Silent Survivors

I salute Elizabeth Volkmann's courage in speaking out [1], adding her very personal story to the growing international calls for better education in the area of sexual violence for medical students and doctors.[2, 3]

My initial response to Elizabeth's article "Silent Survivors"[1] was deeply emotional and personal. I too had cared for a woman like "Katie" as an intern and hospitalized children who had been sexually assaulted as a resident. As a family physician, there were more women: mothers too frightened to breastfeed and touch their new babies because of past sexual assault, women repeatedly sexually assaulted by their partners and older women sexually assaulted in nursing homes. Sexual assault was part of my family story, secret, disbelieved, a "nasty lie".

I add my voice to Elizabeth's, calling for sexual violence education to be included in the training of all medical students and practicing doctors. The current state of sexual violence training is unacceptable. We know that there are serious negative physical and mental health effects [4] of sexual violence across the lifespan, we know early intervention helps and that our services don't provide the care that women need.[5]

At the same time, very little has changed in medical education. In Australia, we see our students still receive an average of less than two hours' education in partner violence [6], and less in sexual violence. How can you possibly respond well to someone like "Katie", a child, a patient, a colleague or a friend with this sort of training? Medical students and doctors interviewed about their sexual violence teaching describe no teaching, or their teachers saying "we'll come back to that" and running out of time. None described integrated or systematic teaching in this area. Teachers describe their own lack of training and being ill prepared to teach about sexual violence.

The challenge of educating medical students and doctors to respond effectively to support survivors of sexual violence extends beyond finding time in a crowded curriculum and training staff to teach. We must remember that approximately 1 in 5 females and 1 in 20 males experience some form sexual violence growing up. The students we teach will bring these experiences to the classroom. Our teaching must recognize and acknowledge the experiences students bring, embedding support and flexible learning opportunities. Large group lecture-based face to face teaching can be particularly problematic with survivors describing feelings of exposure and "being trapped" unable to leave or moderate the material they are exposed to because "everyone with know what happened to me." Some students describe video content at difficult to manage in the classroom and would prefer to learn the same content from a written case. Bedside teaching brings its own challenges, as unprepared students and doctors face the stark reality of patient sexual assault and their own past, present or future experiences.

Education is only the first step towards better care. As I read Elizabeth's reflection, it brought back to me how little we know about how we should talk with (not to) survivors. We have frameworks to help us, but as professionals, the language we use and the actions that we take can create its own barriers, sometimes recreating a place of powerlessness and trauma. We know survivors attend family physicians more frequently than those who haven't experienced sexual violence, we know they are less satisfied with the care they receive [5] but are yet to understand why. It is not just about us learning what to say to sexual assault survivors, we need to listen. Those who have experienced sexual assault can help us create clinical care that better meets their needs.

1. Volkmann, E., Silent Survivors. Annals of Family Medicine, 2017. 15(1): p. 77-79.
2. World Health Organization, Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. 2013, World Health Organization: Geneva.
3. Medical Women International Association, MWIA Resolutions 1929-2013, in Resolution 2010.3. 2013. p. 44.
4. Cutajar, M., et al., Psychopathology in a large cohort of sexually abused children followed up to 43 years. Child Abuse and Neglect, 2010. 34(11): p. 813-22.
5. Coles, J., et al., General practice service use and satisfaction among female survivors of childhood sexual abuse. Australian Family Physician, 2015. 44(1): p. 71-76.
6. Valpied, J., et al., Are Future Doctors Taught to Respond to Intimate Partner Violence? A Study of Australian Medical Schools. Journal of Interpersonal Violence, 2015: p. 0886260515592616.

Competing interests: None declared