Most physiotherapists are familiar with the concept of universal precautions – implementing a standard approach to the care of all patients regardless of their apparent health status. The most common example relates to preventing the spread of blood-borne infections. However, the concept of implementing sensitive practice (also referred to as trauma-informed practice) as a universal precaution may be less familiar.
What is sensitive practice?
The concept of sensitive practice is based on the objective of fostering feelings of safety for the patient who has experienced sexual abuse or assault, or other forms of trauma.1 It is an approach to care that helps to “ensure that the unique needs of trauma survivors as patient are met, and mitigate barriers to care and health disparities experienced by this vulnerable population.”2
You may be asking yourself why you should care about sensitive practice or take steps to implementing a trauma-informed approach to care. You may be thinking that this is a topic that does not apply to you due to the patient population you serve (“I work with seniors,” “all my patients are well-off”), or the nature of your clinical practice and the conditions you treat (“I don’t treat pelvic health conditions.”)
The facts about sexual abuse and sexual assault in Canada say otherwise:
- 33% of females and 16% of males will experience sexual assault before the age of 18.3
- 40% of women experience sexual assault within their lifetime.3
- 50% of girls and 33% of boys will experience sexual abuse* by the time they are 16 years old.4
- *Sexual abuse is defined as exposure of a child to sexual contact, activity or behavior – including exhibitionism, exposure to pornography, sexual touching or sexual assault.
- 95% of survivors do not report sexual assaults to police, making sexual violence the most underreported crime in Canada.5
- The stigma related to sexual violence means that these numbers are widely held to be a significant under-representation of the true prevalence.2
- Survivors of sexual assault and sexual abuse generally demonstrate increased health-care seeking behaviour, and are more likely to experience headaches, migraines, chronic pain, and pelvic pain - conditions physiotherapists commonly treat.6,7,8
Most importantly, although an individual’s risk of experiencing sexual assault or sexual abuse may vary depending on their race, sexual orientation, socioeconomic status and other factors,3,9 this form of trauma affects people from all backgrounds and walks of life.3 No individual or social group is immune from the experience of sexual assault or sexual abuse.
There is also no easy way for a physiotherapist to distinguish survivors from those who have not experienced sexual abuse.10 This gives rise to the call for all physiotherapists to employ sensitive practice as a universal precaution, realizing that every physiotherapist regardless of the sector they work in or the population they serve, encounters survivors of sexual abuse or sexual assault daily.
But I’m treating their ankle
The point of sensitive practice is not what you are treating, but rather who you are treating, and what they bring to the table when they seek physiotherapy. It is ultimately about avoiding re-traumatizing someone who has a history of trauma. To do so, it is important to understand a few fundamental things about how people experience trauma.
- A traumatic event is one that represents “a fundamental threat to one’s physical integrity or survival. Responses involve intense fear, helplessness or horror.”11
- The experience of trauma leads to chemical and physiological changes in the brain that are not under a person’s voluntary control.11 These changes can manifest as the fight or flight responses that most people are familiar with but may also manifest as freeze or dissociation responses.2,3,11 These instinctual responses are the body’s way of ensuring survival of the traumatic event.3
- These chemical and physiological changes affect the survivor’s memory and recall, typically resulting in fragmented memories and the inability to recall details of the traumatic event.3,11
- Trauma theory suggests that if memories of traumatic experiences cannot be processed, they are stored as physiologic responses to stimuli or situations that remind the person of the original trauma, sometimes referred to as triggers.2
While a physiotherapist may be treating a person’s ankle or elbow, some aspects of physiotherapy practice may resemble aspects of a sexual assault and act as a trigger for a survivor. For example, being told to relax,2 or feeling the need to comply with an authority figure or do what was suggested to get help9 are occurrences that sometimes happen within the context of physiotherapy care and may mirror the survivor’s original experience of abuse.
In other situations, triggers may be more concrete, such as feeling trapped or restrained (e.g., mechanical traction, restraints in critical care environments).2
What do I need to do differently?
With the realization that physiotherapists encounter survivors of sexual assault and sexual abuse every day, the understanding that they may never know which patients are trauma survivors, and the realization that things that seem innocuous could be triggering for a survivor, physiotherapists need to re-think how they approach their patients.
The two most important things are communication and consent.
There is no such thing as over-communicating what you are doing and why. Physiotherapists need to provide a steady stream of information to their patients throughout the assessment and treatment process. The information should cover why treatments or assessments are being done and exactly what to expect. More than that, the physiotherapist has a duty to make sure they have the patient’s consent for every action they take. That does not mean repeatedly asking “do I have your consent?” but it does mean providing clear and thorough explanations of what you plan to do, getting explicit consent at the outset, and then re-confirming with the patient throughout with simple questions like “is this ok?” or “can I keep going?”
This needs to be paired with an ongoing assessment of the patient’s reactions to what you are doing.
- Has the patient stopped responding verbally to questions?
- Have they tensed up or attempted to distance themselves?
- Are there other signs of distress, such as rapid, shallow breathing?
- Are there any other reasons to think that something’s not quite right?
These could be non-verbal signals that what you are doing is triggering a memory of a past trauma.2 If the patient is displaying these reactions, the physiotherapist needs to stop and check in with the patient, ensuring the patient knows that they have the right to say stop or to decline a proposed treatment, and that the physiotherapist will work with them to find an approach that will work for the patient.
Fundamentally, sensitive practice is a form of patient-centered care. The approach benefits everyone who comes for physiotherapy services and helps to avoid re-traumatizing an already traumatized and vulnerable individual. It’s a hallmark of quality care that is good for both patients and physiotherapists.
To learn more about sensitive practice and the expectations for physiotherapists, check out the Guide for Physiotherapists: Protecting Patients from Sexual Abuse or Misconduct and the sources listed in this article.
Take a moment to ponder your practice and what this information means for you:
- Were you surprised by the reported prevalence of sexual abuse in Canada? How will this knowledge affect how you interact with patients or others in the clinical environment?
- Looking back on past patient interactions, can you think of a time when a patient did not react as expected to something you said or did in the context of physiotherapy care? Could a patient history of sexual abuse explain the patient’s reactions? What would you do differently if faced with the situation again?
- Are there activities you engage in or things you commonly say to your patients which could be a trigger for a patient who is a survivor of sexual abuse? With this realization, how will you modify your approach to avoid re-traumatizing future patients?
- Schachter CL, Stalker CA, Teram E, Lasiuk GC, Danilkewich A. Handbook on Sensitive Practice for Health Care Practitioners: Lessons from adult survivors of childhood sexual abuse. 2008. Ottawa: Public Health Agency of Canada.
- Reeves E. A synthesis of the literature on trauma-informed care. Issues in Mental Health Nursing 2015; 36(9):698-709.
- Sexual Assault Centre of Edmonton. Sexual violence education for health care practitioners. Presentation to Physiotherapy Alberta – College + Association. Edmonton, AB, March 18, 2019.
- University of Alberta. Understanding Sexual Assault. Available at: https://www.ualberta.ca/current-students/sexual-assault-centre/understanding-sexual-assault. Accessed February 18, 2019.
- Government of Alberta. Commitment to End Sexual Violence. Available at https://www.alberta.ca/commitment-to-end-sexual-violence.aspx. Accessed April 17, 2019.
- Government of Quebec. Consequences of Adult Sexual Assault. Available at: https://www.inspq.qc.ca/en/sexual-assault/understanding-sexual-assault/consequences. Accessed February 15, 2019.
- RAINN. Effects of Sexual Violence. Available at: https://www.rainn.org/effects-sexual-violence. Accessed February 15, 2019.
- Centers for Disease Control and Prevention. Sexual Violence: Consequences. Available at: https://www.cdc.gov/violenceprevention/sexualviolence/consequences.html. Accessed February 15, 2019.
- Sigurvinsdottir R, Ullman SE. Sexual orientation, race, and trauma as predictors of sexual assault recovery. Journal of Family Violence 2016; 31(7):913-921.
- Elliott DE, Bjelajac P, Fallot RD, Markoff LS, Glover Reed B. Trauma-informed or trauma-denied: Principles and implementation of trauma-informed services for women. Journal of Community Psychology 2005; 33(4)461-477.
- Tremblay T. Trauma-informed sexual assault investigations training. Presentation to College and Association of Registered Nurses of Alberta. Edmonton, AB, March 20-21, 2019.
- Physiotherapy Alberta – College + Association. Protecting Patients from Sexual Abuse or Misconduct: A Guide for Physiotherapists. Available at https://www.physiotherapyalberta.ca/physiotherapists/what_you_need_to_know_to_practice_in_alberta/protecting_patients_from_sexual_abuse_or_misconduct. Accessed April 23, 2019.