Natalie Kraemer was 28 when she made her first gynecologist appointment. After being sexually abused by a boyfriend throughout high school, she avoided any situations that involved undressing or being touched. She’d almost scheduled a Pap smear a few years earlier, but changed her mind after a massage triggered traumatic memories.
Luckily, Kraemer’s first time in stirrups went smoothly. After asking around and reading reviews, Kraemer picked an ob-gyn practice with a midwife. During her appointment, Kraemer let the nurse know about her sexual abuse. The nurse told her she could choose not to go through with the pelvic exam if it would be too overwhelming. Kraemer went ahead, and found that her midwife was just as considerate.
“She first examined my top half and then my bottom half so I didn’t have to be totally naked or exposed,” Kraemer says. “She explained everything before she did it, and she told me that she could stop anytime if I wanted her to. Then at the next appointment, she recommended against an IUD because she thought the insertion would be traumatizing for me.”
Kraemer didn’t know it at the time, but her midwife practices what’s known as trauma-informed healthcare. It’s a “philosophical approach where we understand the prevalence of trauma in our patients and ourselves, the impact trauma has on health and how that impacts the ways people interact with healthcare systems,” says Dr. Eve Rittenberg, a physician at Brigham Health and an assistant professor at Harvard Medical School.
Trauma-informed healthcare isn’t a new idea. But in light of the #MeToo movement and the related swell of national conversations about sexual assault, more practitioners are looking for ways to help trauma survivors feel safe in the exam room. As a result, trauma-informed healthcare is becoming a movement in its own right.
Sixty-one percent of American men and 51 percent of American women report having been exposed to at least one traumatic event in their lifetimes. Trauma can seep into our health and well-being in varied, overlapping ways. Not only can trauma cause PTSD and contribute to mood disorders, addiction and other mental illnesses, it’s also associated with a number of physical diseases. The relationship between trauma and disease is well-documented in research, most famously in the 1998 ACE study.
For this seminal study, the Centers for Disease Control and Prevention and Kaiser Permanente surveyed 13,494 people about their medical histories, lifestyle habits and adverse childhood experiences, or ACEs. These can include instances of sexual trauma, physical or emotional abuse, neglect, and living with an addict. More than half of participants reported at least one ACE — and higher numbers of ACEs corresponded to a greater risk for health problems such as heart disease, cancer, chronic lung disease and liver disease, as well as a considerably shorter life expectancy.
While trauma can make people more vulnerable to health problems, it can also make them less likely to seek out medical care. Going to the doctor, and dealing with all those pokes and probes, might feel a little invasive to anyone. For a survivor of sexual trauma or another form of abuse, the experience can become a form of retraumatization. In a recent New York Times story about male victims of sexual assault in the military, one veteran who’d been raped during basic training subsequently stopped seeing a dentist regularly. “It is difficult to have someone in my personal space hovering over me,” he told the Times.
The underlying goal of trauma-informed healthcare is to help trauma survivors access care and learn how to feel comfortable being patients. In practice, providing this type of care can mean a lot of things, from educating patients on the potential health impact of their trauma to creating an environment where they feel empowered and safe. But the guiding principle is always the same: Care for patients comprehensively, as whole people, and try to understand the relationship between what’s happened in their lives and what’s going on with their health.
Right now, primary care is the priority in expanding trauma-informed services, although a growing number of specialists are embracing the approach too, says Karen Johnson, a licensed clinical social worker and the director of trauma-informed services at the National Council for Behavioral Health. Trauma-informed primary care providers can’t and aren’t supposed to replace therapists. Instead, they offer a gentle on-ramp for patients with histories of trauma to get the care they need.
“When we don’t create environments that are trauma-informed,” Johnson says, “we definitely risk missing opportunities to find out what might have happened in a person’s life so we can open the door to possible pathways to recovery.”
At the beginning of an appointment, a trauma-informed practitioner will typically seek information about a patient’s background, either by asking them to fill out a survey or relying on behavioral clues. Using what they learn, the practitioner will take measures to make the space feel safe and tailor the visit to the patient’s needs. For trauma survivors, safety often means having choices — choices they might not have had during their initial trauma. Johnson says simple practices, like listening to patient requests and fears, taking their anxieties seriously, and offering alternative ways to conduct exams or tests, can be critical in encouraging patients to continue receiving care and adhere to treatment plants.
If a patient has a negative experience or feels violated, they might not return, Johnson says, whereas a trusting patient-doctor relationship can lead to an ongoing and open dialogue about what works best for that patient. For example, a patient with diabetes who is afraid of needles might need an alternative method of insulin delivery to stick with their prescribed regimen.
“If an individual understands they can express concerns and won’t be shut down, and a clinician is encouraging those conversations,” says Johnson, “that leads to shared decision-making and increased adherence, which can help people learn to manage their illness.”
A greater understanding of trauma can also help clinicians avoid compassion fatigue and burnout, says Rittenberg, who leads trainings within her healthcare system for other providers who want to learn about the approach. “It can be very hard to sit with stories of suffering, and as physicians, that’s what we do,” she says. “Having an understanding of the way that our patients’ stories might impact us and developing ways of coping with that, all of that is part of trauma-informed care.”
At this point, trauma-informed healthcare is still an informal, self-appointed designation; clinicians decide exactly how to implement its principles into patient care. But its imprint is becoming more visible across the healthcare system. Starting in 2016, the National Association for Behavioral Health teamed up with Kaiser Permanente to create resources for advancing organizational change in primary care settings. These supports include addressing topics like trauma screening, educating staff, and dealing with burnout and compassion fatigue. At the state level, the California Department of Healthcare Services is spending $60 million this year to train providers to screen for trauma in primary care.
Johnson expects the movement to continue spreading and becoming more established in accordance with growing awareness of how common trauma is and how much it can affect health. “The fact that we know there is a high prevalence of trauma and [that it has a] significant impact on health across the life trajectory is just information you can’t unlearn,” she says.
For people interested in finding trauma-informed providers, Johnson recommends looking for specialists who advertise a focus on trauma. Additionally, the website ACES Connection has a resource center and community forums where people share information about local trauma-informed services.