you might instruct the patient as follows: Every time that you find yourself… [Complete with a daily activity that she might have reported, noticing her PFM tension], take a deep breath and try to sooth your vaginal muscles, looking for a downward and ‘melting’ sensation. If the patient tells you that even though they try, they are not aware whether their PFM is relaxing, you might propose that they hold a strong maximum voluntary contraction for 10 seconds and then let it go. This is based on the physiological law of maximum contraction leading to maximum relaxation. However, it is interesting to enable your patient to relax their PFM with other means that do not always contract first. When tolerated, self-touching of PFM tension through vaginal assessment is useful to enable self-consciousness of PFM tension and improve its control. Cessation of vaginal penetration activities other than therapeutic exercises should be encouraged. This is because a vicious cycle of fear–PFM tension–pain should be interrupted, with the aim of establishing a new experience when the woman is ready for sexual penetration. It is important that a new experience of painless vaginal penetration occurs after treatment sessions. |
| Distraction during sex |
Aim: To increase grounding and reduce dispersive thoughts. Tools: Instructions on concentration and fantasy training. Orientation: Distraction during sex is usually reported in women with a sexual abuse history. This usually jeopardizes sexual desire and arousal. Leading the patient to focus on the moment and concentrate on pleasure can improve sexual dysfunction and reduce distraction. Exercises that help the patient to concentrate can be suggested. If sexual activity is still a negative task to be developed by the patient, it can be suggested to start with progressive sex exercises on their own and then with the sexual partner. While concentrating on slow deep breathing, the patient can be encouraged to choose one of the five basic human senses to explore sexually. If the patient reports a negative flashback, instruct them to open their eyes if closed or focus on the present scene. You may instruct the patient as follows: Perceive if the person with you is the same person you are afraid of and if the location is where the violence took place. This can help the patient to self-regulate and break the trauma-triggering response. Fantasy training can help the patient to engage in the sexual response cycle. A suggested exercise is described as follows: Describe a context, environment and feelings of a sexual encounter, choose the partner you want, the talking, the touch you want and allow yourself to imagine it. Research visual resources (including photographs, film, videos) from sexually stimulating situations in order to find out what sexually excites you. |
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Intervention |
| Dealing with abuse-triggering signs |
Aim: To enable the health professional to identify the patient’s anxiety level and avoid further suffering or triggering trauma. Tools: The Buron and Curtis five-point scale11 is used to measure the anxiety score as an objective behaviour support tool. Orientation: Before assessing the patient physically, it is relevant to establish whether the treatment should proceed even though signs of fear and anxiety are perceived by the health professional. You may instruct your patient to self-evaluate their anxiety level by showing them a figure of 1 to 5 (progressively increasing)11 and evaluating it before and then repeatedly during pelvic floor management. At this point, if using the suggested scale, one can agree to reach a score of 2 on the 1–5 anxiety level. Be aware if your patient presents sudoresis, tightening of the fists or aggressive gesturing. These are common signs of the flight and fight response to the sexual abuse history and might be an indication to stop and use distraction manoeuvres. On the other hand, it is usual to find a static reaction, namely tonic immobility,18 when the patient seems to be highly passive to any verbal command or physical management from the health professional. If paralysation or quietness is perceived it is an indication to cease management or slow down while proceeding to distraction manoeuvres to lead the patient to different behaviour. Distraction manoeuvres: When noticing that your patient seems to be reaching a high level of anxiety, it is important to stop it progressing in order to reduce session discomfort and prevent triggering trauma symptoms. You may introduce a short talk on matters of the patient’s interest to refocus their mind. Diaphragm or deep breathing exercises may be guided, along with mindfulness techniques. |
| Aversion to touch, fear of clinical assessment and pain |
Aim: To increase the patient’s tolerance to touch and safety sensation. Tools: A mirror and pelvic floor self-exam instructions for self-awareness of maximum tolerated discomfort. Orientation: It is important that the patient knows what to expect each time they are going to be touched by the health professional. Start explaining what and why, and if possible, show, using a model, what you are willing to do in the session. Ask your patient which parts of their body should be avoided when managing their pelvic floor (e.g. inner thighs). Show respect and rule boundaries that can be limited. Even after explaining what you will do when managing them, always ask permission to touch or change the touch location. In order to increase tolerance to touch, exposure to the location of aversion can be managed with respect and by being mindful of the fear and trauma-triggering signs suggested above. For example: If the patient cannot look at or touch their own vulva, a mirror can be used so that they can look near the vulva, or an exercise can be suggested to touch places nearby, while the health professional guides them to control anxiety to a score of 2 (0–5) or mind their reactions. It is indispensable to understand whether the patient herself prefers to touch the location of aversion or would rather someone else to do it. If instructing the patient to face her own body is a more feasible way to start the exercise, the health professional can suggest a self-exam using a mirror, guiding the patient to touch places around the avoided location, and proceed to touch the location using devices such as a vaginal dilator, swab or pelvic wand. If hypervigilance or distress signs are perceived when the tolerance to touch exercise is proposed, distraction manoeuvres must be used so that anxiety decreases and there is better concentration of the patient to the proposed exercise. The aim is to reach the patient’s emotional skills to face or tolerate touch to the location of aversion. In order to deal with pain during physical management, the patient must be instructed to give verbal commands to the health professional, such as “please stop”, “give me a minute” or “that’s the maximum I can tolerate now”, whenever they feel the need. Patients should be constantly encouraged to bring their manifestations of discomfort to verbalization rather than to their body. However, when dealing with patients with poor communication skills, it can be agreed to reach level 3–4 of the 0–10 numerical rating scale of pain. When reaching maximum tolerated discomfort, the procedure is adjusted to reduce or not increase discomfort. Attention: The sensation of pain can cause many emotional triggers and should be managed with caution during the therapeutic approach, with awareness of patients who tend to show passive behaviour and omit reporting discomfort. Painful treatments dealt without a sensitive approach may cause higher rates of treatment abandonment and reinforce trust issues in patients with a history of sexual abuse. |
| Pelvic floor muscle stretching in the clinic once/week and at home from three times/week |
Aim: To normalize PFM tone, enable painless vaginal penetrative intercourse and provide vaginal desensitization.8 Tools: Manual therapy provided by the patient and by the physiotherapist. Orientation: PFM stretching is recommended for women who report experience of painful penetrative sex. This study protocol suggested that the patient stretch their PFM from three times a week to once a day until achieving painless vaginal touch or insertion of the last vaginal dilator (if applicable). The patient was instructed to introduce her thumb downwards, using her dominant hand, and apply the maximum pressure she could endure until achieving her maximum discomfort level or minimal pain threshold (3 on the numerical rating scale of 0–10). Each vaginal wall (at 4–5, 6 and 7–8 h of vaginal clock) should be stretched for 1 minute.21 The patient also had her PFM stretched once a week by the physiotherapist, who used her index and middle fingers. Breathing exercises were instructed whenever the physiotherapist noticed patient distress. In addition, the patient was encouraged to notice vaginal pain and follow her body sensation, modifying the exercise over time. |
| Dilators |
Aim: To enable autonomy to the patient to maintain PFM stretching and gain self-efficacy.8 Tools: Vaginal dilators. Orientation: Women who presented increased PFM tone of > 3 according to Newman’s scale, even after one week of self-stretching, were instructed to include vaginal dilators in their treatment protocol. Vaginal dilators were first tested after PFM stretching at the office, from the smallest to the largest possible that provided discomfort. The two largest sizes were then instructed to be used at home, always immediately after the stretching exercises, for 3 and 5 minutes, respectively. The patient should proceed to a larger size and drop the use of the smaller size in the next session with physiotherapy assistance, until achieving the largest possible size (or the one agreed to be compatible with the aimed penetrative sex). In the following sequence, desensitization with massage and vaginal dilator use was suggested until the patient was able to return to penetrative intercourse. |
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Intervention |
| Verbal commands |
Aim: To avoid sexual-trauma-triggering and enable a safer sensation during dyspareunia treatment. Tools: Verbal commands. Orientation: Many words used during gynecological consultations can trigger sexual abuse emotions in the woman with a sexual abuse history.10 This may occur because the victim, who is usually fearful or defenseless, can associate some commands with the ones that might have occurred during the abuse. Also, trusting another can be an issue and having someone asking for it can be unhelpful. Some commands to avoid that can trigger abuse trauma sensations, along with their suggested replacements, are provided below. Avoid: “trust me”; “open your legs”; “this won’t hurt”; “relax”; “you have a pretty vulva” (or any other physical-related compliments). Replace by: “Let’s make a deal: you must tell me when to stop whenever you feel uncomfortable”; Now I will place my index finger at your vaginal introitus”; “Is it ok if I move it to your left?”; “Do you think it is possible to take a deep breath until the discomfort/pain you are feeling during this stretching gets better?”. Explain each step of the procedure in detail, ask permission to touch and to change location and share the control of the treatment approach with your patient. |
A sensitive practice framework for treating genitopelvic pain in women with sexual trauma