Accepted Manuscript Posttraumatic Stress Disorder After Sexual Abuse in Adolescent Girls Bethany. D. Ashby, PsyD, P. Kaul, MD PII:
S1083-3188(16)00162-5
DOI:
10.1016/j.jpag.2016.01.127
Reference:
PEDADO 1959
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 21 July 2015 Revised Date:
7 December 2015
Accepted Date: 20 January 2016
Please cite this article as: Ashby BD, Kaul P, Posttraumatic Stress Disorder After Sexual Abuse in Adolescent Girls, Journal of Pediatric and Adolescent Gynecology (2016), doi: 10.1016/ j.jpag.2016.01.127. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Posttraumatic Stress Disorder After Sexual Abuse in Adolescent Girls
Children’s Hospital Colorado
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Bethany. D. Ashby, PsyD
University of Colorado School of Medicine
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Aurora, Colorado
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Departments of Psychiatry, Obstetrics and Gynecology
P. Kaul, MD
Children’s Hospital Colorado
University of Colorado School of Medicine
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Section of Adolescent Medicine Department of Pediatrics
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Aurora, Colorado
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Corresponding Author: Paritosh Kaul, M.D. Associate Professor Pediatrics University of Colorado – School of Medicine Children’s Hospital Colorado 13123 East 16th Avenue, Box B025 Aurora, CO 80045 Phone: (720) 777-6116; Fax: (720) 777-7339 [email protected] The authors have no financial disclosures
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Abstract The sexual assault of girls and women in this country is estimated at around 20%. The development of post-traumatic stress disorder (PTSD) following sexual abuse and
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assault is one of the potential lingering aftereffects. This article will describe PTSD following sexual abuse and its impact on presenting complaints, such as sexually
transmitted infections, contraception, and chronic pain, for the pediatric and adolescent
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gynecology (PAG) clinician. Treatment approaches, including the use of
antidepressants and anxiolytics, as well as evidenced based psychotherapies, will be
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highlighted. In addition this article will assist the PAG clinician in identifying trauma related concerns during clinic visits and will cover specific screening tools to aid in identification of PTSD. A better understanding of PTSD following sexual abuse will allow
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PAG providers to deliver better care to their patients.
Sexual abuse
Pain
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PTSD
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Key Words
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Posttraumatic Stress Disorder After Sexual Abuse in Adolescent Girls Case Vignette
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AB is an 18-year-old adolescent girl who presents with pelvic pain for 6 months. The history is significant for sexual abuse at age 5 by an older male cousin. The patient shared this information with her mother at that time. The mother was supportive and
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immediately alerted social services. After the report, the patient received psychotherapy that specifically focused on the abuse for 6 months. Since then, AB has not had any
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contact with the cousin and reports that this is no longer an issue for her. AB became sexually active about 6 months ago and has had one lifetime partner. The abdominal and pelvic examination is normal and screening for sexually transmitted infections is negative. AB was reassured and told to take NSAIDS. However, the pain continued and an ultrasound was ordered and revealed few follicular cysts. AB continued to have
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pelvic pain and laparoscopy was done which revealed no pelvic pathology. AB became frustrated by the negative findings and began to report increasing anxiety related to the
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pain. Although she reported that the sexual abuse is not the issue, given the lack of medical explanation for pain and the timing of onset of pain at the same time that she
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became sexually active, the clinician decided to screen for post-traumatic stress disorder (PTSD) using the Primary Care PTSD screen (PC-PTSD) which was positive. Introduction
PTSD is associated with adverse health outcomes and increased medical utilization, as well as reproductive health problems.1-5 Pelvic pain and dysmenorrhea are strongly associated with PTSD in adults and research suggests that adolescent girls experience the same physical sequelae following a diagnosis of PTSD following sexual abuse.1-6
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Compared to adolescent patients without PTSD histories, they are more likely to present with idiopathic symptoms and providers should consider the potential of posttraumatic stress symptoms that may underlie these complaints. Recognition of PTSD
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symptoms, particularly those symptoms that result from sexual trauma, is important when discussing contraception, STI counseling, and pregnancy planning6. Further,
medical symptoms may not respond to treatment without attention to PTSD symptoms.
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One study of patients with trauma histories and headache revealed that despite
appropriate medical treatment, no change in headache symptoms occurred until the
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PTSD symptoms were addressed. 7
This article will describe PTSD after sexual abuse, its impact on presenting complaints, and will briefly cover treatment approaches. In addition, it will also assist the pediatric and adolescent gynecology (PAG) clinician in identifying trauma related concerns during
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clinic visits. A better understanding of PTSD following sexual abuse will allow PAG providers to deliver better care to their patients.
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Definition of PTSD
Post-traumatic Stress Disorder is an anxiety disorder that involves exposure to a
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traumatic event with 4 major symptom clusters: a) intrusive thoughts and images related to the trauma, b) avoidance of trauma-related thoughts and feelings and/or avoidance of external reminders of the trauma, c) negative changes in mood and thoughts as a result of the trauma, and d) increased reactivity and physiological arousal8. Patients must have a total of six symptoms across the 4 symptoms clusters and these symptoms must cause impairment in functioning in everyday life. It is important to remember that the patient does not have to directly experience an event to be traumatized by it. For
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example, witnessing domestic violence between parents or learning that a family member was murdered are both considered trauma exposures8.. In addition, individual factors unique to each person impact the development of trauma symptoms and PTSD.
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Further, cumulative trauma exposure is associated with more severe PTSD symptoms9. For example, an adolescent with a preexisting anxiety or depressive disorder who has been through several stressful life circumstances such as parental divorce or multiple
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moves, may be at greater risk for developing PTSD than an adolescent who has effective coping skills, no family history of mental health issues, and no chronic
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psychosocial stressors. Sexual Abuse
The sexual assault of girls and women is all too common in the world and the United States. The World Health Organization’s 2014 Fact Sheet on Violence Against Women
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indicates that 20% of women worldwide are victims of childhood sexual abuse10. In the United States, the lifetime prevalence rate of sexual assault is 20%11. For PAG providers then, one in five of their patients has experienced sexual abuse or assault.
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While most PAG clinicians are aware of the psychological and mental health sequelae
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of sexual abuse, somatic complaints have also been found to be a major outcome. There are a variety of factors that place adolescent girls at risk for sexual abuse. Higher rates of sexual assault and abuse are reported in adolescent girls from low socioeconomic status backgrounds12. Some studies indicate that African American girls had higher rates of sexual abuse than other ethnic groups, while others indicate that Caucasians have higher rates of sexual abuse13,14. No differences among ethnic groups have been found in rates of PTSD.
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Symptoms that an adolescent with history of sexual abuse may present to PAG clinicians include increased perception of pain, early initiation of sexual activity, multiple sexual partners, and unsafe sexual practices such as not using condoms or other forms
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of birth control 15, 16. These symptoms will be described in more detail in subsequent sections of this article.
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Neurobiology of Pain following PTSD
Recent findings indicate that PTSD actually alters the response to pain.17 In animal
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studies, rats that were exposed to early life stress were more reactive to painful stimuli than animals without early life stressors. The researchers found that the increased muscle pain was related to cytokines involved in the inflammatory response system, and catecholamines involved in the fight-or-flight response18. An fMRI study of adults with PTSD found that the blood oxygen level-dependent signal is greater in patients with
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PTSD and that this signal is strongly correlated with symptom severity in regions of the brain responsible for stress-induced analgesia19. Further, recent studies have identified genetic markers that influence the development of PTSD. These markers are also
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involved in interferon signaling and immune response, underscoring the relationship
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between PTSD and physical symptoms20. Medical Comorbidities
PTSD following sexual abuse has been linked to a variety of somatic complaints. This is not surprising given the physical injuries that can accompany rape and sexual abuse, such as contusions and abrasions. A variety of medical conditions co-occur with PTSD following sexual abuse and sexual abuse itself a major risk factor for both persistent PTSD symptoms and chronic gynecologic pain21. PTSD symptoms following sexual
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abuse include dyspareunia and difficulty with orgasm23,24. As compared to women who have not experienced rape, rape victims are nearly three times more likely to have pelvic floor dysfunction, even three years after receiving evidenced based treatment for
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PTSD25. The shared vulnerability model suggests that exposure to trauma leads not only to PTSD but to other mental health and medical disorders in patients who are vulnerable to pathology. This provides an explanation for the heightened anxiety
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experienced in patients with PTSD as well as in patients with chronic pain22.
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High-risk sexual behaviors
Adolescents with histories of sexual abuse and subsequent PTSD are much more likely to engage in high-risk sexual behaviors as compared to peers with no history of PTSD.26 They are more likely to have a higher number of partners. They are four times less likely to use condoms compared to young women who have never been sexually
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assaulted and are three times as likely to participate in prostitution as compared to women who have never been sexually assaulted15. Sexual abuse is also associated with early pregnancy and pregnancy complication16, both of which are themselves
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associated with PTSD. The reasons for the increase in high risk sexual behaviors is
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unclear and may be due to a variety of factors including using sexuality as a means of control and power, feeling less connected to their bodies and therefore more willing to engage in sex indiscriminately6. Regardless of the reason, these behaviors put patients at an increased likelihood of worsening severity of PTSD symptoms since engaging in risky behaviors increases the chances that patients will be victimized again.
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Mental Health Comorbidities Several other comorbid mental health disorders may also be present in a patient with PTSD following sexual abuse. Studies indicate that 25%-70% of children and
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adolescents with PTSD also meet criteria for depression27,28. In addition to PTSD, sexual assault can lead to depression, suicidality, eating disorders, anxiety, and
substance abuse29, 30. Further, the impact of sexual abuse seems to be cumulative, with
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increasing severity of PTSD symptoms associated both with more incidents of abuse and increasing severity of abuse31, 32. For example, the second time a patient is sexually
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abused, her symptoms will be more severe than the first time and rape will cause more severe PTSD symptoms than fondling.
In community samples, approximately 50% of families who have concerns about mental health issues seek initial assessment and treatment from their medical provider33. In a
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recent study of female adolescents seen for routine care in an adolescent medicine clinic, 12% met criteria for PTSD34. However, less than half of the patients referred to mental health care by a pediatric provider actually made and attended an appointment
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with a mental health clinician35. Therefore pediatric providers, including PAG clinicians,
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are a primary source of mental health treatment. PTSD Treatment
Psychotherapy and medication are the major treatment modalities for PTSD. There are few studies in the pediatric literature that examine the effect of medication alone, as the majority of studies focus on psychotherapeutic and psychosocial interventions36. However, in practice, SSRIs, antipsychotics, alpha blockers, beta blockers, tricyclic antidepressants, anxiolytics and anticonvulsant medications are used37, 38. A thorough
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discussion of these treatment modalities is outside the scope of this article, although we will cover them briefly.
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Medications Only sertraline and fluoxetine have been studied in randomized controlled trials for adolescent PTSD, and neither was more effective than placebo39-41. However,
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adolescents who were also depressed demonstrated symptom improvement when
prescribed fluoxetine42. One randomized controlled trial of divalproex in adolescent
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males found improvement in intrusion and avoidance symptoms associated with PTSD43. Other than these, there are no randomized controlled trials for other classes of medications in adolescent populations and providers should be cautious about prescribing medications for which there is limited evidence to support their use.
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Psychotherapy
Trauma-focused cognitive behavioral therapy (TF-CBT) is the treatment of choice for school-aged children and adolescents with PTSD. This is the only treatment with a
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sufficient evidence base, including multiple randomized controlled trials. TF-CBT involves both patients and parents and includes skill building, relaxation techniques,
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affect regulation, telling the trauma narrative, and exposure. Treatment typically lasts from 12 to 16 weeks and over 80% children will show improvement in symptoms44. Eye Movement Desensitization Reprocessing (EMDR) is becoming increasingly wellknown as a treatment for traumatized children and adolescents. EMDR is conducted only with the traumatized patient and treatment occurs in eight phases45. Rather than an exclusive talk therapy focus, EMDR utilizes bilateral eye movement as an external
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stimulus to aid in the reprocessing of traumatic events. The mechanisms surrounding EMDR are not well understood, however in a recent study that incorporated elements of a randomized controlled trial, EMDR was found to be superior to a wait list control group
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in treating PTSD symptoms over an 8 week period46. Practice/Clinical Implications for PAG Providers
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Increased awareness of the prevalence and impact of PTSD on patients has
implications for clinical practice. Some of these are more general, while some
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specifically address issues unique to the PAG clinician (Table 1). General Issues Screening
Screening for mental health concerns should be a regular occurrence in primary care
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settings. The American College of Obstetricians and Gynecologists (ACOG) strongly recommends that all women be screened for a history of sexual abuse and sexual coercion and the American Academy of Pediatrics (AAP) recommends regular
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screening of adolescents for depression and suicidality47,48. Many providers also screen
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for anxiety, substance abuse, and interpersonal violence. Given the incidence of PTSD among children and adolescents and its impact on patient care, PAG clinicians may want to consider the addition of a PTSD screen in their standard practice. There are a variety of very brief tools that can be used to screen for PTSD. However, most of these are validated in primary care populations over the age of 18. Table 2 lists the screening tools recommended by the National Center for PTSD for adults 18 and over. These measures can be downloaded and other useful information can be found at
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the National Center for PTSD’s website: (http://ptsd.va.gov). The AAP has recommended several mental health tools that are appropriate for assessing PTSD in children and adolescents. They are found in Table 3 and more information can be found
initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf
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on the AAP’s website: http://www.aap.org/en-us/advocacy-and-policy/aap-health-
Unique factors related to specific clinical practices are important to consider when
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determining which screening tool to use. Some tools are only available in English, while others are available in Spanish or other languages. Length of time to complete the
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screen, number of questions asked, education level of the clinic population, and whether or not parents are present or should be included in the screening are important factors to review. See tables 2 and 3 for specific information for each tool. With increased screening will come increased identification of PTSD and likely
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increased identification of sexual abuse. As a result, screening implementation must be carefully thought out and must include time built into visits to address screening results with patients as well as parents if appropriate. Also, a plan for referrals should include
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specific community resources where patients can access mental health treatment, as
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well as education of parents and patients on importance of following up with referrals. Chaperones
Given the physical and psychological symptoms that accompany PTSD, the PAG provider must consider how these will impact recommendations, interventions, and procedures. Male PAG providers in particular must consider the impact of their gender on patients, as almost 99% of offenders of sexual assaults in single victim incidents are male49. While the majority of providers have a chaperone present during physical
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exams, it is imperative to do so when treating patients with PTSD. ACOG recommends having a chaperone when evaluating victims of sexual assault and the AAP recommends having a chaperone during all breast, genital, and anorectal exams50,51. A
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chaperone provides the patient with reassurance that nothing inappropriate is going to happen. In addition, this protects the provider from claims of inappropriate sexual behavior or abuse.
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Boundaries
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It is important for the PAG clinician to be aware of boundaries and limit setting while working with this population. These patients’ boundaries were violated by the abuse they experienced and they may not often be aware of their own violations of others’ boundaries. Based on our clinical experience as a PAG provider and psychologist, patients may ask inappropriate questions about their providers’ personal life, request
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personal phone numbers so they can have immediate contact if their symptoms worsen, ask for treatment that the PAG clinician wouldn’t normally provide (refilling pain medications over the phone, more visits than is medically indicated), or request
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procedures that the PAG clinician wouldn’t typically recommend. It is important to create
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a plan that is clearly communicated to the patient and refer back to this plan often. Giving a written copy of the plan to the patient that they can regularly refer to is a helpful tool to maintain the boundary for the patient and the clinician
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Gynecological Issues Contraception
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As mentioned previously, patients with PTSD following sexual abuse are less likely to use condoms, have higher rates of involvement in prostitution, and are more likely to become pregnant15,16. PTSD, and associated disorders such as depression and other
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anxiety disorders, impact executive functioning, concentration, and attention, making it more difficult for these patients to attend to and follow instructions52. As a result,
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patients may have difficulty understanding how to use OCPs, the ring, or the patch appropriately. Simplified, written instructions may be helpful for these patients, as well as frequent review at medical visits.
Although there is no literature to support this, in our clinical practice as a PAG provider
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and a psychologist working with PAG patients we have found that some patients with PTSD find the insertion of an IUD highly traumatizing and this should be kept in mind during the PAG clinician’s discussion of long acting reversible contraceptives (LARC).
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Implants seem to have high levels of acceptability to patients – they aren’t inserted into the vagina and don’t cause vaginal pain. Depo-Provera shots also seem to be
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acceptable to these patients and, while they still have to remember to return to clinic every 12 weeks, they do not have to remember to take a daily pill with associated instructions for what to do when they miss a pill. Sexually Transmitted Infections (STIs) Patients with PTSD often have higher rates of STIs than peers with no history of PTSD53. This may due to a variety of factors. Women who were victimized as
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adolescents are more likely to be sexually victimized again, which puts them at increased risk of STIs. Girls with histories of revictimization are more likely to participate in or be forced into prostitution, thereby increasing their risk15. They may date partners
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who are abusive and who refuse to use condoms or allow the patient to use birth control, thereby increasing their risk of STIs as well as pregnancy54. This perspective can allow PAG clinicians to better understand the factors that underlie their patients’
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refusal or inability to protect themselves during sex, as well as help providers express more patience and empathy.
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Chronic Pain
Regardless of physical findings, care must be given to ensure that patients feel that their perception of pain is understood. It is often helpful to include a simple explanation of the neurobiology of pain, specifically how PTSD increases the perception of and
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sensitivity to pain. This is always necessary in cases where there is known trauma, and can be a useful general practice as many patients have undisclosed histories of abuse. This must be done respectfully, however, so as not to unintentionally communicate that
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pain is “in her head” and with the knowledge that the increased pain patients experience
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is a real phenomenon.
Conclusion
PTSD after sexual abuse is a widespread occurrence with sequelae that can impact patients’ physical and emotional well being. The traumatic events themselves can cause actual physical pain, and the changes that occur in the brain as a result of PTSD can lead to increased reactivity and sensitivity to pain. PTSD is also strongly correlated with depression, which often involves pain as one of its symptoms. Gynecological complaints
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are increased in patients with PTSD following sexual abuse. These patients also engage in more high risk sexual behaviors and, because they place themselves in high risk situations, are at increased likelihood of being victimized again.
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Many patients with mental health concerns will never see a mental health care provider, making PAG clinicians a primary source of mental health treatment. It is imperative then for PAG clinicians to become aware of the signs, symptoms, and physical indicators that
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point to PTSD. It is also critical for providers to become comfortable asking screening questions or using PTSD screening tools to better identify these patients. When
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providers are more cognizant of the role that PTSD after sexual abuse plays in the lives of their patients, interventions can be targeted to best meet the needs of patients, while
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also limiting the burden on PAG clinicians.
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for the U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US); 2009 Apr 49. Greenfeld LA. Sex offenses and offenders: An analysis of data on rape and sexual Assault. Bureau of Justice Statistics. 1997. 50. Committee Opinion: The American Congress of Obstetrics and Gynecology committee opinion on sexual assault [Internet]. Washington DC [2014 April; cited 2015 March 15]. Available from http://www.acog.org/Resources-AndPublications/Committee-Opinions/Committee-on-Health-Care-for-UnderservedWomen/Sexual-Assault. Accessed 2 June 2015 51. Policy Statement—Use of Chaperones During the Physical Examination of the Pediatric Patient Pediatrics 2011;127:991–993 52. M, Polak AM, Witteveen AM, Denys D. Executive function in posttraumatic stress disorder (PTSD) and the influence of comorbid depression. Neurobiol Learn Mem. 2014 Jul;112:114-21 53. van Roode T, Dickson N, Herbison P, Paul C. Child sexual abuse and persistence of risky sexual behaviors and negative sexual outcomes over adulthood: Findings from a birth cohort. 2009 Mar;33(3):161-72 54. Committee Opinion: The American Congress of Obstetrics and Gynecology committee opinion on reproductive and sexual coercion [Internet]. Washington DC [2014 April; cited 2015 March 15]. Available from http://www.acog.org/Resources-And-Publications/CommitteeOpinions/Committee-on-Health-Care-for-Underserved-Women/Reproductiveand-Sexual-Coercion Accessed 2 June 2015 55. Beck AT, Steer RA, Ball R, Ciervo CA, Kabat M. Use of the Beck Anxiety and Beck Depression Inventories for primary care with Medical Outpatients. Assessment. 1997; 4: 211-19. 56. Prins A, Ouimette P, Kimerling R, Cameron RP, Hugelshofer DS, Shaw-Hegwer J, Thrailkill A, Gusman FD, Sheikh JI. The primary care PTSD screen (PCPTSD): development and operating characteristics. Primary Care Psychiatry. 2003; 9: 9-14 57. Prins A, Ouimette P, Kimerling R, Cameron RP, Hugelshofer DS, Shaw-Hegwer J, Thrailkill A, Gusman FD, Sheikh JI. The primary care PTSD screen (PCPTSD): Corrigendum. Primary Care Psychiatry. 2004; 9: 151 58. Lang AJ, Stein MB. An abbreviated PTSD checklist for use as a screening instrument in primary care. Behav Res Ther. 2005; 43: 585-94 59. Breslau N, Peterson EL, Kessler RC, Schultz LR. Short screening scale for DSMIV post-traumatic stress disorder. American Journal of Psychiatry. 1999; 156: 908-11. 60. Davidson, J. (2002). SPAN Addendum to DTS Manual. Multi-Health Systems Inc. New York. 61. Connor K, Davidson J. SPRINT: A brief global assessment of post-traumatic stress disorder. Int Clin Psychopharmacol. 2001; 16: 279-84. 62. Davidson JRT, Colket JT. The eight-item treatment-outcome post-traumatic stress disorder scale: a brief measure to assess treatment outcome in posttraumatic stress disorder. Int Clin Psychopharmacol. 1997; 12: 41-5. 63. Brewin CR, Rose S, Andrews B, Green J, Tata P, McEvedy C, Turner S, Foa EB. Brief screening instrument for post-traumatic stress disorder. Br J Psychiatry, 2002; 181: 158-62. 64. Foa E, Cashman L, Jaycox L, Perry K. The validation of a self-report measure of PTSD: The Posttraumatic Diagnostic Scale. Psychol Assess 1997; 9: 445-51. 65. Foa E. Posttraumatic Diagnostic Scale Manual. Minneapolis, MN: National Computer Systems 1996.
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66. Steinberg AM, Brymer MJ, Decker KB, & Pynoos RS. The University of California at Los Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psychiatry Rep. 2004; 6: 96–100 67. Briere J. Trauma Symptom Checklist for Children: Professional manual. Florida: Psychological Assessment Resources Inc. 1996.
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Table 1
Gynecological Issues
Screening
Contraception
Chaperones
Sexually Transmitted Infections
Boundary Issues
Chronic Pain
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General Issues
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Clinical Implications for PAG Clinicians
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Table 2: PTSD Screening Tools for Adults
4 items
2 minutes
6 items
2 minutes
7 items
18 years and older
3 minutes
4 items
18 years and older
2 minutes
8 items 10 items
3 items 4 minutes
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Administration and Scoring Time 3 minutes
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Sprint61,62 Trauma Screening Questionnaire63
Age Range (if specified) 17-80
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Beck Anxiety InventoryPrimary Care55 Primary Care PTSD screen56,57 Short Form of the PTSD Checklist58 Short Screening Scale for PTSD59 SPAN60
Number of Items 7 items
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Screening Tool
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Table 3: Pediatric and Adolescent PTSD Screening Tools
Number of Items
Age Range
Administrati on and Scoring Time
Parent Component
Post-traumatic Stress Diagnostic Scale64,65
49
18-65
10-15 minutes
No
UCLA PRSD Reaction Index66
Children :20
Child & Parent: 7-13
25-40 minutes
Yes
Availability in Spanish
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Screening Tool
No
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Yes
(21 items
54 items
8-16
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Youth: over 13
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Trauma Symptom Checklist for Children67
Youth: 22
15-20 minutes
No
Yes
S1083-3188(16)00162-5
DOI:
10.1016/j.jpag.2016.01.127
Reference:
PEDADO 1959
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 21 July 2015 Revised Date:
7 December 2015
Accepted Date: 20 January 2016
Please cite this article as: Ashby BD, Kaul P, Posttraumatic Stress Disorder After Sexual Abuse in Adolescent Girls, Journal of Pediatric and Adolescent Gynecology (2016), doi: 10.1016/ j.jpag.2016.01.127. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Posttraumatic Stress Disorder After Sexual Abuse in Adolescent Girls
Children’s Hospital Colorado
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Bethany. D. Ashby, PsyD
University of Colorado School of Medicine
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Aurora, Colorado
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Departments of Psychiatry, Obstetrics and Gynecology
P. Kaul, MD
Children’s Hospital Colorado
University of Colorado School of Medicine
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Section of Adolescent Medicine Department of Pediatrics
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Aurora, Colorado
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Corresponding Author: Paritosh Kaul, M.D. Associate Professor Pediatrics University of Colorado – School of Medicine Children’s Hospital Colorado 13123 East 16th Avenue, Box B025 Aurora, CO 80045 Phone: (720) 777-6116; Fax: (720) 777-7339 [email protected] The authors have no financial disclosures
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Abstract The sexual assault of girls and women in this country is estimated at around 20%. The development of post-traumatic stress disorder (PTSD) following sexual abuse and
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assault is one of the potential lingering aftereffects. This article will describe PTSD following sexual abuse and its impact on presenting complaints, such as sexually
transmitted infections, contraception, and chronic pain, for the pediatric and adolescent
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gynecology (PAG) clinician. Treatment approaches, including the use of
antidepressants and anxiolytics, as well as evidenced based psychotherapies, will be
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highlighted. In addition this article will assist the PAG clinician in identifying trauma related concerns during clinic visits and will cover specific screening tools to aid in identification of PTSD. A better understanding of PTSD following sexual abuse will allow
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PAG providers to deliver better care to their patients.
Sexual abuse
Pain
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PTSD
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Key Words
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Posttraumatic Stress Disorder After Sexual Abuse in Adolescent Girls Case Vignette
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AB is an 18-year-old adolescent girl who presents with pelvic pain for 6 months. The history is significant for sexual abuse at age 5 by an older male cousin. The patient shared this information with her mother at that time. The mother was supportive and
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immediately alerted social services. After the report, the patient received psychotherapy that specifically focused on the abuse for 6 months. Since then, AB has not had any
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contact with the cousin and reports that this is no longer an issue for her. AB became sexually active about 6 months ago and has had one lifetime partner. The abdominal and pelvic examination is normal and screening for sexually transmitted infections is negative. AB was reassured and told to take NSAIDS. However, the pain continued and an ultrasound was ordered and revealed few follicular cysts. AB continued to have
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pelvic pain and laparoscopy was done which revealed no pelvic pathology. AB became frustrated by the negative findings and began to report increasing anxiety related to the
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pain. Although she reported that the sexual abuse is not the issue, given the lack of medical explanation for pain and the timing of onset of pain at the same time that she
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became sexually active, the clinician decided to screen for post-traumatic stress disorder (PTSD) using the Primary Care PTSD screen (PC-PTSD) which was positive. Introduction
PTSD is associated with adverse health outcomes and increased medical utilization, as well as reproductive health problems.1-5 Pelvic pain and dysmenorrhea are strongly associated with PTSD in adults and research suggests that adolescent girls experience the same physical sequelae following a diagnosis of PTSD following sexual abuse.1-6
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Compared to adolescent patients without PTSD histories, they are more likely to present with idiopathic symptoms and providers should consider the potential of posttraumatic stress symptoms that may underlie these complaints. Recognition of PTSD
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symptoms, particularly those symptoms that result from sexual trauma, is important when discussing contraception, STI counseling, and pregnancy planning6. Further,
medical symptoms may not respond to treatment without attention to PTSD symptoms.
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One study of patients with trauma histories and headache revealed that despite
appropriate medical treatment, no change in headache symptoms occurred until the
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PTSD symptoms were addressed. 7
This article will describe PTSD after sexual abuse, its impact on presenting complaints, and will briefly cover treatment approaches. In addition, it will also assist the pediatric and adolescent gynecology (PAG) clinician in identifying trauma related concerns during
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clinic visits. A better understanding of PTSD following sexual abuse will allow PAG providers to deliver better care to their patients.
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Definition of PTSD
Post-traumatic Stress Disorder is an anxiety disorder that involves exposure to a
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traumatic event with 4 major symptom clusters: a) intrusive thoughts and images related to the trauma, b) avoidance of trauma-related thoughts and feelings and/or avoidance of external reminders of the trauma, c) negative changes in mood and thoughts as a result of the trauma, and d) increased reactivity and physiological arousal8. Patients must have a total of six symptoms across the 4 symptoms clusters and these symptoms must cause impairment in functioning in everyday life. It is important to remember that the patient does not have to directly experience an event to be traumatized by it. For
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example, witnessing domestic violence between parents or learning that a family member was murdered are both considered trauma exposures8.. In addition, individual factors unique to each person impact the development of trauma symptoms and PTSD.
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Further, cumulative trauma exposure is associated with more severe PTSD symptoms9. For example, an adolescent with a preexisting anxiety or depressive disorder who has been through several stressful life circumstances such as parental divorce or multiple
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moves, may be at greater risk for developing PTSD than an adolescent who has effective coping skills, no family history of mental health issues, and no chronic
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psychosocial stressors. Sexual Abuse
The sexual assault of girls and women is all too common in the world and the United States. The World Health Organization’s 2014 Fact Sheet on Violence Against Women
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indicates that 20% of women worldwide are victims of childhood sexual abuse10. In the United States, the lifetime prevalence rate of sexual assault is 20%11. For PAG providers then, one in five of their patients has experienced sexual abuse or assault.
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While most PAG clinicians are aware of the psychological and mental health sequelae
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of sexual abuse, somatic complaints have also been found to be a major outcome. There are a variety of factors that place adolescent girls at risk for sexual abuse. Higher rates of sexual assault and abuse are reported in adolescent girls from low socioeconomic status backgrounds12. Some studies indicate that African American girls had higher rates of sexual abuse than other ethnic groups, while others indicate that Caucasians have higher rates of sexual abuse13,14. No differences among ethnic groups have been found in rates of PTSD.
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Symptoms that an adolescent with history of sexual abuse may present to PAG clinicians include increased perception of pain, early initiation of sexual activity, multiple sexual partners, and unsafe sexual practices such as not using condoms or other forms
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of birth control 15, 16. These symptoms will be described in more detail in subsequent sections of this article.
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Neurobiology of Pain following PTSD
Recent findings indicate that PTSD actually alters the response to pain.17 In animal
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studies, rats that were exposed to early life stress were more reactive to painful stimuli than animals without early life stressors. The researchers found that the increased muscle pain was related to cytokines involved in the inflammatory response system, and catecholamines involved in the fight-or-flight response18. An fMRI study of adults with PTSD found that the blood oxygen level-dependent signal is greater in patients with
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PTSD and that this signal is strongly correlated with symptom severity in regions of the brain responsible for stress-induced analgesia19. Further, recent studies have identified genetic markers that influence the development of PTSD. These markers are also
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involved in interferon signaling and immune response, underscoring the relationship
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between PTSD and physical symptoms20. Medical Comorbidities
PTSD following sexual abuse has been linked to a variety of somatic complaints. This is not surprising given the physical injuries that can accompany rape and sexual abuse, such as contusions and abrasions. A variety of medical conditions co-occur with PTSD following sexual abuse and sexual abuse itself a major risk factor for both persistent PTSD symptoms and chronic gynecologic pain21. PTSD symptoms following sexual
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abuse include dyspareunia and difficulty with orgasm23,24. As compared to women who have not experienced rape, rape victims are nearly three times more likely to have pelvic floor dysfunction, even three years after receiving evidenced based treatment for
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PTSD25. The shared vulnerability model suggests that exposure to trauma leads not only to PTSD but to other mental health and medical disorders in patients who are vulnerable to pathology. This provides an explanation for the heightened anxiety
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experienced in patients with PTSD as well as in patients with chronic pain22.
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High-risk sexual behaviors
Adolescents with histories of sexual abuse and subsequent PTSD are much more likely to engage in high-risk sexual behaviors as compared to peers with no history of PTSD.26 They are more likely to have a higher number of partners. They are four times less likely to use condoms compared to young women who have never been sexually
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assaulted and are three times as likely to participate in prostitution as compared to women who have never been sexually assaulted15. Sexual abuse is also associated with early pregnancy and pregnancy complication16, both of which are themselves
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associated with PTSD. The reasons for the increase in high risk sexual behaviors is
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unclear and may be due to a variety of factors including using sexuality as a means of control and power, feeling less connected to their bodies and therefore more willing to engage in sex indiscriminately6. Regardless of the reason, these behaviors put patients at an increased likelihood of worsening severity of PTSD symptoms since engaging in risky behaviors increases the chances that patients will be victimized again.
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Mental Health Comorbidities Several other comorbid mental health disorders may also be present in a patient with PTSD following sexual abuse. Studies indicate that 25%-70% of children and
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adolescents with PTSD also meet criteria for depression27,28. In addition to PTSD, sexual assault can lead to depression, suicidality, eating disorders, anxiety, and
substance abuse29, 30. Further, the impact of sexual abuse seems to be cumulative, with
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increasing severity of PTSD symptoms associated both with more incidents of abuse and increasing severity of abuse31, 32. For example, the second time a patient is sexually
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abused, her symptoms will be more severe than the first time and rape will cause more severe PTSD symptoms than fondling.
In community samples, approximately 50% of families who have concerns about mental health issues seek initial assessment and treatment from their medical provider33. In a
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recent study of female adolescents seen for routine care in an adolescent medicine clinic, 12% met criteria for PTSD34. However, less than half of the patients referred to mental health care by a pediatric provider actually made and attended an appointment
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with a mental health clinician35. Therefore pediatric providers, including PAG clinicians,
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are a primary source of mental health treatment. PTSD Treatment
Psychotherapy and medication are the major treatment modalities for PTSD. There are few studies in the pediatric literature that examine the effect of medication alone, as the majority of studies focus on psychotherapeutic and psychosocial interventions36. However, in practice, SSRIs, antipsychotics, alpha blockers, beta blockers, tricyclic antidepressants, anxiolytics and anticonvulsant medications are used37, 38. A thorough
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discussion of these treatment modalities is outside the scope of this article, although we will cover them briefly.
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Medications Only sertraline and fluoxetine have been studied in randomized controlled trials for adolescent PTSD, and neither was more effective than placebo39-41. However,
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adolescents who were also depressed demonstrated symptom improvement when
prescribed fluoxetine42. One randomized controlled trial of divalproex in adolescent
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males found improvement in intrusion and avoidance symptoms associated with PTSD43. Other than these, there are no randomized controlled trials for other classes of medications in adolescent populations and providers should be cautious about prescribing medications for which there is limited evidence to support their use.
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Psychotherapy
Trauma-focused cognitive behavioral therapy (TF-CBT) is the treatment of choice for school-aged children and adolescents with PTSD. This is the only treatment with a
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sufficient evidence base, including multiple randomized controlled trials. TF-CBT involves both patients and parents and includes skill building, relaxation techniques,
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affect regulation, telling the trauma narrative, and exposure. Treatment typically lasts from 12 to 16 weeks and over 80% children will show improvement in symptoms44. Eye Movement Desensitization Reprocessing (EMDR) is becoming increasingly wellknown as a treatment for traumatized children and adolescents. EMDR is conducted only with the traumatized patient and treatment occurs in eight phases45. Rather than an exclusive talk therapy focus, EMDR utilizes bilateral eye movement as an external
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stimulus to aid in the reprocessing of traumatic events. The mechanisms surrounding EMDR are not well understood, however in a recent study that incorporated elements of a randomized controlled trial, EMDR was found to be superior to a wait list control group
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in treating PTSD symptoms over an 8 week period46. Practice/Clinical Implications for PAG Providers
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Increased awareness of the prevalence and impact of PTSD on patients has
implications for clinical practice. Some of these are more general, while some
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specifically address issues unique to the PAG clinician (Table 1). General Issues Screening
Screening for mental health concerns should be a regular occurrence in primary care
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settings. The American College of Obstetricians and Gynecologists (ACOG) strongly recommends that all women be screened for a history of sexual abuse and sexual coercion and the American Academy of Pediatrics (AAP) recommends regular
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screening of adolescents for depression and suicidality47,48. Many providers also screen
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for anxiety, substance abuse, and interpersonal violence. Given the incidence of PTSD among children and adolescents and its impact on patient care, PAG clinicians may want to consider the addition of a PTSD screen in their standard practice. There are a variety of very brief tools that can be used to screen for PTSD. However, most of these are validated in primary care populations over the age of 18. Table 2 lists the screening tools recommended by the National Center for PTSD for adults 18 and over. These measures can be downloaded and other useful information can be found at
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the National Center for PTSD’s website: (http://ptsd.va.gov). The AAP has recommended several mental health tools that are appropriate for assessing PTSD in children and adolescents. They are found in Table 3 and more information can be found
initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf
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on the AAP’s website: http://www.aap.org/en-us/advocacy-and-policy/aap-health-
Unique factors related to specific clinical practices are important to consider when
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determining which screening tool to use. Some tools are only available in English, while others are available in Spanish or other languages. Length of time to complete the
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screen, number of questions asked, education level of the clinic population, and whether or not parents are present or should be included in the screening are important factors to review. See tables 2 and 3 for specific information for each tool. With increased screening will come increased identification of PTSD and likely
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increased identification of sexual abuse. As a result, screening implementation must be carefully thought out and must include time built into visits to address screening results with patients as well as parents if appropriate. Also, a plan for referrals should include
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specific community resources where patients can access mental health treatment, as
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well as education of parents and patients on importance of following up with referrals. Chaperones
Given the physical and psychological symptoms that accompany PTSD, the PAG provider must consider how these will impact recommendations, interventions, and procedures. Male PAG providers in particular must consider the impact of their gender on patients, as almost 99% of offenders of sexual assaults in single victim incidents are male49. While the majority of providers have a chaperone present during physical
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exams, it is imperative to do so when treating patients with PTSD. ACOG recommends having a chaperone when evaluating victims of sexual assault and the AAP recommends having a chaperone during all breast, genital, and anorectal exams50,51. A
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chaperone provides the patient with reassurance that nothing inappropriate is going to happen. In addition, this protects the provider from claims of inappropriate sexual behavior or abuse.
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Boundaries
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It is important for the PAG clinician to be aware of boundaries and limit setting while working with this population. These patients’ boundaries were violated by the abuse they experienced and they may not often be aware of their own violations of others’ boundaries. Based on our clinical experience as a PAG provider and psychologist, patients may ask inappropriate questions about their providers’ personal life, request
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personal phone numbers so they can have immediate contact if their symptoms worsen, ask for treatment that the PAG clinician wouldn’t normally provide (refilling pain medications over the phone, more visits than is medically indicated), or request
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procedures that the PAG clinician wouldn’t typically recommend. It is important to create
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a plan that is clearly communicated to the patient and refer back to this plan often. Giving a written copy of the plan to the patient that they can regularly refer to is a helpful tool to maintain the boundary for the patient and the clinician
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Gynecological Issues Contraception
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As mentioned previously, patients with PTSD following sexual abuse are less likely to use condoms, have higher rates of involvement in prostitution, and are more likely to become pregnant15,16. PTSD, and associated disorders such as depression and other
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anxiety disorders, impact executive functioning, concentration, and attention, making it more difficult for these patients to attend to and follow instructions52. As a result,
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patients may have difficulty understanding how to use OCPs, the ring, or the patch appropriately. Simplified, written instructions may be helpful for these patients, as well as frequent review at medical visits.
Although there is no literature to support this, in our clinical practice as a PAG provider
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and a psychologist working with PAG patients we have found that some patients with PTSD find the insertion of an IUD highly traumatizing and this should be kept in mind during the PAG clinician’s discussion of long acting reversible contraceptives (LARC).
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Implants seem to have high levels of acceptability to patients – they aren’t inserted into the vagina and don’t cause vaginal pain. Depo-Provera shots also seem to be
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acceptable to these patients and, while they still have to remember to return to clinic every 12 weeks, they do not have to remember to take a daily pill with associated instructions for what to do when they miss a pill. Sexually Transmitted Infections (STIs) Patients with PTSD often have higher rates of STIs than peers with no history of PTSD53. This may due to a variety of factors. Women who were victimized as
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adolescents are more likely to be sexually victimized again, which puts them at increased risk of STIs. Girls with histories of revictimization are more likely to participate in or be forced into prostitution, thereby increasing their risk15. They may date partners
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who are abusive and who refuse to use condoms or allow the patient to use birth control, thereby increasing their risk of STIs as well as pregnancy54. This perspective can allow PAG clinicians to better understand the factors that underlie their patients’
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refusal or inability to protect themselves during sex, as well as help providers express more patience and empathy.
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Chronic Pain
Regardless of physical findings, care must be given to ensure that patients feel that their perception of pain is understood. It is often helpful to include a simple explanation of the neurobiology of pain, specifically how PTSD increases the perception of and
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sensitivity to pain. This is always necessary in cases where there is known trauma, and can be a useful general practice as many patients have undisclosed histories of abuse. This must be done respectfully, however, so as not to unintentionally communicate that
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pain is “in her head” and with the knowledge that the increased pain patients experience
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is a real phenomenon.
Conclusion
PTSD after sexual abuse is a widespread occurrence with sequelae that can impact patients’ physical and emotional well being. The traumatic events themselves can cause actual physical pain, and the changes that occur in the brain as a result of PTSD can lead to increased reactivity and sensitivity to pain. PTSD is also strongly correlated with depression, which often involves pain as one of its symptoms. Gynecological complaints
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are increased in patients with PTSD following sexual abuse. These patients also engage in more high risk sexual behaviors and, because they place themselves in high risk situations, are at increased likelihood of being victimized again.
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Many patients with mental health concerns will never see a mental health care provider, making PAG clinicians a primary source of mental health treatment. It is imperative then for PAG clinicians to become aware of the signs, symptoms, and physical indicators that
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point to PTSD. It is also critical for providers to become comfortable asking screening questions or using PTSD screening tools to better identify these patients. When
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providers are more cognizant of the role that PTSD after sexual abuse plays in the lives of their patients, interventions can be targeted to best meet the needs of patients, while
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also limiting the burden on PAG clinicians.
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1. .Kimerling R, Ouimette P, Wolfe J, eds. Gender and PTSD. New York, NY: Guilford Publications; 2002 2. Ouimette P, Cronkite R, Henson BR, Prins A, Gima K, Moos RH. Posttraumatic stress disorder and health status among female and male medical patients. J Trauma Stress. 2004;17:1–9 3. Kimerling R, Calhoun KS. Somatic symptoms, social support, and treatment seeking among sexual assault victims. J Consult Clin Psychol.1994;62:333–340 4. Irwin C, Falsetti SA, Lydiard RB, Ballenger JC, Brock CD, Brener W. Comorbidity of posttraumatic stress disorder and irritable bowel syndrome. J Clin Psychiatry. 1996;57:576 –578 5. Seng JS, Oakley DJ, Sampselle CM, Killion C, Graham-Bermann S, Liberzon I. Posttraumatic stress disorder and pregnancy complications. Obstet Gynecol. 2001 Jan;97(1):17-22. 6. Seng JS, Graham-Berman SA, Clark MK, McCarthy AM, Ronis DL. Posttraumatic stress disorder and physical comorbidity among female children and adolescents: results from service-use data. Pediatrics. 2005 Dec;116(6):e767-76. 7. Hickling EJ, Blanchard EB, Silverman DJ, Schwartz SP: Motor vehicle accidents, headaches, and post-traumatic stress disorder: assessment findings in a consecutive series. Headache 1992, 32:147–151. 8. American Psychiatric Association: Diagnostic and statistical manual of mental disorders 5th edition, Washington DC, 2013. 9. Breslau N, Peterson EL, Schultz LR (2008). A second look at prior trauma and the posttraumatic stress disorder effects of subsequent trauma: A prospective epidemiological study. Arch Gen Psychiatry. 2008 Apr;65(4):431-7 10. Intimate partner and sexual violence against women [Internet]. World Health Organization; [updated 2014 November; cited 2015 Feb 2]. Available from http://www.who.int/mediacentre/factsheets/fs239/en/ 11. Fact sheet: The national intimate partner and sexual violence survey [Internet]. Atlanta (GA): Centers for Disease Control and Prevention. [2010; cited 2015 Feb 25]. Available from http://www.cdc.gov/ViolencePrevention/pdf/NISVS_FactSheet-a.pdf 12. Teitelman AM, Tennille J, Bohinski, JM, Jemmott, LS, & Jemmott B. Unwanted unprotected sex: condom coercion by male partners and self-silencing of condom negotiation among adolescent girls. ANS Adv Nurs Sci. 2011 Jul-Sep;34(3):24359. 13. Ullman SE & Filipas HH. Ethnicity and child sexual abuse experiences of female college students. J Child Sex Abus. 2005 14(3): 67-89 14. Wyatt GE, Loeb TB, Solis B, Carmona JV, Romero G. The prevalence and circumstances of child sexual abuse: Changes across a decade. Child Abuse Negl. 1998 23: 45-60. 15. Miner MH, Klotz Flitter J, & Robinson BE. Association of sexual revictimization with sexuality and psychological function. J Interper Violence. 2006. 21(4): 503– 524 16. Stevens-Simons C, Reichert S. Sexual abuse, adolescent pregnancy, and child abuse. A developmental approach to an intergenerational cycle. Arch Pediatr Adolesc Med. 1994 Jan;148(1):23-7.
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32. Follette VM, Polusny MA, Bechtle AE, Naugle AE. Cumulative trauma: The impact of child sexual abuse, adult sexual assault, and spouse abuse. J Trauma Stress. 1996 Jan;9(1):25-35 33. Albrecht S, Naugle AE. Psychological assessment and treatment of somatization: adolescents with medically unexplained neurologic symptoms. Adol Med: Sate Art Rev 2002 Oct; 13(3):625-641 34. Lipschitz DS, Rasmusson AM, Anyan W, Cromwell P, Southwick SM. Clinical and Functional Correlates of Posttraumatic Stress Disorder in Urban Adolescent Girls at a Primary Care Clinic. J Am Acad Child Adolesc Psychiatry 2000 Sep; 39(9): 1104-1111. 35. Rushton J., Bruckman D, Kelleher K. Primary care referral of children with psychosocial problems. Arch Pediatr Adolesc Med 2002 June; 156(6): 592-598. 36. Huemer J. Erhart F. Steiner H Posttraumatic Stress Disorder in Children and Adolescents: A Review of PsychopharmacologicalTreatment. Child Psychiatry Hum Dev 2010; 41:624–640 37. Cohen J, Mannarino A, Rogal S Treatment practices for childhood posttraumatic stress disorder. Child Abuse Negl. 2001; 25:123–135 38. Stoddard FJ, Usher CT, Abrams AN. Psychopharmacology in pediatric critical care. Child Adolesc Psychiatr Clin N Am. 2006; 15(3):611–655 39. Cohen JA, Mannarino AP, Perel JM, Staron V. A pilot randomized controlled trial of combined trauma-focused CBT and sertraline for childhood PTSD symptoms. J Am Acad Child Adolesc Psychiatry 2007;46:811–9. 40. Robb AS, Cueva JE, Sporn J, et al. Sertraline treatment of children and adolescents with posttraumatic stress disorder: A double-blind, placebocontrolled trial. J Child Adolesc Psychopharmacol 2010;20:463–71. 41. Robert R, Tcheung WJ, Rosenberg L, et al. Treating thermally injured children suffering symptoms of acute stress with imipramine and fluoxetine: A randomized, double-blind study. Burns; 2008;34:919 –28. 42. Lewis CC, Simons AD, Nguyen LJ, et al. Impact of childhood trauma on treatment outcome in the treatment for adolescents with depression study (TADS). J Am Acad Child Adolesc Psychiatry 2010;49:132– 40. 43. Steiner H, Saxena KS, Carrion V, et al. Divalproex sodium for the treatment of PTSD and conduct disordered youth: A pilot randomized controlled clinical trial. Child Psychiatry Hum Dev 2007;38:183–93. 44. Saunders, B.E., Berliner, L., & Hanson, R.F. (Eds.). (2004). Child Physical and Sexual Abuse: Guidelines for Treatment (Revised Report: April 26, 2004). Charleston, SC: National Crime Victims Research and Treatment Center. 45. Shapiro, F: Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2nd ed.). New York, Guilford Press, 2001. 46. Ahmad A, Sundelin-Wahlsten V. Applying EMDR on children with PTSD. Eur Child Adolesc Psychiatry. 2008 Apr;17(3):127-32. 47. American College of Obstetricians and Gynecologists: Guidelines for women's health care: a resource manual. 3rd ed. Washington, DC, ACOG, 2007ACOG Number 554, February 2013. Committee on Health Care for Underserved Women. Reproduction and sexual coercion. 48. Williams SB, O'Connor EA, Eder M, Whitlock EP. Screening for Child and Adolescent Depression In Primary Care Settings: A Systematic Evidence Review
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for the U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US); 2009 Apr 49. Greenfeld LA. Sex offenses and offenders: An analysis of data on rape and sexual Assault. Bureau of Justice Statistics. 1997. 50. Committee Opinion: The American Congress of Obstetrics and Gynecology committee opinion on sexual assault [Internet]. Washington DC [2014 April; cited 2015 March 15]. Available from http://www.acog.org/Resources-AndPublications/Committee-Opinions/Committee-on-Health-Care-for-UnderservedWomen/Sexual-Assault. Accessed 2 June 2015 51. Policy Statement—Use of Chaperones During the Physical Examination of the Pediatric Patient Pediatrics 2011;127:991–993 52. M, Polak AM, Witteveen AM, Denys D. Executive function in posttraumatic stress disorder (PTSD) and the influence of comorbid depression. Neurobiol Learn Mem. 2014 Jul;112:114-21 53. van Roode T, Dickson N, Herbison P, Paul C. Child sexual abuse and persistence of risky sexual behaviors and negative sexual outcomes over adulthood: Findings from a birth cohort. 2009 Mar;33(3):161-72 54. Committee Opinion: The American Congress of Obstetrics and Gynecology committee opinion on reproductive and sexual coercion [Internet]. Washington DC [2014 April; cited 2015 March 15]. Available from http://www.acog.org/Resources-And-Publications/CommitteeOpinions/Committee-on-Health-Care-for-Underserved-Women/Reproductiveand-Sexual-Coercion Accessed 2 June 2015 55. Beck AT, Steer RA, Ball R, Ciervo CA, Kabat M. Use of the Beck Anxiety and Beck Depression Inventories for primary care with Medical Outpatients. Assessment. 1997; 4: 211-19. 56. Prins A, Ouimette P, Kimerling R, Cameron RP, Hugelshofer DS, Shaw-Hegwer J, Thrailkill A, Gusman FD, Sheikh JI. The primary care PTSD screen (PCPTSD): development and operating characteristics. Primary Care Psychiatry. 2003; 9: 9-14 57. Prins A, Ouimette P, Kimerling R, Cameron RP, Hugelshofer DS, Shaw-Hegwer J, Thrailkill A, Gusman FD, Sheikh JI. The primary care PTSD screen (PCPTSD): Corrigendum. Primary Care Psychiatry. 2004; 9: 151 58. Lang AJ, Stein MB. An abbreviated PTSD checklist for use as a screening instrument in primary care. Behav Res Ther. 2005; 43: 585-94 59. Breslau N, Peterson EL, Kessler RC, Schultz LR. Short screening scale for DSMIV post-traumatic stress disorder. American Journal of Psychiatry. 1999; 156: 908-11. 60. Davidson, J. (2002). SPAN Addendum to DTS Manual. Multi-Health Systems Inc. New York. 61. Connor K, Davidson J. SPRINT: A brief global assessment of post-traumatic stress disorder. Int Clin Psychopharmacol. 2001; 16: 279-84. 62. Davidson JRT, Colket JT. The eight-item treatment-outcome post-traumatic stress disorder scale: a brief measure to assess treatment outcome in posttraumatic stress disorder. Int Clin Psychopharmacol. 1997; 12: 41-5. 63. Brewin CR, Rose S, Andrews B, Green J, Tata P, McEvedy C, Turner S, Foa EB. Brief screening instrument for post-traumatic stress disorder. Br J Psychiatry, 2002; 181: 158-62. 64. Foa E, Cashman L, Jaycox L, Perry K. The validation of a self-report measure of PTSD: The Posttraumatic Diagnostic Scale. Psychol Assess 1997; 9: 445-51. 65. Foa E. Posttraumatic Diagnostic Scale Manual. Minneapolis, MN: National Computer Systems 1996.
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66. Steinberg AM, Brymer MJ, Decker KB, & Pynoos RS. The University of California at Los Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psychiatry Rep. 2004; 6: 96–100 67. Briere J. Trauma Symptom Checklist for Children: Professional manual. Florida: Psychological Assessment Resources Inc. 1996.
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Table 1
Gynecological Issues
Screening
Contraception
Chaperones
Sexually Transmitted Infections
Boundary Issues
Chronic Pain
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General Issues
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Clinical Implications for PAG Clinicians
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Table 2: PTSD Screening Tools for Adults
4 items
2 minutes
6 items
2 minutes
7 items
18 years and older
3 minutes
4 items
18 years and older
2 minutes
8 items 10 items
3 items 4 minutes
EP AC C
RI PT
Administration and Scoring Time 3 minutes
TE D
Sprint61,62 Trauma Screening Questionnaire63
Age Range (if specified) 17-80
SC
Beck Anxiety InventoryPrimary Care55 Primary Care PTSD screen56,57 Short Form of the PTSD Checklist58 Short Screening Scale for PTSD59 SPAN60
Number of Items 7 items
M AN U
Screening Tool
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Table 3: Pediatric and Adolescent PTSD Screening Tools
Number of Items
Age Range
Administrati on and Scoring Time
Parent Component
Post-traumatic Stress Diagnostic Scale64,65
49
18-65
10-15 minutes
No
UCLA PRSD Reaction Index66
Children :20
Child & Parent: 7-13
25-40 minutes
Yes
Availability in Spanish
RI PT
Screening Tool
No
SC
Yes
(21 items
54 items
8-16
M AN U
Youth: over 13
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Trauma Symptom Checklist for Children67
Youth: 22
15-20 minutes
No
Yes
