You roll up your sleeve for the blood pressure test. The doctor holds your forearm while he squeezes the pump. You flinch, and try to hide it.
The doctor leans in and aims a medical device, an otoscope, at your ear, and you jerk your head away without thinking. “Is it cold?” he asks, rubbing the pointy end on his shirt to warm it up.
“No, no,” you tell him, stiffening your neck. “Things in my ears just freak me out.” You laugh a little, or just say sorry. You are always saying sorry for being so touchy, so untouchable.
When you take off your shirt and the doctor applies the electrocardiograph pads across your chest, you stare at the ceiling or just close your eyes. This will be over soon, you tell yourself. Don’t be a difficult patient. If you’re a difficult patient, doctors won’t want to take care of you.
But the last doctor who promised to take care of you didn’t. The last doctor sexually abused you. Now, even years later, it’s your job to be the calm, reasonable person in the exam room — even though every moment spent with your new doctor, or with any doctor, reminds you how you once trusted a doctor and that trust was betrayed. The unfairness is galling.
The you, of course, is me. It’s also many other people, too many. When I was in my mid-30s, I was sexually abused by a psychiatrist who was treating me for depression and anxiety. I’ve written about this event over the years, but I’ve never addressed the lingering aftershocks. To this day, nearly two decades in, I will not go to therapists or psychiatrists. I hate them all. Yes, hate. It’s ugly but true.
Worse yet, I cannot be comfortable with doctors of any kind. Clinics make me anxious; hospitals inspire full-on panic attacks. Even my general practitioner — an easygoing doctor I’ve seen for most of my adult life, a doctor who helped me during the awful period when I confronted my abuser in a legal tribunal and who has seen me through everything from eczema to Restless Leg Syndrome — makes me uneasy. I get through necessary visits by being funny, being the merry patient. I downplay how I actually feel. I make jokes and present a classic Canadian carrying-on face.
“Meh, what are you gonna do?” I often ask my GP rhetorically, dismissing my ailments and signaling that I’m just fine, thanks. But I’m not. I have chronic health concerns that I can’t summon the courage to confront. When I’m in my doctor’s office, I just want out. I’d have to get hit by a car before I would seek any truly invasive (my word, and exactly how it feels for me) hands-on medical treatment. At least I’d be unconscious.
Without being alarmist, it is not unreasonable to say that sexual abuse is a problem in medicine. In 2016, the Atlanta Journal-Constitution published the findings of a yearlong investigation into sexual abuse by doctors. The paper uncovered thousands of cases. One expert described the problem to CNN as “systemic.” The authors of a five-year study conducted in Brazil posit that “since the time of Hippocrates, a sexual relationship between doctor and patient has been prohibited, as there is dysfunctionality in this asymmetric relationship, which has been labeled as polymorphic incest … [S]exual intercourse between doctor and patient is analogically similar to intrafamilial sexual relationships.”
Hard statistics regarding the number of patients who’ve experience sexual abuse are tough to come by. Experts agree that the vast majority of patients do not report their abuse. Furthermore, organizations created to monitor physician behavior and practices follow no single standard, internationally or even between state boundaries. (This is true both in Canada, where I live, and the U.S.) In Women’s Health, one writer compared the situation to the epidemic of abuse by Catholic priests: The systems that protect abusers are deeply ingrained, historically biased against accusers and very difficult to change.
I’m actually on the lucky end of the survivor spectrum. As uncomfortable and occasionally terrified as medical situations make me, I’ve learned to force myself up onto the examination table. But once I’m there, I don’t trust anything that happens. I don’t even trust myself.
I worry about overreacting to perceived slights, about being hypersensitive to everything from too-casual medical practitioners to too-formal caregivers, from being the temporary center of physical attention to not being the center of a doctor’s mental attention. I’m impossible and I’m keenly aware of it. So when I see a doctor, I fake it. I fake being the carefree healthcare consumer.
Eric Pierni, a psychotherapist and founder of the counselling service Men Therapy Toronto, works with men who have been sexually abused. He stresses that abuse survivors have enormous difficulty “trusting anyone, at all, even a therapist.”
While Pierni does not specialize in treating patients abused by doctors — I couldn’t find a single person who does — he outlined three core principles that guide his work.
First, there’s the establishment of trust between therapist and patient, with an emphasis on creating an environment where patients feel safe on all levels. This is no easy task.
“There is no direct way to establish trust between a therapist and a client,” Pierni told me, “but clear boundaries and informed consent are the start. And making sure the client is being heard: A big issue with clients who have been abused is that they don’t feel understood. Because trust is so difficult, leaving them feeling powerless, that can lead to poor self-care and negation or avoidance of healthcare.”
Second comes a gradual building of communication between therapist and patient based on equality of expression, as opposed to the old-fashioned but still standard scenario wherein a doctor’s views are read as law.
“One of the first things I do in a meeting is to outline how power works in session,” Pierni said. “I tell clients that they can interject if they wish, because clients are often reluctant to ask a lot of questions.”
Dissolving the traditional doctor-patient hierarchy sounds like a good first step, a form of patient empowerment I wish I could have accessed when I was younger.
The third principle is an intriguing concept called practitioner congruency. Essentially, it’s a form of supervision. Doctors who use the congruency model have voluntarily agreed to have their work clinically supervised and scrutinized on an ongoing basis by fellow doctors. “An extra set of eyes on our practice” is how Pierni describes it.
Hearing this with a survivor’s ear, congruency strikes me as having the greatest potential to make patients feel secure again.
“People go to therapists, but they never ask how the therapist is being supervised or how the therapist lives out the principles they advocate in their own lives,” Pierni said. “In order for me to tell people how to get better, I have to get better in my own life. I have to live my own words. Nobody’s perfect, but if a clinician is not doing their own work, how can they be of help to others?”
We patients who have experienced sexual abuse by doctors are a special subset of survivors within the larger movement to empower the abused and confront abusers. We need champions and specialists, doctors trained to help patients who’ve been abused by other doctors. We are the abuse survivor equivalent of people with so-called “orphan diseases.”
While we have every right to demand care that is attentive to our unique needs, that care can only come from a medical industry committed to fixing itself first. Until congruency is the norm, we’ll be the patients nervously watching the examining room door and waiting for the first chance to get out.