ARCHIVED: Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse – Sensitive practice at-a-glance


Sensitive Practice at-a-Glance

The goal of Sensitive Practice is to foster a sense of safety for patients. Although the principles and guidelines articulated in this Handbook and outlined in Tables 7 and 8 are based on studies with Canadian men and women with histories of childhood sexual abuse, they represent a basic approach to care that should be extended to all patients. By adopting the principles of Sensitive Practice as the standard of care, health care providers convey respect, support clients' autonomy and right to participate in healthcare, and decrease the likelihood of inadvertently retraumatizing the survivors of abuse with whom they work knowingly or unknowingly.

Table 7 - Summary of principles of Sensitive Practice

Respect Acknowledging the inherent value of clients as individuals with unique beliefs, values, needs, and histories means upholding and defending their basic human rights and suspending judgment of them.
Taking time Taking adequate time with patients ensures that they do not feel depersonalized or objectified.
Rapport Developing and maintaining an interpersonal style that is professional, yet conveys genuine caring, promotes trust and a sense of safety.
Sharing information Informing patients of what to expect on an going basis and inviting them to ask questions and offer information and feedback helps reduce anxiety and promotes active engagement in their health care.
Sharing control Seeking consent and offering choices enables the clinician to work with rather than on patients, and ensures that patients become full active participants in their own health care.
Respecting boundaries Paying ongoing attention to boundaries and addressing difficulties that arise reinforces patients' right to personal autonomy.
Fostering mutual learning Fostering an environment in which information sharing is a two-way process encourages survivors to learn about their health and how to become active participants in their own health care. It also assists clinicians to learn how best to work with individuals who have experienced interpersonal violence.
Understanding nonlinear healing Checking in with patients throughout each encounter and over time, and being willing to adjust their actions accordingly, enables caregivers to meet the needs of individuals whose ability to tolerate health care examinations and procedures vary over time.
Demonstrating awareness and knowledge Showing that they are aware of interpersonal violence helps professionals foster a sense of trustworthiness and promotes an atmosphere in which patients are willing to work alongside their health care providers.
Table 8 - Summary of guidelines of Sensitive Practice
Context of encounters
Administrative staff and assistants
  • Train all personnel about Sensitive Practice
  • Work with staff and assistants to establish a few "routine responses" that are survivor- friendly
Waiting areas
  • Keep patient informed of length of wait or invite patient to check intermittently
  • Provide printed materials related to interpersonal trauma
  • Provide and clearly identify washrooms
  • Knock and wait for acknowledgement before entering
  • Have at least one soundproof examination or interview room
  • Problem-solve with patients to meet their needs for privacy and safety
Preparation of clients
  • Provide introductory information in plain language, both written and verbal
  • Negotiate with patient to identify needs and workable solutions
  • Encourage presence of support person or chaperone; agree upon roles for all parties
Encounters with patients
  • Discuss and negotiate roles for patient and clinician prior to all examinations or treatments
  • Allow enough time to help individuals understand fully what you are doing
  • Do not assume the patient knows what is involved in an exam, treatment, or procedure
  • Seek consent in an ongoing way throughout the encounter
  • Meet patient fully clothed before and after
  • Explain why removal of clothing is necessary
  • Discuss clothing requirements with patients and collaborate with them to find an agreeable solution
  • Minimize amount of clothing being removed and length of time patient must be disrobed
  • Provide gowns in a wide variety of sizes for all body types
  • Leave the room while the patient is changing
Task-specific inquiry
  • Inquire about patient's past experiences, preferences, difficulties with the exam/ procedure
  • Inquire about how to increase the person's comfort
  • Inquire about whether the patient thinks there is anything else that the clinician should know about
  • Repeat inquiry intermittently over time, and if body language suggests discomfort
General approach
  • Use task-specific inquiry to identify difficulties; problem-solve together to increase comfort
  • Monitor body language and follow up on signs of distress
  • Explain why positions for patient and clinician are necessary
  • Describe what is involved before and during the exam or treatment
  • Seek consent before beginning and when shifting from one part of the body to another
  • Encourage individuals to ask you to pause, slow down, or stop the examination or treatment at any time to lessen their discomfort or anxiety
  • When a presenting problem necessitates examination of areas of the body other than the site of the symptoms, explain the rationale
Genital, rectal exams and procedures
  • Acknowledge discomfort
  • Offer a running commentary about what you are doing
  • Minimize time the patient must remain in a subordinate position
  • Drape parts of the body not being examined
Oral and facial health care
  • Agree on hand signals so that the patient can give instant feedback when verbal communication is not possible
  • Problem-solve with the patient around difficulties with smell/feel of gloves, dental dam, body position, other task-specific difficulties
  • Ensure that your comments to the patients around their oral health and behaviour during the appointment are offered in a nonjudgmental way
  • Keep the length of appointments as short as possible; consider doing longer procedures over two or more appointments
Challenges in encounters
Pain & disconnection from body
  • Assess pain in systematic, nonjudgmental manner
  • Work with client to set realistic goals and determine appropriate referrals
  • Repeatedly invite individuals to focus on their bodies
  • Provide clear verbal and written instructions that the patient understands
  • Suggest a range of strategies to increase self-awareness
Non-adherence to treatment
  • Explore all types of barriers with the patient and problem solve to identify workable solutions
  • Adapt treatment to fit patient
  • Create a "same-day" appointment for patients who frequently cancel appointments whenever possible
SAVE the situation
  • Stop what you are doing and focus fully on the present situation
  • Appreciate and understand the person's situation
  • Validate the person's experience
  • Explore the next steps with the patient
Triggers and dissociation
  • Examine list of common triggers and consider what can be avoided/accommodated
  • Become familiar with signs of a 'fight or flight' response
  • Work with patients who have been triggered to ground and reorient them
  • Normalize the experience
  • Ensure adequate follow-up
Anger and agitation
  • Pay attention to personal safety
  • Adopt non-threatening body language
  • Negotiate and assure patients of your interest and concern
Responding effectively

Upon hearing a disclosure of past abuse:

  • Accept the information
  • Express empathy and caring
  • Clarify confidentiality
  • Normalize the experience by acknowledging the prevalence of abuse
  • Validate the disclosure and offer reassurance to counter feelings of vulnerability
  • Address time limitations
  • 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 in a future interaction:
  • Discuss the implications of the abuse history for future health care and interactions with clinician
  • Inquire about social support around abuse issues
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