This piece is part of in-Training Mental Health Week.
I am a medical student, yes. I am also a survivor of sexual violence.
With the recent Columbia University commencement, the surge of articles surrounding the narratives of Emma Sulkowickz and Paul Nungesser prompted me to reflect on this latter identity. When histories of sexual harassment at my school emerged last November, my survivor status edged its way into my path toward doctorhood. I know I will always carry the mark of my trauma with me, and I am learning how I will better empathize with patients because of it.
Reading about a Yale professor using his erections to harass female colleagues hurtled me back to a moment when something similar happened to me. That day, I was the only one of my college freshman peers to appear at our group problem-solving session. While we were alone, my peer mentor urged me to touch his genitals and to have a sexual relationship with him. I resisted, and he masturbated in front of me, again pushing me to feel him.
Like Sulkowicz, I waited to report. Like Sulkowicz, I attempted to obscure my horror through amicable message exchanges after the incident — a fact that haunted me two years later when his case coordinator cited a smiley face I used in an email as evidence that I was “fine.” Like Sulkowicz, this need to defend myself frustrated me; I was unprepared for it, despite spending months overcoming my denial, shame and fear.
Fear ultimately drove me to come forward: I feared if I said nothing, it might happen to someone else. Sulkowicz, in her demand for attention to university management of sexual misconduct, has mobilized dialogue and policy action on issues of sexual violence. This is a critical step in responding to cases — what people in the health care world call “tertiary care.”
But what is the primary care for sexual violence? This is where, I hope, my identity as a survivor becomes an advantage.
In my view, primary care for sexual violence takes the form of understanding. It is the awareness that sexual violence is ubiquitous and detrimental to health — both physical and mental. Beyond the risk of sexually transmitted infections, unwanted pregnancy and physical trauma, many survivors like me often face post-traumatic stress disorder (PTSD). This syndrome can steal our control over our lives. In my case, I changed my routes to avoid the man who harassed me, I cried aloud to wake myself from nightmares, I mapped escape plans for one-on-one meetings with male classmates and professors, and I swallowed down my frantic heart each time I had to made these choices.
In the two years between the incident and the time I reported, my trauma had transformed into high-pressure water contained in the pipes of my everyday life. Most days, the walls were sturdy and I scarcely noticed the rushing sound from inside. But on others, corrosion by images from that day weakened that pipe to a crusted hull and the gush of unbridled emotion would burst through it.
Once I started speaking with a counselor, I began to feel I could contain this flood of emotion. I learned that yes, my experience was awful and that it was okay to not be okay: to ask for help and to take it. With this perspective, confronting my experience felt less like stopping a fire hose with my bare hand and more like washing out two-year-old stains from my clothing.
Clinicians can have this power, if they choose. By using intentional language, asking questions with confidence and sensitivity and respecting reticence, providers can offer immense relief to survivors in what might otherwise constitute an anxiety-provoking situation.
For instance, while teaching the pelvic exam, our instructors demonstrated language that avoids potential triggers for survivors. They told us to call it an exam table, not a bed; a drape, not a sheet; and said, we examine — we don’t feel.
This, to me, is intuitive: the thought of cowering naked on a cold vinyl table, covering myself with a crimped paper blanket while a stranger, especially a man, tells me, “Okay, I’m just going to lift this sheet and feel inside” sends my heart rate surging. For my classmates who, thankfully, never acquired this instinct, such training ensures we all consider the vulnerabilities of some future patients.
For the many who will not perform regular pelvic exams, the sexual history can form a keystone of rapport construction. While we need to ask about patients’ partners, the kind of sex they have (oral, anal, vaginal), whether they use protection and, if applicable, contraception, we should avoid questions that are clinically unnecessary. Asking about the mechanics by which a transman has sex — or, in Sulkowicz’s case, about the positions used during a possible sexual assault — reflects intrigue more than insight into risk factors. These “curiosity questions” may provoke distrust of the provider, which can hinder healthcare.
By contrast, the sexual history can segue into positive conversation on consensual sex and healthy relationships. While screening for intimate partner violence, we can ask, “Has your partner ever forced you to have sex, or continue to have sex, when you didn’t want to?” Questions like these normalize the experience of sexual assault and can help connect survivors with support.
Now, patients may say “no” to that question and still bite their lips or blink away tears. We can name what we see (“It looks like you’re fighting back some tears right now. Is something upsetting you?”) and we can offer resources. But we should never force someone to share an experience they would rather conceal.* Sometimes respecting their silence and giving them the choice to come forward, or not, is the most empowering thing we can do.
While I can’t ignore the thud that rocks my chest when I see the words “sexual harassment” or “sexual assault” in a national headline, I am heartened that these issues are garnering the attention they deserve. I hope the conversations stirred by Emma’s statement broaden the burden of responsibility for caring for sexual violence to policymakers, to educators, to parents and to clinicians.
You can look at me in my white coat and never know that I once passed hours sobbing in my college dorm room, mucus streaming down my quivering lips, unable to leave or go to class for fear of the man who violated me. But if you know what that’s like, I hope if I meet you in my clinic someday I treat you in a way that says, “I’m sorry. What happened to you was not okay, and you don’t have to be alone.”
* This does not apply to minors, for which physicians are mandated reporters in cases of suspected child abuse.
Editor’s note: A version of this article was previously published on The Huffington Post.