Autonomy in Practice: Trauma-Informed Pelvic Exams

Medscape

2 days ago

'I just can't do it.'
My patient, a 43-year-old woman with a history of childhood sexual abuse and young adult assault, sat across from me, her shoulders hunched. She'd avoided pelvic exams for years, despite her desire for cervical cancer screening. Even scheduling an appointment triggered panic and dissociation. Years of therapy — including eye movement desensitization and reprocessing (EMDR) — had helped, but not enough. Previous providers, even those she trusted, had 'gotten the job done' while ignoring her pleas to slow down or stop. Sadly, her experience is all too common.
Why Trauma-Informed Exams Matter
To many clinicians, pelvic exams are routine. But for patients with a history of trauma — sexual, medical, or both — pelvic exams can feel terrifying and impossible. Even well-intentioned can fall short if they move too quickly or miss subtle cues. Traditional models prioritize efficiency and focus on 'getting it done,' often at the expense of patient comfort and agency.
And let's be honest: The legacy of medicine has not always inspired trust. For female patients, the impact of historic injustices like nonconsensual gynecologic procedures on enslaved women or the abuses of Dr Larry Nassar continue to reverberate — especially among marginalized communities. For many, mistrust of medical settings is not just personal, but generational.
What the Literature Offers (and What It Doesn't)
General guidance on trauma-informed care is plentiful but rarely offers concrete, actionable, step-by-step guidance on treating patients who have severe trauma responses with pelvic exams. Talli Rosenbaum's mindfulness-based pelvic floor physical therapy stands out as a specific protocol for working with clients with sexual pain.
As a sexual medicine specialist, I also wanted to develop a process rooted in patient autonomy, explicit consent, and nonexploitation — skills that benefit patients in medical settings as well as in their sexual relationships.
I designed my approach to:
Equip patients with self-advocacy tools. Teach patients their rights, such as requesting an exam under anesthesia or their right to stop a medical procedure at any time. Coach patients on how to use clear, assertive language to communicate their needs effectively to medical providers.
Teach patients their rights, such as requesting an exam under anesthesia or their right to stop a medical procedure at any time. Coach patients on how to use clear, assertive language to communicate their needs effectively to medical providers. Honor the body's wisdom. I've explored a variety of trauma-informed approaches, including Somatic Experiencing, Eugene Gendlin's Focusing, and Gina Ogden's 4-D Wheel, and these modalities sharpened my ability to notice subtle bodily signals. By recognizing these signals, providers can help their patients listen to the quiet voice of their body's discomfort before it escalates and needs to 'shout.'
I've explored a variety of trauma-informed approaches, including Somatic Experiencing, Eugene Gendlin's Focusing, and Gina Ogden's 4-D Wheel, and these modalities sharpened my ability to notice subtle bodily signals. By recognizing these signals, providers can help their patients listen to the quiet voice of their body's discomfort before it escalates and needs to 'shout.' Make space for internal conflicts. Internal Family Systems language helps patients acknowledge the parts of themselves that seek healing alongside those that deeply fear vulnerability.
My Protocol: Principles and Process
Three core principles shape my patient encounters:
No exam unless necessary for the patient's goals or questions. Proceed only if the exam aligns with your collaborative care plan and if the patient explicitly consents. The patient is in control of every step of the exam. Encourage self-advocacy and support and validate any request to slow down or pause the process at any point. No enduring is allowed. Although we cannot guarantee that a patient won't experience moments of discomfort, we can shift, adjust, or stop if anything feels mentally, emotionally, or physically uncomfortable. We do not want any patient 'white-knuckling it' through the exam.
Share these core principles with your patient before any exam. Then, describe the exam in detail and ask the patient if there are any components they'd like to adjust or exclude.
Stepwise, Patient-Led Approach
Assessment and window of tolerance. Start in a talking office — not the exam room — to establish the patient's 'window of tolerance,' which is the range in which patients can engage without shutting down or becoming overwhelmed. Ask the patient, 'How will I know you're uncomfortable?' and 'How does your body let you know when it's not okay?' During medical exams, individuals with a history of trauma can unknowingly push through their body's early warning system. To avoid escalation, together we identify early signs of discomfort (eg, elevated heart rate, shallow breathing, muscle tension, mental haze) and plan on grounding techniques (eg, breathing exercises, humming, orienting) we can implement if or when they arise. Gradual exposure. Proceed step by step. First describe the exam, then have the patient imagine the exam, then enter the exam room, and continue to advance in that fashion. Each session progresses only as far as the patient's window of tolerance allows. Cultivating interoception. Treat early warnings as vital information. If a patient notices and reports a sensation of discomfort, welcome it as an important indicator that something in the environment needs to shift. If a patient gets the 'shakes' after accomplishing a difficult step, reframe this reaction as a sign of resilience, as the body has completed a stress cycle. Celebrate every act of self-advocacy and rehearse how to communicate needs to future providers, reinforcing the notion that the patient is the expert on their lived experience. Environmental adjustments. Encourage patients to bring a support person, a warm blanket, music, or even a stuffed animal. Simple changes like covering anatomical diagrams or putting fun socks on the footrests can make a substantial difference.
What Success Looks Like
After 15 sessions, a 39-year-old with lifelong medical anxiety who experienced panic during her first pelvic exam at 21 years of age went from viewing her anxiety as insurmountable to tolerating a full pelvic exam with the support of her partner. Thanks to this trauma-informed approach, we were able to complete the pelvic exam and identify a manageable muscular issue.
Another patient, who'd experienced a psychogenic seizure during her first pelvic exam, completed a Pap smear by the seventh session. We discovered that her initial psychogenic seizure was probably due to a typical vasovagal response. As a result of our sessions, she now uses grounding tools with new providers — proudly advocating for herself in both medical and personal settings.
At the end of our sessions, my female patients often tearfully ask, 'Why isn't it always this way?'
Barriers and Realities
Let's not sugarcoat it: The doctor-patient power imbalance is real and demands our constant vigilance. Furthermore, systemic barriers such as limited time, inadequate space, and liability-driven policies often make trauma-informed approaches challenging to implement in routine care. Although not every provider may be able to fully adopt a practice like this, we can all work to move the field toward more patient-led, trauma-informed care. Ultimately, the goal is a future where trauma-informed exams are the norm, not the exception.
Takeaway for Clinicians
Clinicians should screen for past traumas of all types and recognize that routine medical care is inherently vulnerable and boundary crossing; as such, trauma responses will inevitably arise. We all need to be prepared with tools and attitudes that can help our patients move through them.
So, the next time you perform a pelvic exam:
Slow down.
Center consent and bodily autonomy.
Listen to bodily cues, not just spoken words.
Equip yourself with tools to help patients when trauma responses are activated.
Empower patients to lead the process.
Evaluate the necessity of your planned exams and always explain their rationale.
Collaborate with the patient to create an environment for exams that feels empowering and safe.
Let's move away from 'getting it done' and start 'getting it right.'