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11/7/2023

Trauma-Informed Care in Gynecology Clinics: Creating a Safe Environment to Improve Collaborative Care

There is no universal definition of trauma, yet it is a pervasive, harmful, and costly public health problem.  The Substance Abuse and Mental Health Services Administration (SAMHSA) states that, “individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being.” Each instance of trauma is defined by 3 “E’s”: events, experience of these events, and long-lasting adverse effects of these events. A wide range of events (both in the past and ongoing) may be traumatic, ranging from abuse to natural disasters. The traumatic event is experienced as threatening to the individual, causing distress and long-lasting effects on ability to function. Individuals experience trauma differently and, therefore, have various immediate and long-term reactions. Trauma affects patients of all races, ages, genders, and socioeconomic status, with nearly 83% of patients having experienced at least one traumatic event in their lifetime. 

Trauma influences all health outcomes; those specific to gynecology can include chronic pelvic pain, unintended pregnancy, and sexually transmitted infections. Further, the intimate nature of the obstetrics-gynecology office setting and gynecologic examination may be particularly challenging and can potentially result in avoidance of care. Consequently, it is imperative that gynecologists provide a safe and supportive environment for patients by using a trauma-informed care model. Trauma-informed care is a delivery approach that aspires to understand and respond to the impact of trauma, emphasizes safety for both patients and providers, and focuses on opportunities for survivors to regain control. Trauma-informed care recognizes practices that may re-traumatize survivors and seeks to minimize these effects. This care model must include all aspects of patient interaction and all members of the health care team. Providing trauma-informed care does not mean that trauma-related treatment services are immediately available; however, referral resources should made readily accessible.

SAMHSA provides a framework of 4 key assumptions and principles of trauma-informed care, referred to as the 4 “R’s”: realize, recognize, respond, and resist re-traumatization. 

• All members of the care team should realize trauma and its effects on patients and their experience with the health care system.
• Staff should be able to recognize signs of trauma. Signs and symptoms may include anxiety, agitation, outbursts, diaphoresis, or flashbacks. All patients should be screened for trauma to aid in its recognition because not all patients readily share their experiences. A variety of evidence-based screening tools exist (see further readings).
• The health care system or organization must respond by having procedures and policies in place to resist re-traumatization. System-wide policies and full staff training are imperative in evidence-based, trauma-informed care.

When trauma is suspected or identified, a variety of techniques may be useful in providing patient-sensitive care. These care practices should abide by 6 key principles:

• Safety: staff and patients feel physically and psychologically safe.
• Trustworthiness and transparency: operations are conducted transparently with the goal of building trust.
• Peer support: individuals establish safety, trust, and healing.
• Collaboration and mutuality: emphasis is placed on leveling power differences among all staff members and patients.
• Empowerment, voice, and choice: patients’ needs and experiences are recognized, and empowerment is promoted.
• Cultural, historical, and gender issues: the health care system actively moves past historical trauma, stereotypes, and biases and serves community needs.
  
  

By recognizing trauma’s effects on patient health care outcomes and by practicing a trauma-informed care approach, gynecologists create safe spaces for patients and members of the health care team. Because trauma disproportionately affects marginalized communities, implementing a universal care delivery system based on trauma-informed principles may reduce inequities in health care access.

Further Reading:

Caring for Patients Who Have Experienced Trauma: ACOG Committee Opinion, Number 825. Obstet Gynecol. 2021 Apr 1;137(4):e94-e99. doi: 10.1097/AOG.0000000000004326. PMID: 33759830.

Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. Available at: https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf

Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. A Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. Available at: https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4816.pdf.

International Society for Traumatic Stress Studies: Adult Trauma Assessments (https://istss.org/clinical-resources/adult-trauma-assessments)

Initial Publication November 2023

 

********** Notice Regarding Use ************

The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. (“SASGOG”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. SASGOG reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. SASGOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither SASGOG nor its respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

Copyright 2023 The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. All rights reserved.  No re-print, duplication or posting allowed without prior written consent.

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