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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Collusion of silence- Who is responsible?
Praise for Dr. Neher's honesty and courage.
Praise for the Decade Dance
Thank you
To Tell or Not to Tell
Kudos for Dr. Neher
A reminder of what we know
Continuity Care and Domestic Violence
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Laura Hays, Littleton, US BSN, Doctoral/NP candidate
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I applaud the posting of this article and the honesty, however, I feel nausea at the reality. I am in school specifically to address this issue. When are we going to recognize our perpetration by silence? How do we expect the abused, the hurting, and the damaged to be the ones to save themselves from monstrous power inequities? We have access to the victim's life and body and the story is available if we take the time, instead of doing our fix-up without touching their lives. HOW LONG before the victims ask where were we; HOW LONG before we ask ourselves? Competing interests: None declared |
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Virginia L. Gaskell, Pensacola USA Licensed Clinical Social Worker, Project Recovery
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After returning from a forensic workshop in 1986, I determined to ask all the boys in my caseload about sexual abuse as routinely as I did the girls. Fully 50% of the boys who were referred to the exceptional education program (which included gifted, visually impaired, hearing impaired and physically impaired as well as learning disability and cognitively impaired) reported unwanted sexual contact. I was stunned and humbled that I had, through ignorance, neglected to open for discussion this important topic. Although embarrassed, the boys were greatly relieved to learn how common the experience is, and to have an opportunity to be told it was not their fault. Hopefully, your article will help others open discussions in their caseloads. Competing interests: None declared |
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j hendricks, usa former teacher//nys teacher
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I applaud Dr. Neher for his article, The Decade Dance. I have forwarded the Denver information I have about survivors of childhood sexual abuse to him. Maybe you can circulate it in HOPES of helping other victims. The Foundation in Denver is: WINGS; 1.800.373.8671 or 1.303.238.8660; fax--1.303.238.4739. Competing interests: None declared |
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Jane Lott, Marin County, CA USA equestrian assistant, CYO program
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Thank you to the author and commentators for the enlightenment.... particularly the doctor who said he asks not "Have you ever been abused?" but the more productive "How has abuse affected your life?" I work with abused boys ages 7 to 16 (in an equine-assisted program in residential treatment).... I can't imagine what they've been through, but I hope what little I do to help also helps prevent some of the subsequent physical consequences. Thank you all for the enlightenment. Competing interests: None declared |
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Saragale Tucker, Madison, USA secretary
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As a 56 year old patient, I've had many opportunites of whether or not to tell about my sexual abuse. On balance, I would say it is probably better not to. None of the doctors I've told have been able to use the information in a helpful way, and I opine most have held it against me. My favorite example is a gynecologist who hurt me during the exam --after I told him I had been sexually abused.When he was finished he said "I knew I was hurting you, but it was more important to get the data." This is perhaps another issue, but many of the interactions I've had with medical professionals have been re-traumatizing or traumatizing. As far as numbers of horrible indicidents, medical professionals have provided many more than my childhood abusers. Any time I have to give my history, I risk panic attack and flashbacks with suicidal thoughts. Yes, I've had lots of therapy and psychiatric treatment--better than nothing perhaps, but not nearly effective! I hope you find this helpful, and I'd love to help medical professionals deal with this issue, understanding that those of us who have had this experience deal with it in a variety of ways. Best wishes and thank you for this article. Competing interests: None declared |
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Kathleen Cole-Kelly, MS, MSW, Cleveland, USA Professor, Family Medicine, CWRU School of Medicine
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First I want to applaud Jon Neher for his work with this patient and for his taking time to share the interesting story. Patients like Mr. Kelley are not unusual. Nor is the time (10 years) that it took for Mr. Kelley to share his secrets unusual. Many many individuals, who have been traumatized from early sexually abusive relationships, take 1, 2 or 3 decades to divulge the trauma and tragedy. In fact, John Neher can take comfort that the patient did this at all, versus beating himself up about the fact it took so long. Many patients never divulge this unbearable truth. A couple of red flags are worth being sensitive to as a general rule in practice. A patient that is presenting with a rectal prolapse as a male with a story that doesn’t quite add up, would be a patient that should be questioned about his/her sexual history. However, that doesn’t guarantee by any means that the patient will disclose their sexual abuse. And in fact, it could scare a patient, who is so well defended against this painful memory, away from returning to a practitioner who does this prematurely. “Torrents of anger’ might be another red flag. My inclination with a patient whose affect doesn’t seem to match the situation described would always be a patient that I would recommend a thorough examination of his family tree and other sources of support and stress. This might potentially either by explicit comments or by nuanced non-verbal/verbal mis-match alert the clinician to a higher level of concern. Referring the patient to anger management was a wonderful example of collaborative practice. Hopefully in addition to the anger management being addressed in a purely behavioral approach, other psychological wounds would be addressed in a psychotherapeutic manner. For many patients the cognitive approach of anger management is less threatening than referring the patient for general psychotherapy. Hopefully however, as the patient pursues the management training, other issues might be addressed if necessary. Ideally, there is close collaboration with the anger management professional and the physician. This model we know is best for the patient, the physician treating the patient and the mental health worker involved. Again, I congratulate Dr. Neher on his Decade Dance. It’s a dance that responds to no external choreographer other than the patient deciding his timing, the physician tracking red flags and working hard to maintain a relationship with a challenging patient. Competing interests: None declared |
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Therese Zink, Rochester MN Physician/researcher
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Dr. Neher does a nice job of articulating an occurance in primary care that often goes unaddressed. The adverse childhood experiences study, a decade-long and ongoing collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego, California, and the Centers for Disease Control and Prevention, documents that growing up (prior to age 18) in a household with: --Recurrent physical abuse. --Recurrent emotional abuse. --Sexual abuse. --An alcohol or drug abuser. --An incarcerated household member. --Someone who is chronically depressed, suicidal,institutionalized or mentally ill. --Mother being treated violently. --One or no parents --Emotional or physical neglect is associated with many of the chronic illnesses we treat daily: diabetes, lung disease, cardiac disease, depression, anxiety, unplanned pregnancy, etc. The web site (http://www.acestudy.org/)lists the now over 27 publications that document these associations. Although naming the history may not erease the diseases, the naming of the issue may make if easier for all parties (clinician and patient) to procede. Competing interests: None declared |
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Peter F. Cronholm, MD MSCE, Philadelphia, PA USA Family Physician
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I am a clinician who has made identifying and treating domestic violence a priority in my practice. I "routinely" ask all of my patients - both men and women - how violence or abuse has affected their lives. As I read Dr. Neher's reflections on The Decade Dance, I was reminded of several recent encounters with patients I had known for years and who had only recently disclosed to me that they had been victims of abuse. Standing out the most, I was reminded of a woman who had been my patient since I was an intern. I had delivered her children who are also my patients. We had discussed abuse early on in our relationship, but I doubt if I had revisited the issue in years feeling that I knew her well and our mutual trust would provide the conduit for her to disclose any issues of substance that were affecting her life. During the past few years she was involved in off-and-on relationships with her partner - the one who beat her and cut her with a butcher knife as she tried to defend herself from his abuse. When she told me about the abuse, I was crushed and angry. She had come in to be evaluated by one of my associates after having been raped by her partner - why hadn't she come in to see me? I remember looking down at her forearm where the scar was from her attack - how could I have not noticed that? For years I had treated her for depression - how could I have not have made that connection? I look back on our relationship with both pride and shame. In many ways I feel that she was also a victim of continuity care - and I a perpetrator. When I asked why we had never talked about her abuse she told me she was ashamed of what had happened to her. I was devastated by her fear of not being able to talk to me - not because our relationship was weak, but because it was strong. I am struck by how my attempts at domestic violence vigilance could so easily be undermined by my assumptions and the fallacies that go along with trust. The social determinants of domestic violence are incredibly complicated and intertwined. Domestic violence happens because it can. Partners are abusive because we live in a society that rewards controlling behaviors with a muted response from those that are witness. We often speak of social change and role of the community in ending family violence. It gives me pause to consider how alone she must have felt, surrounded by her community and her healthcare provider, unable reach out to people whom she trusted and valued. Her case reminds me of the strengths and weaknesses of the primary care relationship. The primary care provider has such a strong opportunity to partner with patients in improving their health and wellbeing given the nature of their relationship. However, caution to the providers resting on their laurels of continuity care - sometimes the relationship itself can be the barrier. Competing interests: None declared |
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