The Decade Dance

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.

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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.

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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

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

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