ARCHIVED: Chapter 8: Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse – Guidelines for sensitive practice: disclosure

Guidelines for Sensitive Practice: Disclosure

The challenge of disclosure for survivors

“[Choosing whether to disclose] depends on where you are in your journey. Because sometimes in your journey you don't want them [health care providers] to know [you're a survivor].” (Woman survivor)

Although this discussion speaks of survivors collectively, survivors are not a homogenous group; each survivor is a unique individual with a unique history and point of view. While survivors may or may not disclose their histories, their abilities to recall the abuse and their places in the journey towards recovery consistently play significant roles in disclosure. For example, most of the study participants have always had clear memories of the abuse they experienced, while a smaller number only began to remember the abuse in adulthood. Some attempted to deny to both themselves and others that the abuse occurred:

“I just buried it and pretended that it didn't happen ... and sort of just [said to myself], No, no-how could that affect my life? And it wasn't until last year I really started to realize that it did affect my life. I knew it wasn't right at the time, way back, but I didn't know that it could potentially have the effect that it had.” (Man survivor)

Survivors who disclosed their abuse spon-taneously did so in the hope that the information would help the practitioners to understand them better.

Some survivors also told us that they had always remembered their childhood abuse, but did not identify it as abusive (believing that what happened to them happens to all children) until some new learning prompted them to reconsider their experience:

“My awareness of my childhood sexual abuse only dates from about nine or ten years [ago]. [I'm] not saying that I didn't remember things that happened to me. I did, but I didn't appreciate the dynamic that was there and I just sort of thought of them as early sexual experiences and said [to myself], Well, doesn't that happen to everyone? Then you suddenly discover that no, it doesn't happen to everyone. The real dynamic just really clicked one day and it really hit me hard.” (Man survivor)

Participants described a number of factors that influenced their decisions about whether to disclose to practitioners, and also how much and what information they shared. Some did so spontaneously early in the relationships, while others held back until they felt more comfortable with the clinicians. Still others chose not to disclose at all.

Survivors who disclosed their abuse spontaneously (i.e., not in response to questioning by a practitioner) did so in the hope that the information would help the practitioners to understand them better:

“[I disclosed so that the clinician would] have some of the understandings of the feelings that are associated with that part of the physical exam ... the shame and the guilt and the things that you have going on inside your head, the flashbacks that could happen while you're having an exam, the not being present in the moment.” (Woman survivor)

For many survivors, disclosure is a process. Unlike survivors who want to "get it over all at once," others prefer to reveal their history gradually over time, often so that they can take control of the timing and pace of disclosure:

“[My doctor's response] helped me, little by little, disclose more of my deep dark secrets and helped me to ask more questions.” (Man survivor)¹⁵⁹

Finally, some survivors want to avoid having to disclose repeatedly and take a proactive approach to the issue:

“At this point in my life I think differently [than I used to about disclosing]. I want survivor written on the front of my chart so that [clinicians] know and recognize that I want to be treated sensitively. Then, if a new [person] in the practice sees me it would be a reminder to them. Other survivors may not want that, but I think it would be great if I did not have to disclose every time I see a new [practitioner]. ” (Woman survivor)

A reluctance to disclose may relate to: (a) survivors' feelings about themselves; (b) pressure from families, friends, or abusers to remain silent; (c) their fear of negative responses; and/or (d) the sense that their practitioners do not have the time to listen or seem unaware of the potential longterm health implications of violence.

Many individuals spoke about how their own feelings of shame and guilt affected their attitudes towards disclosure:

“There's a whole lot of shame [about having been victimized] and disclosing that.” (Man survivor).

Others told us of the vulnerability they feel when disclosing:

“Every time you disclose, you expose yourself.” (Woman survivor)¹⁵⁹

Previous experiences with disclosure play a major role in survivors' decisions about disclosure. Many were reluctant to say anything because they feared a negative reaction, particularly rejection:

“I'm really hesitant on mentioning it to people, especially ... [to health practitioners] I don't want to start talking about it or mention it and get that rejection. Cause that's the worst. Cause then I clam up and I my headaches will probably get worse and everything will just get worse.” (Woman survivor)^{143p.258,164p.94}

Others fear being blamed for the abuse or being judged:

“One [practitioner] that I saw ... reacted with insensitivity, by asking me, How did you let it happen? In the moment I felt revictimized and took all of the blame for what happened. That really had an impact on me.” (Woman survivor)

Many male survivors, in particular, are fearful that if they disclose past abuse a clinician will assume that they are also perpetrators:

“I called the hospital to talk about sexual abuse and they thought that I was the abuser and referred me to domestic sexual abuse centre. ” (Man survivor)

Both men and women whose abuser(s) were women were reluctant to disclose for fear of not being believed:

“Female survivors of female-perpetrated abuse ... experience disbelief as to the likelihood of having been abused by a woman.” (Woman survivor)

“If it was with a woman it's, Well aren't you mistaking it for nurturing? ” (Man survivor)

Finally, both survivor participants and health care practitioner participants identified practitioners' apparent lack of time as a huge barrier to disclosure:

“I was almost 60 when I started [to deal with issues of sexual abuse] and it came to light after a lot of very significant [psychotherapeutic] work of mine ... So these are deep things. In other words, this is a deep question and to think of it in terms of a 15-minute segment [with a clinician] is hard.” (Man survivor)

Possible indicators of past abuse

While there is no single indicator or cluster of symptoms and/or behaviours that provides evidence of past abuse, there is a growing body of research that documents a relationship between adverse childhood experiences and certain behaviours and/or experiences in later life. Some of these include:

• Avoidance of all health care practitioners and/or health serving agencies;
• Repeated cancellations of appointments;
• Repeated postponement of a physical exam;
• Poor adherence to medical recommendations;
• Chronic unexplained pain (e.g., headache, pelvic, back, muscular);
• Unexplained gastrointestinal symptoms/distress;
• Disordered eating, obesity, or wide fluctuations in weight;
• Sleep disturbances (insomnia, hypersomnia);
• Sexual problems (e.g., avoidance, many sexual partners, unsafe sex practices);
• Alcohol or drug misuse;
• Depression;
• Pattern of difficulty in interpersonal relationships;
• Self-harm behaviours and/or suicide ideations/attempts;
• Posttraumatic Stress Disorder or other anxiety problems;
• Dissociative states (blanking out, long silences).

Recognizing clusters or patterns of these behaviours and symptoms along with inconsistencies or gaps in information provided by the patient should alert a clinician to consider the possibility of abuse or violence.

Recognizing clusters or patterns of these behaviours and symptoms along with inconsistencies or gaps in information provided by the patient should alert a clinician to consider the possibility of abuse or violence:

“But I would ask [practitioners] to go a step further, to [talk] ... to men, particularly males who have addiction problems, who have eating disorders, sleep disorders, depression, anything that has to do with emotion, emotional things or mental health issues. I think it's important that these [clinicians] ... get trained to be able ... to identify [behaviours that may be related to past abuse] and to be up on what the actual symptoms are.” (Man survivor)¹⁵⁹

It is crucial that health care providers be aware that these indicators, although clearly suggestive of abuse or psychological trauma, may actually stem from other causes. Abuse is not always the source of these behaviours; nonetheless, inquiry about a history of childhood sexual abuse is essential.

Inquiring about past abuse

A growing body of evidence indicates a relationship between abuse or violence and health problems. Our studies further demonstrate a range of ways in which past abuse can negatively affect survivor-practitioner interactions. Accordingly, inquiring about violence and abuse should be an integral part of collecting a health history:

“I think it's important that [health care practitioners] ask questions about abuse as part of a medical history, particularly of women, and I think that anyone dealing with women's pain who doesn't ask questions about violence in a woman's life is not doing their job. I feel that very, very strongly.” (Woman survivor)^164p.93

By routinely asking about past violence and abuse, practitioners open the door for individuals to disclose if they choose to do so. In asking the question, practitioners: (a) demonstrate that they have an understanding of the relationship between interpersonal violence and health; (b) break the harmful silence surrounding abuse and violence; (c) signal that they recognize interpersonal violence as a health issue; and (d) validate their patients' experiences. Asking about a history of abuse can also lead to improvements in health care and may help avoid or reduce retraumatization, which often occurs in health care settings.

Some survivors who want to disclose find the topic too difficult to initiate on their own and are relieved when a practitioner broaches the topic:

“It was a huge relief to have my doctor ask, Were you ever abused? ” (Man survivor)

Inquiring about violence and abuse should be an integral part of a health history.

Inquiring about past abuse may also be a first step towards helping a survivor develop a network of support. Because some survivors deal with chronic health problems related to childhood abuse, they may experience ups and downs in their health - that is, periods of time during which they are relatively healthy interspersed with exacerbations of symptoms (e.g., pain, anxiety, or depression). Assessing this pattern as part of the routine health history allows the practitioner to work with the individual proactively to ensure that adequate supports are in place in times of relative health. On the other hand, if a clinician learns about the past abuse for the first time during a crisis, it can be more difficult to respond effectively:

“If we don't talk about it for years and suddenly open up the can [of worms], it becomes difficult to deal with the outburst of reactions.” (Man survivor)

As one practitioner participant reported:

“Most patients present for chiropractic care for pain (lower back pain, neck pain, headaches). During history taking I ask if they can identify aggravating factors. Sometimes patients will relate stress as an aggravating factor. At other times I will ask if stress or being emotionally upset causes their symptoms to worsen. If they respond Yes, then I will ask what the greatest causes of stress are for them ( Is the source of your stress: home life, relationships, work, school, finances, family issues etc.? ). Once the patient confirms that stress is a factor and that they can identify what their main stress reaction triggers are, then I will ask if they have a good support system ( Do you confide in friends, significant others, other family members? ). I next will ask if they actually use their support system. Many patients will respond with comments such as Not as much as I should or Yes, and I think that they are tired of listening to me. At this point I am able to intervene by explaining to the patient that I have a good referral network, and that perhaps they should consider seeing a counsellor. I reassure the patient that I do not necessarily require any details regarding their stress, but many patients will spontaneously divulge ... In short, history taking allows me to develop a relationship with the patient. During history taking, when the patient feels heard and cared for, then the patient will often disclose childhood sexual abuse. Patients are always reassured that they are in control of everything that takes place during their visit. Communication is established during history taking and is reinforced during examination and treatments. ”

While our own research and that of others makes it clear that health care practitioners have a professional and ethical responsibility to inquire about abuse or violence, it is important to understand this statement in relation to the debate regarding the evidence pertaining to inquiry about/screening for interpersonal violence. It is also important to acknowledge that not all survivors want to be asked about past abuse and may choose not to disclose:

“If I wanted to tell him, I'd tell him. It's not his business.” (Man survivor)¹⁵⁹

As long as health care providers respect the wishes of survivors who prefer not to disclose a history of abuse to them, there is no harm caused by inquiring about abuse. The Family Violence Prevention Fund's Research Committee made this point when it stated, "We know of no research to suggest that assessment and/or interventions [of family violence or intimate partner violence] in health care settings are harmful to patients."^57p.5 As one survivor participant explained:

“I don't know that there's any harm in asking. My guess is that if you are denying it or you aren't sure that you want to reveal any secrets, you probably won't say anything. But at least it would give an opportunity to either ask, What are you talking about? or to say a little bit about that ... If I'm not ready to talk about it, I'll just skip over that and say I don't know anything.” (Man survivor)

History taking allows me to develop a relationship with the patient. During history taking, when the patient feels heard and cared for, then the patient will often disclose childhood sexual abuse. - Health care practitioner -

For many practitioners, the first step towards routine inquiry about interpersonal violence is an attitudinal one. Studies have shown that barriers to inquiring about interpersonal violence include: (a) a lack of knowledge and training about the topic and how to ask relevant questions;44,80 (b) lack of privacy and time limitations;55 (c) the belief that abuse is not a problem for their patients; and (d) frustration with being unable to help the victim.119 A clinician's own experience with violence might also factor into an unwillingness to address the topic with patients.110 Nonetheless, routine inquiries about interpersonal violence are fundamental to Sensitive Practice:

“Surely [practitioners] realize that it's a part of who I am and it needs to be acknowledged, and it does have an impact in terms of how I need to be treated.” (Woman survivor)

Both women and men described a number of factors that might encourage disclosure. They look for signals that the clinician has an understanding of the effects of interpersonal violence, including posters and pamphlets (directed at both women and men) prominently displayed in waiting rooms, washrooms, and examination rooms. Survivors also stressed the importance of feeling safe, and trusting their practitioners:

“My doctor made me comfortable from the beginning so I felt I had someone to talk to. I've been married for 28 years and I wasn't even able to tell my wife, but I was able to tell him. If I wasn't able to tell him I don't know if I would have been able to move in the direction of recovery.” (Man survivor)

“There was this one specific [practitioner who] was just so, so kind ... that person would definitely be someone that I would not have a problem sharing, you know, what had happened to me, what I had experienced.” (Woman survivor)

Survivors emphasized the importance of confidentiality in their decision to disclose:

“I guess the primary issue is ... confidentiality. [I need to know,] are you going to tell anybody? Are you going to do anything with the information?” (Man survivor)

For many practitioners, the first step towards routine inquiry about interpersonal violence is an attitudinal one.

Although a number of professional and regulatory/licensing bodies have guidelines and recommendations in place for inquiring about past violence or abuse (e.g.,^6,7,12), most are not specific about how to approach the task. As gastroenterologists Alexandra Ilnyckyj and Charles Bernstein⁸⁸ observe, this lack of specificity contributes to the fact that, in practice, inquiries about past violence or abuse are not part of routine care, even when health care providers may suspect that it is relevant for an individual.

The therapeutic relationship and the health care environment are crucial factors in the inquiry about past abuse. The Society of Obstetricians and Gynaecologists of Canada153p.366 clinical practice guidelines offer a valuable reminder to clinicians about the therapeutic relationship: "Several validated questionnaires exist for enquiring about [interpersonal violence]; however, the nature of the clinician-patient relationship and how questions are asked seem more important than the screening tool." Regarding the environment, survivor participants emphasized that privacy and clearly visible and available information (e.g., posters or brochures) convey the impression that a practitioner acknowledges the relationship between interpersonal violence and health.

There is no one correct way to ask about a history of childhood abuse. Direct approaches are a relief to some survivors, but may be too intrusive for others.

Verbal inquiry. There is no one correct way to ask about a history of childhood abuse. Direct approaches are a relief to some survivors, but may be too intrusive for others. Introducing questions in a way that relates past abuse to health and health care provides context and rationale. Practitioners could draw on the following statements as possible lead-ins to an inquiry of childhood sexual abuse history:

• "Research tells us that child sexual abuse among both girls and boys is much more common than was once believed. We also know that it can have long-term health effects."
• "Is there anything in your history that makes seeing a practitioner or having a physical examination difficult? If there is, I would like to hear about it so that we can work together more easily."
• "Some women (or men) want to talk with their health care providers about very personal or difficult topics. If you do, I am open to hearing about them."

Statements and questions such as these may open the door to disclosure, either in the moment or at some later time. If an individual hesitates or seems very reluctant to respond, another effective response from a clinician would be something such as:

• "I know these things can be hard to talk about. I think it is important to ask because there is growing evidence that violence and abuse can affect a person's health and create difficulties when they see health care practitioners. You don't have to discuss this with me if you don't want to. If you do, I can work with you to ensure you are comfortable when you see me and to get whatever support or assistance you need."

Regardless of how the questions are framed, participants told us that trust in their healthcare provider influenced their decision to disclose:

“I had one [practitioner] ask me, Was there any trauma in your childhood or lately that could cause these symptoms? And right then, I thought, Oh, okay. I can talk about it. And I'm not going to get rejection. ” (Woman survivor)

Some men survivors told us that they were unclear whether clinicians were asking if they were victims or perpetrators of sexual abuse when asked questions such as, "Have you encountered sexual abuse?" Therefore, they urged health care practitioners to clearly ask if the man is a victim of past abuse.

Most of the survivors in our research, both women and men, indicated that they did not want to discuss the details of their abuse with their practitioners:

“Some people press for more info upon disclosure and that is invasive and unacceptable.” (Woman survivor)

Written inquiry. Survivors in our studies varied in their views about the merits of written and oral inquiries. Proponents of written questionnaires believe that they are less intimidating than verbal inquiries. Others prefer verbal inquiries, because they open the door for an ongoing conversation. Given what survivors told us about their preference for a written or verbal approach to assessment, it seems that the most prudent strategy is for health care providers to use both written and verbal forms to collect every health history and to keep in mind that survivors may or may not choose to disclose.

Responding effectively to disclosure

“Well, for one thing, it's really important [to tell survivors] ... that you believe them, because this might be the first person they've told. And also, it's really important to accept them as a person. You can say whatever your real feelings are. [For example,] I'm really sad to hear that. ” (Woman survivor)^{143p.258,164p.95}

The most prudent strategy is for health care providers to use both written and verbal forms as part of every health history.

Communicating to survivors that they have been heard and believed is crucial whenever survivors disclose. While follow-up is also important (as the next section indicates), the practitioner's immediate verbal and nonverbal responses to disclosure can have a tremendous impact on the survivor.

Accept the information. Individuals need to know that their health care providers have heard them, have accepted the information, and believe that children are never responsible for abuse:

“His response was first one of acknowledging what I said and, you know, genuinely looking like he cared and kind of going with that and not really pushing anything, not giving me advice or telling me what to do but, you know, just kind of going slowly with me through that. And I found that was excellent.” (Woman survivor)

When survivors disclose their history of abuse, it is usually because they hope that something positive will come from it. If practitioners do not respond, survivors may interpret the silence as an indication of lack of interest, which may deter them from mentioning it again. Moreover, they may stop seeing that particular clinician or, in the extreme, avoid all health services:

“I told the [health care provider] about my history of abuse. She didn't acknowledge [it] ... She just kept right on going with what she was doing ... Oh boy! If somebody says it, then you've got to acknowledge it. Because then what that says to me is that it's not valid, it's not important, it doesn't have anything to do with us.” (Woman survivor)^164p.95

Express empathy and caring. Survivors also want to know that their practitioners care about them. Simple statements of empathy and concern can convey both compassion and interest:

“He just looked at me and he said, you know, I'm really sorry this happened to you. And that was the best thing he could have said.” (Woman survivor)¹⁵⁹

“I remember feeling comforted by her, probably by her words. She probably said, It's okay to cry or she might have even rubbed my arm. I remember her telling me that she was going to give me a phone number where I could call so I could talk to somebody about it, which she did. She handled it very professionally.” (Woman survivor)

Clarify confidentiality. Confidentiality is a vital concern for many survivors. Although a clinician may have already discussed it previously, following a disclosure of abuse, health care practitioners need to repeat information about the level of confidentiality that they can extend. For example, the clinician might say, "Because you are an adult now, I am under no legal obligation to report this to police or a child welfare agency" and "I think it is important to write something about your childhood history in the chart. What would you like me to put down?"

“The most important thing is, Whatever you say is confidential with me. Because confidentiality is so huge.” (Man survivor)

Acknowledge the prevalence of abuse. Understandably, many survivors feel very isolated and alone in their experience. Having health care providers demonstrate awareness about the prevalence and long term effects of childhood sexual abuse normalizes the experience for survivors and may reduce their sense of shame. For example, a clinician might say, "We know that as many as one in three women and one in seven men are survivors of childhood sexual abuse. It is sad to realize that so many children have suffered in this way."

Validate the disclosure. Health care practitioners must validate the courage it took to disclose and communicate that they believe what they have been told. Visible distress needs to be acknowledged (e.g., "I see that this is painful [distressing, disturbing] for you right now. What can I do to help?" or "It is okay if it takes more than one visit to do a complete examination"). Failure to validate the individual's experience, silence, or judgemental comments can be shaming and contribute to a reticence to disclose in the future:

“[It is important] to validate that experience because ... [it is hard] to keep that buried for 20 years and then bring it out and start talking about it and then look across and see a look of what you might perceive to be disbelief in somebody's eyes and you're wondering inside yourself, you know, . . maybe I am crazy and it didn't really happen or it wasn't like that or, you're supposed to be a man and it wasn't that bad and just shake it off and carry on right? ” (Man survivor)^167p.510

Address time limitations. Time pressures are one of the biggest impediments to disclosure. If individuals disclose a history of abuse and the health care provider can spend only a few minutes with them afterward, it is important that the time constraints are communicated in a way that will not leave survivors feeling dismissed or that they have done something wrong by disclosing (e.g., "Thank you for telling me about being abused. I can only imagine how difficult things have been for you. I have another patient waiting - do you want to book a longer appointment later this week?").

Offer reassurance. Because individuals who have disclosed have shared some very personal information, they may feel vulnerable and exposed - both at the time of the disclosure and during future encounters with the practitioner to whom they have disclosed. To minimize this sense of vulnerability, practitioners can reassure survivors that they applaud the courage it takes to talk about past abuse and that the information that has been shared will be useful in providing appropriate health care.

Health care practitioners must validate the courage it took to disclose and communicate that they believe what they have been told.

Collaborate to develop an immediate plan for self-care. Some survivor participants identified unsettled feelings or flashbacks of their abuse as an immediate after-effect of disclosure:

“I was triggered more, and I was getting more flashbacks after [disclosing the abuse].” (Man survivor)

Accordingly, health care providers should caution individuals who have just disclosed to be prepared for these feelings. They should then work with survivors to make a specific plan for self-care (e.g., "Sometimes talking about past abuse stirs up upsetting memories. Tell me what you can do to look after yourself if this happens to you."). In working out this plan, clinicians should encourage individuals to:

• Include activities and coping strategies that have been successful (i.e., are supportive, comforting, or help the individual to manage distressing emotions).
• Be specific and realistic, and include things that are easy to implement in a moment of distress. An unspecific plan (e.g., to take it easy for the next few days) may be too ambiguous to translate into meaningful activity, whereas a more specific plan (e.g., to call a specific support person or engage in a specific activity, such as going to the gym, meditating or praying, writing in a personal journal, or attending a self- help group meeting) gives survivors clear direction.
• Include ideas about what to do if the usual coping strategies do not work. This step is particularly important if the individual has a history of depression or self-harm. It might involve calling a health information line or crisis line or going to the emergency department of the local hospital.

Recognize that action is not always required. Health care practitioners tend to be problem- oriented and may respond to disclosure as a problem that requires immediate action or resolution; however, survivors may simply want the clinician to have the information. Survivors who have just disclosed may not necessarily expect clinicians to do anything except to be present with them in the moment. While it is important to ask survivors if there is anything they want done related to their disclosure, it may be preferable to identify a later time for discussion about what actions (if any) the survivors want from the practitioner.

Ask whether this is the patient's first disclosure. As well as responding to a disclosure as outlined above, health care providers can inquire whether the patient is disclosing for the first time. By asking "Have you talked with anyone else about this?" practitioners can get a sense of whether the survivor has previously taken any steps to address the abuse. An answer of "No, I have never told anyone before today," as compared to "Well, my counsellor knows and suggested that I tell you," can help clinicians to shape their next response. It may also help them learn what supports the clients have in place and what they may need.

Additional actions required at the time of disclosure or over time

Either immediately following the disclosure or during the next interaction, health care providers should seek to understand the survivors' reasons for disclosing and determine what (if anything) they want from the practitioners. It is also important to clarify the survivors' general expectations of the clinician and to explore any implications that the disclosure has for the survivors' health care. Such questions need to be asked in a manner that indicates clear support for the individuals' choice to disclose and may provide a bridge to discuss ways to maximize their feelings of safety and comfort. While such discussions may take some time (and be spread over a few interactions), the information which comes from them will provide a basis for future interactions:

“When I came in, [the clinician] said, I did some reading up on your condition, and he said, This is what we're going to do. He says, We're going to work out a system, okay, so that I know if you're having trouble and you need to stop. ” (Woman survivor)

Survivors who have just disclosed may not necessarily expect clinicians to do anything except to be present with them in the moment.

Practitioners might say, for example, "Knowing this will help me care for you better. Can we talk about things that might make you more comfortable during your appointments?" or "Is there anything I can do differently?" The ensuing discussions may lead to disclosures of task-specific issues as survivors gradually feel freer to express their needs or preferences. As difficulties are identified, clinicians can integrate changes into the individual's ongoing care. Regardless of what is accomplished, health care practitioners should not assume that all issues have been dealt with in one or two discussions; rather, they should check in with their clients throughout each interaction and make repeated invitations for feedback:

“[The practitioner could say,] Just let me know [what you need]; the lines are open. I know this [abuse] happened and if you need to talk about it or have any questions [you can talk about them with me]. ” (Man survivor)

“[After] I told him I was a survivor ... he always questioned if I was comfortable doing anything ... Communication was more [important].” (Woman survivor)

Health care providers should not assume that all issues have been dealt with in one or two discussions; rather, they should check in with their clients throughout each appointment and make repeated invitations for feedback.

Some survivors hope for a response that is beyond the clinician's ability or scope of practice. It is therefore important for practitioners to be clear about what they can and cannot do to help. If clinicians feel that individuals require assistance beyond that which they can offer, then a referral to someone more able or qualified may be suggested.

Most survivors recognized that disclosing their history of abuse was important to both their health and their health care. Nevertheless, many were concerned that, once they had disclosed their history of childhood sexual abuse, their health care practitioners would tend to attribute their health problems to the abuse before thoroughly investigating other possible reasons for the problems:

“[Practitioners] should never assume. Just because I was abused, that doesn't or shouldn't rule out the possibility that there could be something physical and serious that is wrong. That's one of the reasons I don't like to tell ... health practitioners about my abuse. They tend to write everything off as nerves and don't even check to see if the problem is something else.” (Woman survivor)

While an abuse history may contribute to some illnesses, it is the clinician's responsibility to ensure that health problems are investigated thoroughly for all patients.

Because of the vulnerability that they felt after disclosing their abuse histories, some survivors were wary about being referred to other health care practitioners. Although clinicians typically see referrals as a normal and reasonable action to ensure accurate diagnosis and treatment, survivors may think that the referral implies that their practitioners cannot take care of them because they are "too complicated." As well, survivors may feel uncomfortable or anxious about having to meet one more clinician, whom they do not yet know or trust.

All patients have the right to make an informed choice about the health care practitioners with whom they will work. Thus, before making referrals, practitioners are encouraged to discuss the issue with their clients in order to come to an agreement on a new practitioner. These discussions may be very significant for survivors who, for example, are uncomfortable working with clinicians who are the same gender as their abuser(s). Whenever possible, practitioners should refer to health care providers who are knowledgeable about and sensitive to issues of interpersonal violence. Local resource registries may maintain a list of service providers (including health care practitioners) who specialize in working with survivors.

While some survivors may disclose past abuse as a lead-up to asking for a referral to specialized counselling or support services, it is a mistake to assume that all survivors who disclose need or want to be referred to a mental health practitioner. By offering a referral before exploring the survivors' intentions, practitioners may give the impression that they think they know what is best for the individual or do not want to deal with the disclosure. An immediate referral to a mental health practitioner, regardless of whether the client is having difficulties related to past abuse, can feel like a clear statement that the clinician has judged the survivor to be "not okay." Under many circumstances, raising the issue of referral to a mental health practitioner may best be postponed to a later interaction so that practitioners can reinforce their acceptance of the survivor after the disclosure.

A preferable response to disclosure is for practitioners to ask about the presence and effectiveness of supports (e.g., friends, family, counsellor, spiritual advisor, or self-help group) available to the survivor. Such questioning gives the practitioner information about the survivor's current resources and helps identify gaps. Questions such as "To whom do you turn for support?" or "Do you have enough support in your life?" can help assess the individual's situation. Further questions can help the practitioner make survivors aware of the organizations in the community that offer information, support, and other services to survivors:

“I needed to be reminded of resources and also that it was okay for me to call and use the resources. I needed permission to get the support I need.” (Man survivor)

Responses to avoid following a disclosure

There are, unfortunately, instances when health care practitioners fail to respond sensitively to a disclosure. This failure often leaves the survivor who has risked sharing deeply personal information feeling more distressed.

TABLE 5 - Components of an effective response to disclosure

After hearing a disclosure of past abuse, the clinician should:

• Accept the information
• Express empathy and caring
• Clarify confidentiality
• Normalize the experience by acknowledging the prevalence of abuse
• Validate the disclosure
• Address time limitations
• Offer reassurance to counter feelings of vulnerability
• Collaborate with the survivor to develop an immediate plan for self care
• Recognize that action is not always required
• Ask whether it is a first disclosure

At the time of disclosure or soon after:

• Discuss the implications of the abuse history for future health care and interactions with clinician
• Inquire about social support around abuse issues

“[Sometimes] someone [will start] to disclose [and the practitioner will say,] You don't have to tell me this if you don't want to. People who are really nervous about hearing [a disclosure] keep saying that, and it gives the message, I don't want to hear this.” (Woman survivor)

Negative responses (such as ignoring the disclosure, disbelief, denial of the negative impact of the abuse, or telling a survivor to "just get over it") are both painful and silencing:

“He told me that I should just get over this and move on.” (Woman survivor)

“Don't push the person and be really aware not to use the shoulds, like You should call the crisis line. ” (Woman survivor)^143p.259

Men survivors also cautioned against minimizing the effects of female-perpetrated abuse. Viewing the survivor as lucky to have had such an early introduction to sex or perceiving the abuse as merely a sowing of wild oats was very damaging.

Legal and record-keeping issues

Legal obligations. In our studies, we use the term disclosure to refer to survivors telling health care practitioners that they have a history of childhood abuse, as distinct from task-specific disclosure, which occurs when individuals identify discomfort or difficulty with all or part of a specific examination or treatment. With the exception of this section, when we speak about disclosure in this handbook, we are referring strictly to adults revealing a history of past abuse .

Health care practitioners do not have a legal obligation to report past child abuse disclosed by an adult, unless, in disclosing his or her own experience, an individual identifies a child who may be currently in need of protection (e.g., if a male patient who was abused by a family member tells the practitioner that he has reason to believe that the same perpetrator is continuing to abuse children).

In contrast, all Canadian jurisdictions, except Yukon, have laws that mandate a duty to report cases of suspected abuse or neglect of children to child welfare agencies or to police.^103,127 Although the definitions of a child and the definitions of a child at risk vary somewhat among individual provinces,¹²⁷ these same laws require that all cases of suspected abuse of children (under the age of majority) be investigated by the appropriate child welfare service to determine whether the children are in need of protection. When the suspicions are substantiated, child welfare authorities are mandated to intervene.

Responses to avoid after a disclosure

Survivors identified the following responses as clearly not helpful:

• Conveying pity (e.g., "Oh, you poor thing").
• Offering simplistic advice (e.g., "Look on the bright side," "Put it behind you," "Get over it," or "Don't dwell on the past.").
• Overstating or dwelling on the negative ("A thing like that can ruin your whole life").
• Smiling (while you may hope that your smile conveys compassion, a neutral or concerned expression is more appropriate).
• Touching the person without permission even if you intend it as a soothing gesture.
• Interrupting (let the individual finish speaking).
• Minimizing or ignoring the individual's experience of abuse, the potential impact of past abuse, or the decision to disclose (e.g., "How bad could it be?", "I know a woman that this happened to and she became an Olympic gold medalist," "Let's just concentrate on your back pain," or "What's that got to do with your sprained ankle?").
• Asking intrusive questions that are not pertinent to the examination, procedure, or treatment.
• Disclosing your own history of abuse.
• Giving the impression that you know everything there is to know on the subject.

If clinicians think that they have inadvertently responded to the disclosure in an inappropriate way, or if the patient's nonverbal feedback suggests a negative reaction to their initial responses, they should immediately clarify the intended message and check with the survivor for further reaction.

It is the responsibility of all health care practitioners to know the legal requirements for reporting child abuse and neglect in their jurisdiction. Information and guidance about this obligation is available from regulatory/ licensing bodies and local child welfare authorities (Children's Aid Societies or Child and Family Services).

Health care records. Health care records are both a means of communication among health care practitioners and legal documents. The type of information collected and how it is documented and shared must comply with national, provincial, and territorial legislation. The onus is on all practitioners to understand and comply with the privacy and confidentiality requirements within their jurisdiction.

It is the responsibility of all health care pra-ctitioners to know the legal requirements for reporting child abuse and neglect in their jurisdiction.

In the interests of safeguarding the privacy of Canadians, the federal, provincial, and territorial deputy ministers of health have undertaken the development of the Pan-Canadian Health Information Privacy and Confidentiality Framework .⁷⁸ The aim of the Framework is to address Canadians' privacy and confidentiality needs and to articulate "a harmonized set of core provisions for the collection, use, and disclosure of personal health information in both the publicly and privately funded sectors." The Pan-Canadian Health Information Privacy and Confidentiality Framework outlines a set of core provisions aimed at protecting the privacy and confidentiality of individuals' health information, while at the same time enabling the appropriate sharing of information to facilitate effective health care. These core provisions are consistent with the Canadian Charter of Rights and Freedoms and with The Personal Information Protection and Electronic Documents Act (PIPEDA) ⁴⁰ and endeavour to reflect the realities of the current health system.

A guiding principle underlying the Framework ⁷⁸ is that the collection, use, and disclosure of health information are to be done on a need-to-know basis and with the highest degree of anonymity possible under the circumstances. Furthermore, the Framework understands privacy as a consent- based right and, unless otherwise stated in legislation, an individual's consent must be obtained for any collection, use, and disclosure of personal health information. As well, Alberta, Saskatchewan, Manitoba, and Ontario have enacted provincial legislation that addresses the collection, use, and disclosure of personal health information by health care providers and health care organizations.

In responding to survivors' requests not to document their abuse histories, a practitioner needs to balance the patient's right to privacy and legal reporting requirements.

Documenting a history of abuse. Some of the survivors in our studies specifically asked their health care providers not to document past abuse. In responding to this request, a practitioner needs to balance the patient's right to privacy and legal reporting requirements. While not reporting suspected abuse of a child clearly contravenes the intent of the law, the same is not true of past abuse of a person who is currently an adult. Both practitioner and survivor participants concluded that it is important for clinicians to discuss with their patients how documentation of past abuse might be done while still protecting their privacy. Survivors, for example, might agree to a chart note that states they have a history of abuse but provides no further details. Privacy may, however, be an issue when working with patients whose care is being paid for by a third party (e.g., insurance companies, employee assistance programs, or workers' compensation). Clinicians involved in fee-for-service practices are urged to pay particular attention to the reporting that is required of them.

Health care practitioners are further urged to consider the possible ramifications of sharing information about patients' histories of abuse when referring them to other health care practitioners:

“On many occasions when I've been referred to a specialist, it has been noted in the referring letter/form that I have a history of abuse. Too often the referring [practitioner] assumes it is sexual abuse although I have never specified. I have learned the hard way that this information is not seen only by the [receiving health care practitioner] ... but is also read by some of the staff at the clinic I am going to. I don't want my history of abuse broadcast to the world so I now ask the referring clinician to state that a sensitive approach to any physical examination is required rather than disclose my abuse history. If the referring doctor needs to know, I am in a position to disclose or not and to only that person.” (Woman survivor)

Documentation about past abuse may have legal implications for clients who are (or may in the future be) involved in a court case. If, for example, a client chooses to press criminal charges or launches a civil action against an abuser, or if civil litigation follows a motor vehicle crash, relevant health records may be subpoenaed. Sometimes the records will be sought to support the client's case; however, in other instances, they might be used to challenge the client's credibility or account of events. Regarding consent for the provision of medical records to insurance companies, survivors should be advised that they have the option of sharing all or only specific portions of their record. Health care practitioners are strongly encouraged to seek legal advice in situations where a client's health record is requested by a third party before taking any action.

Questions for reflection

• Does my environment foster a sense of safety for potential disclosure?
• Do my clients trust me enough to disclose? Are there any steps I could take to increase their feelings of trust and safety?
• How do I want to integrate routine inquiry about child sexual abuse? Do I have a "script" that feels natural to me?
• How would I feel if a client disclosed a history of child sexual abuse? Are my reactions different for males and females? How would I know whether my reactions are helpful for my clients?