The role of community healthcare professionals in discussing sexual assault experiences during obstetrics and gynecological healthcare appointments

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DeMaria, Stephanie Meier, Hannah King, Haley Sidorowicz, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2082063/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 May, 2023 Read the published version in BMC Women's Health → Version 1 posted 8 You are reading this latest preprint version Abstract Background Nearly half of adult women in the US report experiencing sexual assault, with almost one-fifth reporting rape. For many victims of sexual assault, healthcare professionals are the first point of contact and disclosure. The purpose of this study was to understand how healthcare professionals working in community settings perceived their role in discussing sexual violence experiences with women during obstetrics and gynecological healthcare appointments. The secondary purpose was to compare healthcare professionals’ perspectives with those of the patient to determine how sexual violence conversations should occur in these environments. Methods Data were collected in two phases. Phase 1 consisted of 6 focus groups (Sept-Dec, 2019) with women aged 18–45 (n = 22) living in Indiana who sought community-based or private healthcare for women’s reproductive healthcare needs. Phase 2 included 20 key-informant interviews with non-physician healthcare professionals (i.e., NP, RN, CNM, doula, pharmacist, chiropractor) living in Indiana (September 2019-May 2020) who provided community-based women’s reproductive healthcare. Focus groups and interviews were audio-recorded, transcribed, and analyzed using thematic analyses. HyperRESEARCH assisted in data management and organization. Results There were three resulting themes: (1) healthcare professionals’ approaches to screening for a history of sexual violence varied depending on how they ask, what setting they work in, and type of professional is doing the asking; (2) healthcare experiences can compound traumatic experiences and create distrust with survivors; and (3) sexual violence impacts patient healthcare experiences through what services they seek, how professionals may interact with them, and what professionals they are willing to utilize. Conclusions Findings offered insight into actionable and practical strategies for enhancing sexual violence screening and discussions in community-based women’s reproductive health settings. The findings offer strategies to improve by addressing barriers and facilitators among community healthcare professionals and the people they serve. Incorporating healthcare professionals’ and patient experiences and preferences for violence-related discussions during obstetrics and gynecological healthcare appointments can assist in violence prevention efforts, improve patient-professional rapport, and yield better health outcomes. Sexual assault reproductive health qualitative methodologies USA Introduction Nearly half of adult women in the US report experiencing sexual assault, with almost one-fifth reporting rape [ 1 , 2 ], and many cases occur during the postpartum period [ 3 ]. Sexual abuse, in particular, is a risk factor for myriad conditions, including chronic and autoimmune diseases (e.g., irritable bowel syndrome, fibromyalgia, cardiovascular disease, chronic pelvic pain; [ 4 , 5 ], mental health conditions (e.g., anxiety, depression, post-traumatic stress disorder, eating disorders; [ 6 – 14 ], and risky health behaviors (e.g., increased alcohol and tobacco use; [ 8 ]. Sexual assault negatively impacts reproductive and sexual health, with victims being less likely to access and maintain routine gynecological care, including contraception use [ 3 , 15 ], and having an increased risk for repeat unintended pregnancy and abortion [ 16 – 23 ]. Additionally, victims of sexual assault are more likely to experience sexually transmitted and reoccurring infections [ 15 , 19 , 24 ]. For many victims of sexual assault, healthcare professionals are the first point of contact and disclosure [ 20 , 25 ]. These patients may visit healthcare offices more frequently due to increased health-related needs [ 14 , 26 ], and as a result, spend more money on healthcare services [ 10 , 27 ]. The obstetrician-gynecologist medical community [ 28 ], including the American College of Obstetricians and Gynecologists (ACOG), recommend routine screening for sexual and interpersonal violence during obstetrics and gynecological healthcare appointments [ 29 ]; however, research suggests healthcare professionals rarely screen for sexual abuse or discussed sexual abuse history [ 11 , 14 , 30 , 31 ]. In one recent study, only 2% of women were asked about a sexual assault history by professionals in healthcare settings [ 32 ], which supported additional research noting limited sexual assault-related discussions with unprepared healthcare professionals during routine visits [ 20 , 26 , 28 , 33 – 41 ]. However, patients supported being screened [ 42 – 44 ], noting this helped the patient build trust with professionals and comfort with exam procedures [ 45 , 46 ]. Despite patients’ support for screening, healthcare professionals may not be adequately trained to screen for or have conversations about sexual assault experiences [ 39 , 47 ]. As a result, they often respond to disclosures rather than initiate discussions [ 48 – 50 ]. Making sexual assault screening a routine part of obstetrics and gynecological healthcare appointments may reduce distress or discomfort during examinations [ 39 , 51 ]. Routine screening among pregnant and non-pregnant patients and subsequent intervention have demonstrated positive health outcomes, including early identification of unmet needs for timely referrals [ 52 ], decreased depression and improved pregnancy outcomes [ 53 ], and greater follow-up support [ 54 ]. However, more education may be needed for healthcare professionals to emphasize the importance of screening [ 55 ], make appropriate referrals to community-based resources [ 55 , 56 ], and handle the dynamic responses from patients who have experienced sexual assault. The absence of protocols and policies surrounding sexual assault screening presents a deficiency within obstetrics and gynecological and primary care settings, and it is important to understand how healthcare professionals navigate these insufficiencies. Further, there is a need for trauma-informed care approaches within obstetrics and gynecological healthcare [ 45 , 49 , 50 , 57 , 58 ] that go beyond the immediate care after an act of violence and extend to the long-term medical consequences, especially those impacting sexual and reproductive health [ 57 , 59 ]. In the gynecological setting, trauma-informed care, which requires professionals to understand the broad impacts of trauma and treat patients accordingly [ 60 ], could include changes to how they capture patient history, solicit consent before conducting physical exams, maintain confidentiality of information, and connect patients to wraparound and interdisciplinary team-based services [ 8 , 59 , 61 ]. Trauma-informed care has two components: universal trauma precautions and trauma-specific care [ 50 ]. Universal trauma precautions are implemented in all settings regardless of patient trauma history [ 57 ]. Utilizing this strategy and its precautionary measures may help build trust with patients [ 50 ]. Establishing trust is critical because victims of sexual assault are more likely to share their experiences if they have a positive relationship with their healthcare professional [ 62 ]. The second component, trauma-specific care, occurs when professionals are aware of a history of trauma and modify their approach to care, such as providing interprofessional care, delivering more targeted services, and using a holistic approach [ 50 ]. Trauma-specific care may also emphasize empowerment, social connectedness, and self-esteem [ 63 , 64 ]. Patient-centered, trauma-informed care during obstetrics and gynecological healthcare appointments may create outlets for disclosure and improve overall reproductive health and wellbeing [ 20 ]. Screening may be particularly important during the COVID-19 pandemic as the social distancing requirements have increased women’s risk for violence- and mental-health-related concerns [ 65 ]. Due to the wide range of strategies and the individuality of screening for sexual assault, it is necessary to understand how healthcare professionals are interacting with their patients in the context of sexual assault assessments and care, along with their perspectives on their approaches. Study Purpose The purpose of this study was to understand how healthcare professionals working in community settings perceived their role in discussing sexual assault during obstetrics and gynecological healthcare appointments. A secondary purpose was to compare healthcare professionals’ perspectives with those of the patient to determine how sexual assault conversations are occurring within these settings. Method Focus group discussions with reproductive-aged women and in-depth interviews with non-physician healthcare professionals practicing in community settings were conducted as part of a larger study on reproductive healthcare in community settings [ 66 ]. The discussions offered insight into group dynamics, which can be particularly impactful when exploring shared experiences among participants [ 67 ]. Because women’s reproductive health decisions may depend on lifestyle and context, focus groups provided an effective way to understand how women constructed sexual assault in the broader context of their lives [ 67 ]. The interviews offered insight into how sexual assault-related discussions occur within obstetrics and gynecological healthcare appointments. The first author’s university approved all protocols and procedures for this study (IRB-2019-160). Focus Group Discussions with Reproductive-Aged Women We completed six semi-structured focus groups with 2–9 participants each ( n = 22), ranging 88–131 minutes, in September-December 2019. Women were eligible to participate in the study if they were 18–45 years of age and had ever sought reproductive healthcare at a community health center or program in Indiana. We recruited through flyers at community health centers and in public locations (e.g., community centers, libraries), emails through community health service listservs, and shareable social media advertisements along with in-person recruitment with onsite sign-up sheets. Community partners assisted recruitment efforts in three Indiana counties (Tippecanoe, Montgomery, Marion), which were selected based upon demographic and geographic makeup (i.e., race/ethnicity, rurality), established connections, and convenience. Theoretical and snowball sampling, which included referrals from participants for other eligible women, improved data robustness and increased community member inclusion [ 68 ]. Following each focus group, participants completed an anonymous demographic survey. Focus groups were conducted in locations convenient to the participants and researchers (e.g., reserved, private conference room in a community building). All participants received a $ 25 gift card to compensate their time, and all participants provided informed consent for participation and audio-recording. Each focus group was led by a moderator (the second author) and a co-moderator who were both trained in graduate-level qualitative methodology. All discussions were conducted using a semi-structured protocol, allowing participant experiences and social dynamics to drive the conversation and researchers to explore unique perspectives, novel experiences, and shared knowledge [ 67 , 68 ]. Focus groups began with general questions about participants’ health to build rapport and facilitate inter-participant discussions [ 68 ]. Researchers then transitioned into discussing reproductive health experiences and sexual assault perspectives (Table 1 ). Focus groups continued until data reached theoretical saturation (i.e., when study categories and themes were stabilized and reinforced rather than further explained with incoming data; [ 69 ]. Participant characteristics are noted in Table 2 . Table 1 Focus group and interview questions FOGUS GROUP QUESTIONS FOCUS GROUP PROBES How might sexual violence affect how women make decisions about their body? For example, about birth control or pregnancy? Do you think this would affect women? Why or why not? What about coercive behaviors by a partner, such as deliberately breaking a condom or being convinced to do something they didn’t want to do? Who do you think has control over women’s choices about their health, specifically their reproductive and sexual health? Why? Have you or someone you know ever had an experience with sexual abuse or violence that affected decisions you made about your reproductive or sexual health choices (e.g., birth control, pregnancy, etc.) How? Has a healthcare provider ever asked you or someone you know about sexual violence or sexual abuse experiences when talking about sexual or reproductive health? Do you think healthcare providers should ask about this? Why or why not? Do you think this would be a good thing, a bad thing? Why or why not? If yes, how did this make you feel? If not, do you wish they would have? Why or why not? INTERVIEW QUESTIONS INTERVIEW PROBES What do you perceive is the provider’s role in discussing sexual violence experience with women in community reproductive healthcare? Why do you think this? Do you think these experiences play a role in women’s reproductive health decision-making? Why or why not? Do you think these experiences are important in community health settings, specifically? Why or why not? Have you ever discussed a patient’s sexual violence experience during a reproductive health consultation? Why or why not? [if yes] Please describe what leads to these conversations? [if yes] How do you broach the subject of sexual violence with women? [if yes] How do these conversations go? Why do you think so? [if no] Can you share why you haven’t had these conversations? Table 2 Focus group participant characteristics n = 22 Age 25.8 ± 5.3 Race Ethnicity White/Caucasian 12 (54.5%) Black/African American 7 (31.8%) Education Some College or Undergraduate Degree 13 (59.1%) Graduate Degree 5 (22.7%) Employment Student 10 (45.5%) Full-Time 11 (50.0%) Insurance Private 17 (77.3%) Public 3 (13.6%) Relationship Status Single 19 (86.4%) Primary Birth Control None 8 (36.3%) Pill 4 (18.2%) IUD 4 (18.2%) Condoms 4 (18.2%) Had Been Pregnant 6 (27.3%) Listed as n(%) or Mean ± Standard Deviation. Items that do not add up to 100% reflect missing data. In-Depth Interviews with Healthcare Professionals We conducted 20 in-depth interviews with non-physician healthcare professionals (i.e., registered nurses (RN), nurse practitioners (NP), certified nurse-midwives (CNM), clinical pharmacists, doulas, and a chiropractor) who provided reproductive healthcare in Indiana (September 2019-March 2020). Inclusion criteria were: 1) working in a community healthcare setting, and 2) being a non-physician healthcare professional. The chiropractor was included because she served in community health settings and treated pregnant and postpartum women in concert with CNMs and doulas. Interviewees were recruited via purposive and snowball sampling, including email invitations to healthcare professionals from community partners (i.e., office managers at clinics, agency directors, public health practitioners). Interviews continued until data saturation was reached for each thematic category [ 70 , 71 ]. Interviews occurred at the participant’s convenience, either in person or via phone. All participants provided informed consent for participation and audio-recording. Interviews were audio-recorded and lasted between 49 and 91 minutes. Interviews were conducted by the second author and followed a semi-structured approach allowing interviewees to present novel concepts and discuss their experiences and knowledge holistically [ 68 , 69 ]. Interviews began with rapport-building questions to enhance comfort and sharing before inquiring into community-based reproductive healthcare provision experiences. Following a discussion of patient-care experiences, the interviews transitioned to sexual assault, including perceived role of healthcare professionals in having sexual assault-related conversations (Table 1 ). All participants completed a brief demographic survey (Table 3 ) at the end of the interview, and they did not receive an incentive for participating. Table 3 Interview participant characteristics n = 20 Gender Woman Man Age 19 (95.0%) 1 (5.0%) 39.7 ± 12.7 Years in Women’s Reproductive Healthcare 9.5 ± 8.7 Years Serving Current Community 11.2 ± 10.3 Healthcare Organization Type Community-Based Program 10 (50.0%) Health System 3 (15.0%) University Affiliated 2 (10.0%) Private Organization/Agency 5 (25.0%) Professional Title Nurse Practitioner 7 (35.0%) Registered Nurse 3 (15.0%) Certified Nurse Midwife 2 (10.0%) Nurse Practitioner/Certified Nurse Midwife 1 (5.0%) Clinical Pharmacist 3 (15.0%) Doula 3 (15.0%) Pregnancy & Postpartum Chiropractor 1 (5.0%) Specialty Primary/Family Practice 7 (35.0%) Obstetrics/Gynecology 13 (65.0%) Race Ethnicity White/Caucasian 18 (90.0%) Latino/a 1 (5.0%) Black/African American 1 (5.0%) Education Associate’s Degree/Some College 3 (15.0%) Undergraduate Degree 1 (5.0%) Graduate Degree 16 (80.0%) Location Urban 12 (60.0%) Rural 8 (40.0%) Listed as n(%) or Mean ± Standard Deviation Data Analysis We utilized thematic analysis, a widely used, accessible, and flexible framework for analyzing qualitative data through identification, organization, and analysis in systematic phases [ 72 , 73 ]. First, we conducted immersive, full content review to ensure familiarity with all data [ 72 ]. During this phase, we noted immediate patterns or ideas for potential codes and themes [ 72 ]. Following familiarization, we utilized a deductive/inductive approach for codebook development to allow greater representation of the data during the coding process [ 74 , 75 ]. Initial codes were generated deductively and compiled into a preliminary codebook draft [ 75 ]. The inductive component permitted us to modify or add codes to better capture emerging themes from participant responses [ 75 ]. Coding was performed using HyperRESEARCH 4.5.1 [ 76 ]. Multiple rounds of coding were conducted until saturation was reached (i.e., no additional new codes were being added to the data set) [ 72 ]. Data were then collated into potential themes and subthemes by the first, third, and fourth authors. Theme development was data-driven and closely reflected participant responses [ 77 ]. Resulting candidate themes were reviewed by all co-authors. We thoroughly and collaboratively discussed and analyzed individual themes and incorporated relevant subthemes to provide structure and differentiate levels of meaning [ 72 ]. Any discrepancies were resolved via consensus discussion and data review until final themes were fully agreed upon. Results There were three resulting themes: (1) healthcare professionals’ approaches to screening for a history of sexual assault varied depending on how they ask, setting they work in, and type of professional is doing the asking; (2) healthcare experiences can compound traumatic experiences and create professional distrust with survivors; and (3) sexual assault impacts patient healthcare experiences through the services they seek, how professionals interact with them, and type of professional they are willing to see. Quotes are presented with focus group number (FGX) or healthcare professional specialty (e.g., NP, doula, CNM). Screening for Sexual Assault: “I mean it's mainly domestic violence screening… not really sexual assault screening.” (NP) Healthcare professionals described their approach to screening patients about sexual assault. Focus group participants discussed the impact their healthcare professional’s approach had on their healthcare experience. Screening experiences and perspectives . Interviewees had a variety of responses when asked if they screen for a history of sexual assault. One interviewee shared, “For a very first visit, I probably wouldn't even though, you could definitely make an argument that you should.” (NP) Another stated, “I mean it's mainly domestic violence screening… not really sexual assault screening. I don't think… I doubt very many providers ask [sexual assault].” (NP) These professionals’ responses signify the variation in sexual assault screening. Other forms of screening, such as probing questions during in-person exams, were noted. One healthcare professional noted using a questionnaire when one-on-one with a patient, “Typically if I just have a patient in front of me…we have like a little questionnaire thing that we kind of go through.” (NP) Another mentioned discussing the questionnaire and responses once in the exam room, “That's something that we ask about on intake and I'll also broach it again later on, because sometimes they're not comfortable sharing that on intake.” (Doula) Interviewees utilized questionnaires to guide them during the screening process and to prudently navigate sexual assault screening. Their careful navigation of sexual assault screening, and continued efforts while with a patient, illustrate the caution and persistence necessary by professionals when performing sexual assault assessments. Focus group discussions also emphasized an absence of screening for sexual assault, with one participant stating, “I definitely don't remember my doctor that I see regularly asked me anything about.” (FG3) These sentiments were echoed by a professional, “I can't think if I've ever been asked that question in all my years of being a patient.” (NP) Overall, narratives emphasized the lack of sexual assault screening taking place in obstetrics and gynecological appointments while also highlighting healthcare professionals’ experiences during assessments. Context-dependent healthcare. Interviewees discussed how patient-professional dialogue on sexual assault appeared to be reliant on the healthcare setting. One professional stated, “In the ER, and I'm pretty sure this is nationwide, and at Planned Parenthood, I did too. We asked everybody ‘is there anybody hurting you or making you do things that you don't want to do in your life right now?’” (NP) Another echoed a similar experience: So, the experience I, that I've had like in an OB/GYN office, it actually was not something that was asked very often, even if the patient was alone. Which I thought was interesting. Because in the emergency department, you know, we ask every person, men, female. We ask everybody. (NP) These shared experiences by healthcare professionals validate the discussion over the absence of screening for sexual assault within a obstetrics and gynecological healthcare setting. This same professional later shared, “I took that from my emergency room training to that clinic. But it's not part of, it's not necessarily part of like the physicians [standard of care] or anything like that, it's not built in that way.” (NP) This specific professional recognized the need for sexual assault screening within obstetrics and gynecological appointments and elected to implement it themself. Other professionals spoke on how inquiring may be situational, “Those are the ones that really red flags for me that she might be abused or sex trafficking or there might be something deeper going on that, you know.” (Nurse Manager) In place of screening all patients for sexual assault, this professional utilized their intuition when choosing to perform a sexual assault assessment. These discussions with professionals have highlighted the absence of sexual assault screening within obstetrics and gynecological healthcare appointments and illustrated its need as these professionals employed their form of screening depending on the patient they were seeing. Traumatic Healthcare: “The way that a clinical care provider treats a woman in labor can have a huge impact on her life forever. And she doesn't understand that.” (Doula) When discussing how healthcare can become traumatic for some patients, factors impacting this outcome presented themselves in two forms: 1) how healthcare professionals may prevent distressing care and 2) how professionals may be contributing to traumatic experiences in healthcare. Preventing distressing care. Many healthcare professionals shared how they utilize precautionary approaches when interacting with patients and probing on previous experiences. One discussed their method of addressing questionnaire responses, “I would just say you mentioned you know, in your history… like we do have… counseling here if that would be helpful, or is there anything else… you want me to know so that I can best care for you that I can put in the chart?” (CNM) Another professional discussed broaching the conversation of a patient’s previous experiences by inquiring about possible triggers. This healthcare professional stated: Sometimes it is, are there any triggers you have that I should worry about? Because then it's kind of broad, that doesn't necessarily mean sexual triggers. It just means, you know, overall life triggers. Or are there any experiences that you have that you think might make any part of labor and delivery a little bit more challenging for you, kind of again, with those open-ended questions, not necessarily directing it at sexual assault. (Doula) This interviewee outlined how healthcare professionals may approach sexual assault history by situating probing questions within conversations on how to best care for the patient while also showing respect for any sensitivities the patient may have. This interaction allows the professional to delicately collect necessary information for appropriate care while simultaneously building trust with their patient. Another way healthcare professionals may build trust with their patients is how they react to the information they have received. One interviewee shared how she responds to patients after they have revealed sensitive information, “We'll write it on the birth plan… and we'll say we don't want to talk about this at the bottom. Here's this disclaimer… these are their triggers don't say some things… don't say a certain phrase.” (Doula) When speaking on how to ease the process of obstetrics and gynecological exams, one professional shared, “I try to be really vocal through like all of that component for sure.” (CNM) Another shared similar experiences when performing physical examinations, “really letting the woman kind of guide that… and what that looks like and letting them just tell me what's okay and what's not okay, versus me saying, I'm going to check your cervix now.” (CNM) These healthcare professionals highlight their strategies for sensitivity when working with victims of sexual assault. In addition to providing cautionary care, some professionals took it further to ensure their patients felt supported. One interviewee shared their approach: I make sure that every woman knows that you have to give consent for everything. If somebody's saying I'm going to check your cervix. Now you can say No, thank you. And it doesn't matter if they get shi**y about it. If they get hostile with you, you ask for a new nurse until you find one that is willing to respect your wishes. (Doula) Another professional echoed these thoughts saying: Being clear that they know that they can always tell someone to stop any sort of exam… pointing out parts of the process that they can ask to lead instead of having like a provider… physically do like for pap smear, it's a really good example of that, like, patients don't maybe always know that they can insert their own speculum if they want, like that sort of thing. (CNM) Focus group participants discussed cautionary approaches to care, which highlighted similar attitudes previously expressed by professionals. One participant shared, “Maybe just… having the exam itself could trigger stress for them… just always re-stating exactly what they're about to do, what the patient should feel, what the patient will experience and just being very, very thorough.” (FG2) Healthcare professional-induced trauma. As healthcare professionals discussed precautionary care, they also discussed patient outcomes when sensitivities are not considered. One interviewee outlined how a patient may feel if experiences are ignored, “I think it's to find out if they've…ever been assaulted, to know their comfort level. Because, you know… you don't want them to feel like they're being re-assaulted.” (NP) Additionally, another healthcare professional shared, “I mean, that caused a lot of women to suffer post-traumatic stress from their birth… it isn't even about that she had a C section it is about she was violated.” (NM, NP) These two professionals’ thoughts emphasize the necessity of precautionary care to address sexual assault so that patients feel respected in their healthcare experiences. Further driving this point, one interviewee explained to researchers their patient had been previously pressed into an unwanted C-section, “the birth of her previous child was the worst day of her life.” (Doula) This professional continued to tell researchers the patient’s second birthing experience required another C-section, and outlined how the birthing process played out: She went through the C section, entire section with headphones and her hands over her eyes. She refused to look at her babies, she wouldn't look at them in recovery. And that's not because she's a bad mom. It's because she had horrible PTSD from a previous birth experience. And not understanding things like that can be devastating to these moms and it can have an impact on their ability to care for their infants. (Doula) When appropriate and cautionary care is ignored, it can lead to additional painful experiences, increasing patient distress. One interviewee also emphasized the impact professionals’ insensitivities can have on a woman during the birthing process. This professional spoke specifically on women with previous sexual assault history and their birthing process, “Those women tend to want a more hands-off pushing stage, because if there's a bunch of hands inside them, touching them, rubbing them stretching them, it can cause rape flashbacks or sexual trauma flashbacks” (Doula) Another interviewee added to this saying, “The way that a clinical care provider treats a woman in labor can have a huge impact on her life forever. And she doesn't understand that.” (Doula) These narratives demonstrate the weight of ignoring patient sensitivities, priorities, and preferences in their healthcare experiences. In a focus group discussion, one participant echoed the healthcare professionals’ attitudes when sexual assault experiences are ignored, “I mean yeah because you can throw somebody back into traumatic moments by doing things like if they don't know.” (FG1) In addition to the discussion of healthcare professional-induced trauma, interviewees spoke of patient consent and the distrust they may have toward professionals for forcing services. Some participants highlighted how their colleagues ignore patient choice. Two separate professionals shared similar sentiments on cervical exams for women with one stating, “I don't think these physicians realize what they're doing to these women and that they are abusing them or, you know, going and doing a vaginal exam, all these unnecessary vaginal exams on women that the women think that they have to submit to.” (Doula) Another healthcare professional shared with researchers: I have a lot of clients who will deny cervical exams to check for progression of labor, one because it really doesn't get that much useful information. The cervix isn't a crystal ball, you can go from zero to 10 in five minutes, or you could go from nine to 10 in six hours… Sometimes it can, you know, in certain situations, but as a rule of thumb, checking somebody dilation every two hours, isn't really that beneficial or evidence-based… for those clients, they because the feeling of somebody else going inside their vagina can be very triggering to them. (Doula) Adding to this, one interviewee shared, “They tend to deny cervical exams. And then there's this hostility with the providers, if they're not understanding well, ‘I want this information,’ and the client then not feeling comfortable enough to say, ‘well, this is why I don't want this.’” (Doula) These healthcare professionals stress the significance of patient consent and choice when interacting with any patient whether they have a history of sexual assault or not, as these deliberate acts could inflict harm and create a culture of distrust. In one focus group, the discussion of unreceptive professionals presented itself when one participant described being asked about a history of sexual assault, “that question [about sexual assault history] caught me off guard and then I had like a very traumatizing experience too, because the doctor was like aggressive with it. And, you know, I feel like how the question was asked would have definitely changed that experience.” (FG6) These narratives highlight the importance of interactions with patients, patient choice, and the way healthcare professionals approach screening and services. Impact on overall care. “Some of them won't even go seek healthcare.” (NP) Healthcare professionals described the impact a patient’s history of trauma has when providing care, and the long-term implications that stem from it. Focus group participants continued to describe the discomfort that can arise in healthcare after previous traumatic experiences. Influence of trauma on health. As professionals discussed the impact sexual assault may have on a patient’s healthcare it became apparent that unaddressed trauma appeared to impact overall health. Many interviewees discussed patient discomfort and hesitancy in seeking care while also citing the limits trauma places on care: It prevents them from coming in or, you know, kind of limits them on contraception options… they'll usually tell us, some people will talk about it. Some people will just say, ‘you know, I've had trauma in my past and I do not want to come into the office.’ (Clinical Pharm Specialist) Healthcare professionals also described the amplified discomfort patients with previous sexual assault experience may feel due to routine reproductive health examinations. One interviewee also mentioned the mental health toll, “yeah panic attacks. Either like feeling uncomfortable with exams, who's in the room you know who touches them, cares for them?” (CNM) One professional emphasized the distress certain forms of contraception may have for victims, “let's say the NuvaRing most women with trauma regarding like their vagina don't really want to remove and insert something you know, like, regularly from their vagina, vulva, so I think it definitely can affect like how quick they are to seek care.” (CNM) This interviewee continued to explain, “If they feel like they're going to be required to, you know, have a vaginal exam or something breast exam, that kind of stuff, too. I'm sure, it’ll be traumatic as well.” (CNM) These professionals clarified the impact sexually violent experiences have on a patient’s health by citing hesitancy seeking care, and the fear connected to examinations. Healthcare professionals further emphasized this point noting the physical health implications of sexual assault trauma. One interviewee stated, “they would come in a lot with you know, decreased libido problems or they would be concerned that their thyroid wasn't working right or whatever, because they just had this aversion to having sex and they just didn't like sex because they had had a bad experience.” (NP) For this professional, knowing a trauma response was impacting the patient’s health was important in delivering adequate care. Healthcare professionals continued to list the impacts sexual assault experiences have on healthcare; some citing issues related to pregnancy, such as “they may not want to breastfeed or so or like having cervical exams may be very uncomfortable for them” (Doula) and: Some of it is a power thing to a lot of women that I've seen that are domestic abuse survivors are more apt to want to have unmedicated births because they feel like it's a challenge. It's an empowering thing. They can say they did something really hard. And it kind of makes them feel better about themselves makes them feel stronger. (Doula) Professionals’ experiences with patients highlight the impact traumatic experiences have on a patient’s health, the services they seek, and how care may be delivered. Focus group discussions also revealed how sexual assault can impact patient decision-making and overall health: I know people who, like felt like they needed to be on some sort of hormonal birth control. Like they were sexually assaulted, and the person didn't use a condom or like, if they had a history of that happening and they didn't want that to happen again. They made sure they were on something that they could rely on. (FG6) The similarities between healthcare professionals’ interactions with patients and the experiences voiced by focus group participants only further emphasize the overall impact sexual assault can have on obstetrics and gynecological health. Professional Interactions. Healthcare professionals emphasized the importance of knowing about a patient’s history of sexual assault so they may provide better care. One interviewee shared, “these are things that can kind of clue you into, okay, there's something else here. It is surprising how many women in this context, once you build a relationship with them, will tell you.” (Doula) Yet some professionals noted not being equipped to handle the information, with one sharing: I think there's a lack of communication as far as you know, or education, I should say, as far as okay, once you ask that question, they say ‘yes’ and then what, you know? what, what should we say? Or how should we say it? Or there's really no education for providers as what we're supposed to do, you know, once they say ‘yes’ to that. (NP) Another professional shared how they utilize resources, “we definitely can be a supportive person to talk to, we always suggest we would refer out to a therapist if they weren't already utilizing one. But we have resources, you know, at our disposal to get them to the right person.” (Doula) In addition to offering resources and support, professionals may discuss other options in response to the information provided, with one interviewee noting: I just kind of asked her, like, I would like to put some information in the chart so that people are sensitive to what has happened to you in the past. So, if there's any, you know, and I don't have to put I can put in there, whatever you want people to know, or don't want them to know, however you want me to put it in there just so that they like that you don't want lots of actual exams that you don't want to male provider, those types of things. (CNM) In these conversations with professionals, it was described how and what issues of communication may arise when these situations go unaddressed. One explained the responses to patients who may have unreported trauma experiences: You see fight or flight for those people in situations, but to a clinician are everyday things so they don't understand what's happening… of course that it escalates because the clinician thinks they’re being ignorant or negligent or non-compliant or you know, and no, you have a terrified person. (NM, NP) Within the focus groups, one participant discussed their thoughts on the importance of healthcare professionals in listening and communicating. One focus group participant shared, “you know what we can get from this is being really good at communicating with your patient. I think that's more vital than anything and just like trying to be really empathetic and focusing on like, making them feel comfortable but also in a way that's encouraging them.” (FG2) This participant illustrated the importance of patient-professional communication in these situations so professionals may establish relationships with patients to help guide the care they receive. Male Healthcare Professionals. Interview and focus group participants frequently addressed male professionals’ understanding of sexual trauma and how it presents itself in healthcare. An interviewee shared: One male provider I have talked to before and I used the term traumatic birth and he got really upset. He said, ‘I'll show you trauma. If the baby dies, it's trauma. If the mom has to have a hysterectomy, it's trauma’ and he got really upset and I'm like, ‘No, I understand those things are trauma but what I'm telling you is there's traumas that you can't see, that you can't quantify. And you're not caring about those traumas, and those have an impact on life’. (Doula) While this participant highlighted a lack of understanding this male health professional had, another shared a similar experience of misunderstanding: “I think honestly, he might have just thought it was like his eyes on the patient were enough of a screening.” (NP) While discussing male professionals’ understanding of trauma care, the narrative turned to the capacity of male professionals in addressing trauma when presented with it. One interviewee shared how a patient’s healthcare history suggested a possible trauma experience: I recently had someone come to me for a pap smear, who had been seen at like a local community health center, mostly and kind of like jumped around a lot and her primary care, it was male, and his note said something like ‘she prefers a female to do her pap smear’ and I like looked through history, and she had had an elective abortion at age 13. And so, like I started off the office visit, just, you know, saying it like, it's okay if, she was like in her fifties, like, it's okay, if you don't want to talk about this, but I just wanted to know, since part of this exam will be a pelvic exam if you've ever been sexually abused, and if that's something that I need to know about to be able to complete your exam. (CNM) The healthcare professional continued to describe the response of the patient, reporting: “She had been and told me all about it, you know, as a child and the abortion that she had, and she told me that I'm the first healthcare provider who's ever asked her that.” (CNM) While male professionals’ understanding and attention toward sexual assault was often discussed, the comfortability that female survivors have with male professionals presented itself just as frequently. One interviewee shared, “She just admitted to me that she had been raped in the past. And she was asking if there were any male providers that I was, you know, just educating there, there were not.” (CNM) This professional also shared a similar experience with a different patient: So when you come in for labor and delivery, you know, is there anything that you do or don't want and it's like I don't want a man or I don't want a lot of vaginal exams, or I don't want you know, this this and this.... (CNM) These narratives indicate the sensitivity surrounding male professionals when accessing healthcare. Focus group participants shared similar attitudes as well. One participant stated: I'm sure that play like a huge part in like, whether they choose a female or male doctor. You know, if it's a woman who's been raped by a man like she's probably not going to want a male doctor, right and vice versa. Yeah. Huge role in future healthcare decisions. (FG2) Another participant shared their thoughts on male professionals, which echoed previous narratives on male professionals screening for sexual assault, “A man wouldn't think to ask that cause he's not a woman.” (FG3) Overall, there was an overlapping perception among this sample of both professional and non-professional participants that male healthcare professionals struggle not only to provide a safe environment for survivors to share their experiences but also to understand traumatic experiences and adequately address them. Discussion Professionals and patients highlighted the absence of sexual assault screening within obstetrics and gynecological healthcare appointments and illustrated its need, including myriad ways professionals use their screening practices and tools. Participants also noted how professionals can use strategies during routine visits to prevent traumatic experiences. However, instances were also noted where professionals contribute to trauma through the care they provide. These experiences may create distrust among patients and professionals, thus impacting current and future care. Lastly, both interview and focus group participants noted how a history of sexual assault can impact patient-professional communication and rapport, including how a professional’s demographics influence the environment and care quality. Findings revealed healthcare professionals’ and non-healthcare participants’ perceptions and experiences of the impact of sexual assault, including undisclosed sexual assault, on obstetrics and gynecological healthcare. These impacts spanned negative patient reactions during gynecological and obstetric care (e.g., panic attacks, discomfort), reduced follow-up, and impacts on healthcare choices (e.g., choosing not to breastfeed, preferring non-medicated childbirth, contraceptive choice). Prior research has identified reduced healthcare-seeking, follow-up, and suboptimal clinical experiences resulting from sexual assault history [ 3 ], which supports findings from this sample. Though extant literature identified the influence of prior trauma (emotional, physical, or sexual abuse) on contraceptive method choice and continuation [ 3 , 15 ], healthcare professionals also described how sexual assault affected other healthcare decisions. This finding highlights the importance of screening for sexual assault by engaging patients in provider-initiated conversations to discuss patients’ sexual assault history and outline potential needs before, during, and after a healthcare appointment, while ensuring comfort and consent. Building trauma-informed care into obstetrics and gynecological healthcare that is intuitive to patient experiences, needs, and priorities may improve women’s care, health outcomes, and empower women in their gynecological and birth choices [ 45 , 46 ]. Doing so requires equipping healthcare professionals with the language and tools needed to regularly engage women in sexual assault screening in a patient-centered way. By developing and strengthening relationships, healthcare professionals were better able to identify possible sexual assault among their patients and broach conversations about it, as well as make women feel more comfortable sharing. This finding aligns with prior research on the importance of patient relationship on disclosure [ 45 , 46 ]. Providing possible screening verbiage and education for healthcare professionals on what to do after a disclosure is made and how to build this context into a patient’s care continuum is critical for enhancing obstetrics and gynecological healthcare experiences [ 56 ]. Prior work has identified strategies for developing trauma-informed care practice [ 59 ]. For example, some women who experienced sexual assault by a man may desire a woman healthcare professional to avoid re-traumatization, building on prior research suggesting women select their providers to prepare for, navigate, and recover from healthcare experiences if they have experienced prior trauma [ 45 , 46 ]. This is a contextual factor specific to each patient with a history of sexual assault but should be considered when identifying obstetrics and gynecological healthcare needs at the onset of an appointment to ensure a more positive care experience in the long term. One strength of this study was the inclusion of doulas. Doulas may be able to gain additional patient context that a healthcare professional can then use, with patient permission, to increase sensitivity to women’s needs in their birth experience. This aligns with prior work that found women may bring support people to appointments to help them navigate potentially difficult healthcare experiences [ 45 , 46 ]. Thus, opportunities exist to bridge the gap between routine trauma-informed care and current healthcare practice, in addition to building provider-driven trauma-informed care capacity, by including other types of healthcare professionals in women’s care teams. These healthcare professionals (e.g., doulas, clinical pharmacists) can also build these relationships with women and advocate, support, empower, and/or share information─ with patient consent─ during qualifying healthcare appointments to establish consistent, quality care. Limitations and Future Research Results should be interpreted in the context of some limitations. Results may not be generalizable across different populations, including other geographic locations or sociodemographic groups, though these findings may transfer to other contexts and samples. Because of the social nature of focus groups, some participants may not have shared their experiences due to desirability bias. Complete confidentiality could not be guaranteed due to the social environment, and the sample was a convenience sample; healthcare professionals also self-reported their behaviors, which may have led to social desirability and recall bias. Additionally, most professionals were white and female, which aligns with healthcare professional demographics in Indiana, but limits generalizability to other locations. Despite these limitations, this study had many strengths. Qualitative methodology allowed for robust insight into rich experiences. Different healthcare professional-type and community healthcare settings allowed for triangulation of ideas and consistent themes across professional experiences. Varied recruitment strategies also assisted in enrolling healthcare professionals from different women’s reproductive healthcare sub-fields. Interview and focus group guides were reviewed by research experts and healthcare professionals. Future research should further identify what impacts healthcare professionals’ decisions to discuss and screen for a history of sexual assault during obstetrics and gynecological healthcare appointments, beyond those identified in this study, and examine their role in sexual assault prevention and recovery. Additionally, future research should explore the acceptability of the sexual assault screening procedures suggested by participants in enhancing patient involvement in their obstetrics and gynecological healthcare appointments. Implications Community healthcare professionals serve a critical role in discussing sexual assault during obstetrics and gynecological healthcare appointments. Demonstrating listening, even when communication barriers exist, offers professionals one way to ensure patients feel valued, safe, and secure. Inquiring into sexual assault history and consenting prior to engaging with patients may allow professionals to personalize care and support patients who may be traumatized. Healthcare professionals should keep in mind patients may have prior negative healthcare interactions that impact their current views and behaviors. Thus, professionals should facilitate positive engagement for all via communication strategies, such as building quick rapport, refraining from abruptly ending conversations, validating experiences, and engaging in demonstrative listening. Community healthcare professionals may be one touchpoint for connecting victims to care and wraparound services. Conclusions Findings offered insight into actionable and practical strategies for enhancing sexual assault screening and discussions in community-based obstetrics and gynecological healthcare appointments. Incorporating healthcare professionals’ and patient experiences and preferences for sexual assault-related discussions during routine obstetrics and gynecological care can assist in sexual assault prevention and treatment efforts, improve patient-professional rapport, and yield better health outcomes. Declarations Ethics Approval and Consent to Participate: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Purdue University (Approved September 27, 2019. IRB-2019-160). All participants gave written informed consent. Consent for Publication: Not applicable. Availability of Data and Materials: Data and interview guide available by request. Please email Andrea L. DeMaria at [email protected] . Competing Interests: The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. This research was partially funded by the Purdue University Office of Engagement and the Purdue University Health and Human Sciences Undergraduate Research Honors Scholars Program. Additionally, the study was funded by Purdue University internal funds. Authors Contributions: Andrea L. DeMaria : Conceptualization, Analysis, Writing, Editing, Supervision. Stephanie Meier : Conceptualization, Data curation, Analysis, Writing, Editing. Hannah King : Analysis, Writing, Editing. Haley Siderowicz: Analysis, Writing, Editing. Kathryn C. Seigfried-Spellar : Writing, Editing, Supervision. Laura Schwab Reese Writing, Editing, Supervision. Acknowledgments: The authors would like to thank members of the Interdisciplinary Women’s Reproductive Health Collaborative at Purdue University who are not listed as co-authors for their continued support of the project. 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Transforming qualitative information: thematic analysis and code development. Thousand Oaks: Sage Publications; 1998. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 May, 2023 Read the published version in BMC Women's Health → Version 1 posted Editorial decision: Major revision 30 Mar, 2023 Reviews received at journal 14 Mar, 2023 Reviewers agreed at journal 09 Mar, 2023 Reviewers invited by journal 03 Mar, 2023 Editor assigned by journal 01 Mar, 2023 Editor invited by journal 29 Sep, 2022 Submission checks completed at journal 29 Sep, 2022 First submitted to journal 19 Sep, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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DeMaria","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYFCCBBAhwcAPongQIkRokWwgUQsDg8EBYrXwtycf3fBzj4W88e0esw9v22wY+NlzDPBqkTjzLO1mzzMJw213zhjPnNuWxiDZ8wa/FoYbOWY3eA5IMG67kWPMzNt2mMHgBgFb5G/kf7v554CE/eYZYC3/GewJaQGayXYbaEviBgmwlgMMBhIEtBieeWZ2W+aARPKMO8eKGeecS+YB+q4Arxa548nPbr45UGfbP7t5M8ObMjs5YBhuwKsFASQgFA+RypG0jIJRMApGwSjAAABGFkmTh+PRhAAAAABJRU5ErkJggg==","orcid":"","institution":"Purdue University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"L.","lastName":"DeMaria","suffix":""},{"id":140480751,"identity":"c87da699-2f18-4431-8d3d-f523ab6611f7","order_by":1,"name":"Stephanie Meier","email":"","orcid":"","institution":"Purdue University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Stephanie","middleName":"","lastName":"Meier","suffix":""},{"id":140480753,"identity":"11d3b812-1c1a-4032-bd52-ac5ed0b7b78d","order_by":2,"name":"Hannah King","email":"","orcid":"","institution":"Purdue University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hannah","middleName":"","lastName":"King","suffix":""},{"id":140480754,"identity":"51032702-c693-41c2-86c4-65f8bbb3d104","order_by":3,"name":"Haley Sidorowicz","email":"","orcid":"","institution":"Purdue University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Haley","middleName":"","lastName":"Sidorowicz","suffix":""},{"id":140480756,"identity":"17182af2-2399-4ba5-bb62-171ead76ca00","order_by":4,"name":"Kathryn C Seigfried-Spellar","email":"","orcid":"","institution":"Purdue University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kathryn","middleName":"C","lastName":"Seigfried-Spellar","suffix":""},{"id":140480758,"identity":"c1bad920-8f0c-4946-bb51-af8d5cd1ef44","order_by":5,"name":"Laura Schwab Reese","email":"","orcid":"","institution":"Purdue University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Laura","middleName":"Schwab","lastName":"Reese","suffix":""}],"badges":[],"createdAt":"2022-09-19 18:29:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2082063/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2082063/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12905-023-02401-4","type":"published","date":"2023-05-15T20:52:28+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44729126,"identity":"a59ea1f7-1c17-4f3e-92a4-7549a58dd7b8","added_by":"auto","created_at":"2023-10-16 21:13:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":531105,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2082063/v1/e67d43bc-6548-4b4a-9a91-9883e42bcbb9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The role of community healthcare professionals in discussing sexual assault experiences during obstetrics and gynecological healthcare appointments","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNearly half of adult women in the US report experiencing sexual assault, with almost one-fifth reporting rape [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and many cases occur during the postpartum period [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Sexual abuse, in particular, is a risk factor for myriad conditions, including chronic and autoimmune diseases (e.g., irritable bowel syndrome, fibromyalgia, cardiovascular disease, chronic pelvic pain; [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], mental health conditions (e.g., anxiety, depression, post-traumatic stress disorder, eating disorders; [\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], and risky health behaviors (e.g., increased alcohol and tobacco use; [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Sexual assault negatively impacts reproductive and sexual health, with victims being less likely to access and maintain routine gynecological care, including contraception use [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and having an increased risk for repeat unintended pregnancy and abortion [\u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Additionally, victims of sexual assault are more likely to experience sexually transmitted and reoccurring infections [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor many victims of sexual assault, healthcare professionals are the first point of contact and disclosure [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These patients may visit healthcare offices more frequently due to increased health-related needs [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], and as a result, spend more money on healthcare services [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The obstetrician-gynecologist medical community [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], including the American College of Obstetricians and Gynecologists (ACOG), recommend routine screening for sexual and interpersonal violence during obstetrics and gynecological healthcare appointments [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]; however, research suggests healthcare professionals rarely screen for sexual abuse or discussed sexual abuse history [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In one recent study, only 2% of women were asked about a sexual assault history by professionals in healthcare settings [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], which supported additional research noting limited sexual assault-related discussions with unprepared healthcare professionals during routine visits [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan additionalcitationids=\"CR34 CR35 CR36 CR37 CR38 CR39 CR40\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. However, patients supported being screened [\u003cspan additionalcitationids=\"CR43\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], noting this helped the patient build trust with professionals and comfort with exam procedures [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite patients\u0026rsquo; support for screening, healthcare professionals may not be adequately trained to screen for or have conversations about sexual assault experiences [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. As a result, they often respond to disclosures rather than initiate discussions [\u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Making sexual assault screening a routine part of obstetrics and gynecological healthcare appointments may reduce distress or discomfort during examinations [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Routine screening among pregnant and non-pregnant patients and subsequent intervention have demonstrated positive health outcomes, including early identification of unmet needs for timely referrals [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], decreased depression and improved pregnancy outcomes [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], and greater follow-up support [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. However, more education may be needed for healthcare professionals to emphasize the importance of screening [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e], make appropriate referrals to community-based resources [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], and handle the dynamic responses from patients who have experienced sexual assault. The absence of protocols and policies surrounding sexual assault screening presents a deficiency within obstetrics and gynecological and primary care settings, and it is important to understand how healthcare professionals navigate these insufficiencies. Further, there is a need for trauma-informed care approaches within obstetrics and gynecological healthcare [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e] that go beyond the immediate care after an act of violence and extend to the long-term medical consequences, especially those impacting sexual and reproductive health [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the gynecological setting, trauma-informed care, which requires professionals to understand the broad impacts of trauma and treat patients accordingly [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e], could include changes to how they capture patient history, solicit consent before conducting physical exams, maintain confidentiality of information, and connect patients to wraparound and interdisciplinary team-based services [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Trauma-informed care has two components: universal trauma precautions and trauma-specific care [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Universal trauma precautions are implemented in all settings regardless of patient trauma history [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Utilizing this strategy and its precautionary measures may help build trust with patients [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Establishing trust is critical because victims of sexual assault are more likely to share their experiences if they have a positive relationship with their healthcare professional [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. The second component, trauma-specific care, occurs when professionals are aware of a history of trauma and modify their approach to care, such as providing interprofessional care, delivering more targeted services, and using a holistic approach [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Trauma-specific care may also emphasize empowerment, social connectedness, and self-esteem [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatient-centered, trauma-informed care during obstetrics and gynecological healthcare appointments may create outlets for disclosure and improve overall reproductive health and wellbeing [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Screening may be particularly important during the COVID-19 pandemic as the social distancing requirements have increased women\u0026rsquo;s risk for violence- and mental-health-related concerns [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Due to the wide range of strategies and the individuality of screening for sexual assault, it is necessary to understand how healthcare professionals are interacting with their patients in the context of sexual assault assessments and care, along with their perspectives on their approaches.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eStudy Purpose\u003c/h2\u003e \u003cp\u003eThe purpose of this study was to understand how healthcare professionals working in community settings perceived their role in discussing sexual assault during obstetrics and gynecological healthcare appointments. A secondary purpose was to compare healthcare professionals\u0026rsquo; perspectives with those of the patient to determine how sexual assault conversations are occurring within these settings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Method","content":"\u003cp\u003eFocus group discussions with reproductive-aged women and in-depth interviews with non-physician healthcare professionals practicing in community settings were conducted as part of a larger study on reproductive healthcare in community settings [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. The discussions offered insight into group dynamics, which can be particularly impactful when exploring shared experiences among participants [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. Because women\u0026rsquo;s reproductive health decisions may depend on lifestyle and context, focus groups provided an effective way to understand how women constructed sexual assault in the broader context of their lives [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. The interviews offered insight into how sexual assault-related discussions occur within obstetrics and gynecological healthcare appointments. The first author\u0026rsquo;s university approved all protocols and procedures for this study (IRB-2019-160).\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eFocus Group Discussions with Reproductive-Aged Women\u003c/h2\u003e \u003cp\u003eWe completed six semi-structured focus groups with 2\u0026ndash;9 participants each (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;22), ranging 88\u0026ndash;131 minutes, in September-December 2019. Women were eligible to participate in the study if they were 18\u0026ndash;45 years of age and had ever sought reproductive healthcare at a community health center or program in Indiana. We recruited through flyers at community health centers and in public locations (e.g., community centers, libraries), emails through community health service listservs, and shareable social media advertisements along with in-person recruitment with onsite sign-up sheets. Community partners assisted recruitment efforts in three Indiana counties (Tippecanoe, Montgomery, Marion), which were selected based upon demographic and geographic makeup (i.e., race/ethnicity, rurality), established connections, and convenience. Theoretical and snowball sampling, which included referrals from participants for other eligible women, improved data robustness and increased community member inclusion [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Following each focus group, participants completed an anonymous demographic survey.\u003c/p\u003e \u003cp\u003e Focus groups were conducted in locations convenient to the participants and researchers (e.g., reserved, private conference room in a community building). All participants received a \u003cspan\u003e$\u003c/span\u003e25 gift card to compensate their time, and all participants provided informed consent for participation and audio-recording. Each focus group was led by a moderator (the second author) and a co-moderator who were both trained in graduate-level qualitative methodology. All discussions were conducted using a semi-structured protocol, allowing participant experiences and social dynamics to drive the conversation and researchers to explore unique perspectives, novel experiences, and shared knowledge [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Focus groups began with general questions about participants\u0026rsquo; health to build rapport and facilitate inter-participant discussions [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Researchers then transitioned into discussing reproductive health experiences and sexual assault perspectives (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Focus groups continued until data reached theoretical saturation (i.e., when study categories and themes were stabilized and reinforced rather than further explained with incoming data; [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. Participant characteristics are noted in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFocus group and interview questions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFOGUS GROUP QUESTIONS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFOCUS GROUP PROBES\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow might sexual violence affect how women make decisions about their body?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFor example, about birth control or pregnancy?\u003c/p\u003e \u003cp\u003eDo you think this would affect women? Why or why not?\u003c/p\u003e \u003cp\u003eWhat about coercive behaviors by a partner, such as deliberately breaking a condom or being convinced to do something they didn\u0026rsquo;t want to do?\u003c/p\u003e \u003cp\u003eWho do you think has control over women\u0026rsquo;s choices about their health, specifically their reproductive and sexual health? Why?\u003c/p\u003e \u003cp\u003eHave you or someone you know ever had an experience with sexual abuse or violence that affected decisions you made about your reproductive or sexual health choices (e.g., birth control, pregnancy, etc.) How?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas a healthcare provider ever asked you or someone you know about sexual violence or sexual abuse experiences when talking about sexual or reproductive health?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo you think healthcare providers should ask about this? Why or why not?\u003c/p\u003e \u003cp\u003eDo you think this would be a good thing, a bad thing? Why or why not?\u003c/p\u003e \u003cp\u003eIf yes, how did this make you feel?\u003c/p\u003e \u003cp\u003eIf not, do you wish they would have? Why or why not?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eINTERVIEW QUESTIONS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eINTERVIEW PROBES\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhat do you perceive is the provider\u0026rsquo;s role in discussing sexual violence experience with women in community reproductive healthcare?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhy do you think this?\u003c/p\u003e \u003cp\u003eDo you think these experiences play a role in women\u0026rsquo;s reproductive health decision-making? Why or why not?\u003c/p\u003e \u003cp\u003eDo you think these experiences are important in community health settings, specifically? Why or why not?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHave you ever discussed a patient\u0026rsquo;s sexual violence experience during a reproductive health consultation? Why or why not?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[if yes] Please describe what leads to these conversations?\u003c/p\u003e \u003cp\u003e[if yes] How do you broach the subject of sexual violence with women?\u003c/p\u003e \u003cp\u003e[if yes] How do these conversations go? Why do you think so?\u003c/p\u003e \u003cp\u003e[if no] Can you share why you haven\u0026rsquo;t had these conversations?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFocus group participant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;22\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace Ethnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite/Caucasian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (54.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack/African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (31.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSome College or Undergraduate Degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (59.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduate Degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (22.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (45.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull-Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInsurance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (77.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (13.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelationship Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (86.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrimary Birth Control\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (36.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePill\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (18.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIUD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (18.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCondoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (18.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHad Been Pregnant\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eListed as n(%) or Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard Deviation. Items that do not add up to 100% reflect missing data.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eIn-Depth Interviews with Healthcare Professionals\u003c/h2\u003e \u003cp\u003eWe conducted 20 in-depth interviews with non-physician healthcare professionals (i.e., registered nurses (RN), nurse practitioners (NP), certified nurse-midwives (CNM), clinical pharmacists, doulas, and a chiropractor) who provided reproductive healthcare in Indiana (September 2019-March 2020). Inclusion criteria were: 1) working in a community healthcare setting, and 2) being a non-physician healthcare professional. The chiropractor was included because she served in community health settings and treated pregnant and postpartum women in concert with CNMs and doulas. Interviewees were recruited via purposive and snowball sampling, including email invitations to healthcare professionals from community partners (i.e., office managers at clinics, agency directors, public health practitioners). Interviews continued until data saturation was reached for each thematic category [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Interviews occurred at the participant\u0026rsquo;s convenience, either in person or via phone. All participants provided informed consent for participation and audio-recording. Interviews were audio-recorded and lasted between 49 and 91 minutes. Interviews were conducted by the second author and followed a semi-structured approach allowing interviewees to present novel concepts and discuss their experiences and knowledge holistically [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. Interviews began with rapport-building questions to enhance comfort and sharing before inquiring into community-based reproductive healthcare provision experiences. Following a discussion of patient-care experiences, the interviews transitioned to sexual assault, including perceived role of healthcare professionals in having sexual assault-related conversations (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All participants completed a brief demographic survey (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) at the end of the interview, and they did not receive an incentive for participating.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterview participant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;20\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWoman\u003c/p\u003e \u003cp\u003eMan\u003c/p\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (95.0%)\u003c/p\u003e \u003cp\u003e1 (5.0%)\u003c/p\u003e \u003cp\u003e39.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears in Women\u0026rsquo;s Reproductive Healthcare\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears Serving Current Community\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealthcare Organization Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity-Based Program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth System\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity Affiliated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate Organization/Agency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessional Title\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse Practitioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (35.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegistered Nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCertified Nurse Midwife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse Practitioner/Certified Nurse Midwife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePregnancy \u0026amp; Postpartum Chiropractor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecialty\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary/Family Practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (35.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetrics/Gynecology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (65.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace Ethnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite/Caucasian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (90.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLatino/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack/African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociate\u0026rsquo;s Degree/Some College\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergraduate Degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduate Degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (80.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (60.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eListed as n(%) or Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard Deviation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eWe utilized thematic analysis, a widely used, accessible, and flexible framework for analyzing qualitative data through identification, organization, and analysis in systematic phases [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. First, we conducted immersive, full content review to ensure familiarity with all data [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. During this phase, we noted immediate patterns or ideas for potential codes and themes [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Following familiarization, we utilized a deductive/inductive approach for codebook development to allow greater representation of the data during the coding process [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. Initial codes were generated deductively and compiled into a preliminary codebook draft [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. The inductive component permitted us to modify or add codes to better capture emerging themes from participant responses [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. Coding was performed using HyperRESEARCH 4.5.1 [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]. Multiple rounds of coding were conducted until saturation was reached (i.e., no additional new codes were being added to the data set) [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Data were then collated into potential themes and subthemes by the first, third, and fourth authors. Theme development was data-driven and closely reflected participant responses [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. Resulting candidate themes were reviewed by all co-authors. We thoroughly and collaboratively discussed and analyzed individual themes and incorporated relevant subthemes to provide structure and differentiate levels of meaning [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Any discrepancies were resolved via consensus discussion and data review until final themes were fully agreed upon.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThere were three resulting themes: (1) healthcare professionals\u0026rsquo; approaches to screening for a history of sexual assault varied depending on how they ask, setting they work in, and type of professional is doing the asking; (2) healthcare experiences can compound traumatic experiences and create professional distrust with survivors; and (3) sexual assault impacts patient healthcare experiences through the services they seek, how professionals interact with them, and type of professional they are willing to see. Quotes are presented with focus group number (FGX) or healthcare professional specialty (e.g., NP, doula, CNM).\u003c/p\u003e \u003cp\u003e \u003cb\u003eScreening for Sexual Assault: \u0026ldquo;I mean it's mainly domestic violence screening\u0026hellip; not really sexual assault screening.\u0026rdquo; (NP)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eHealthcare professionals described their approach to screening patients about sexual assault. Focus group participants discussed the impact their healthcare professional\u0026rsquo;s approach had on their healthcare experience.\u003c/p\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eScreening experiences and perspectives\u003c/span\u003e. Interviewees had a variety of responses when asked if they screen for a history of sexual assault. One interviewee shared, \u0026ldquo;For a very first visit, I probably wouldn't even though, you could definitely make an argument that you should.\u0026rdquo; (NP) Another stated, \u0026ldquo;I mean it's mainly domestic violence screening\u0026hellip; not really sexual assault screening. I don't think\u0026hellip; I doubt very many providers ask [sexual assault].\u0026rdquo; (NP) These professionals\u0026rsquo; responses signify the variation in sexual assault screening. Other forms of screening, such as probing questions during in-person exams, were noted. One healthcare professional noted using a questionnaire when one-on-one with a patient, \u0026ldquo;Typically if I just have a patient in front of me\u0026hellip;we have like a little questionnaire thing that we kind of go through.\u0026rdquo; (NP) Another mentioned discussing the questionnaire and responses once in the exam room, \u0026ldquo;That's something that we ask about on intake and I'll also broach it again later on, because sometimes they're not comfortable sharing that on intake.\u0026rdquo; (Doula) Interviewees utilized questionnaires to guide them during the screening process and to prudently navigate sexual assault screening. Their careful navigation of sexual assault screening, and continued efforts while with a patient, illustrate the caution and persistence necessary by professionals when performing sexual assault assessments.\u003c/p\u003e \u003cp\u003e Focus group discussions also emphasized an absence of screening for sexual assault, with one participant stating, \u0026ldquo;I definitely don't remember my doctor that I see regularly asked me anything about.\u0026rdquo; (FG3) These sentiments were echoed by a professional, \u0026ldquo;I can't think if I've ever been asked that question in all my years of being a patient.\u0026rdquo; (NP) Overall, narratives emphasized the lack of sexual assault screening taking place in obstetrics and gynecological appointments while also highlighting healthcare professionals\u0026rsquo; experiences during assessments.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eContext-dependent healthcare.\u003c/span\u003e Interviewees discussed how patient-professional dialogue on sexual assault appeared to be reliant on the healthcare setting. One professional stated, \u0026ldquo;In the ER, and I'm pretty sure this is nationwide, and at Planned Parenthood, I did too. We asked everybody \u0026lsquo;is there anybody hurting you or making you do things that you don't want to do in your life right now?\u0026rsquo;\u0026rdquo; (NP) Another echoed a similar experience:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSo, the experience I, that I've had like in an OB/GYN office, it actually was not something that was asked very often, even if the patient was alone. Which I thought was interesting. Because in the emergency department, you know, we ask every person, men, female. We ask everybody. (NP)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese shared experiences by healthcare professionals validate the discussion over the absence of screening for sexual assault within a obstetrics and gynecological healthcare setting. This same professional later shared, \u0026ldquo;I took that from my emergency room training to that clinic. But it's not part of, it's not necessarily part of like the physicians [standard of care] or anything like that, it's not built in that way.\u0026rdquo; (NP) This specific professional recognized the need for sexual assault screening within obstetrics and gynecological appointments and elected to implement it themself. Other professionals spoke on how inquiring may be situational, \u0026ldquo;Those are the ones that really red flags for me that she might be abused or sex trafficking or there might be something deeper going on that, you know.\u0026rdquo; (Nurse Manager) In place of screening all patients for sexual assault, this professional utilized their intuition when choosing to perform a sexual assault assessment. These discussions with professionals have highlighted the absence of sexual assault screening within obstetrics and gynecological healthcare appointments and illustrated its need as these professionals employed their form of screening depending on the patient they were seeing.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTraumatic Healthcare: \u0026ldquo;The way that a clinical care provider treats a woman in labor can have a huge impact on her life forever. And she doesn't understand that.\u0026rdquo; (Doula)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWhen discussing how healthcare can become traumatic for some patients, factors impacting this outcome presented themselves in two forms: 1) how healthcare professionals may prevent distressing care and 2) how professionals may be contributing to traumatic experiences in healthcare.\u003c/p\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003ePreventing distressing care.\u003c/span\u003e Many healthcare professionals shared how they utilize precautionary approaches when interacting with patients and probing on previous experiences. One discussed their method of addressing questionnaire responses, \u0026ldquo;I would just say you mentioned you know, in your history\u0026hellip; like we do have\u0026hellip; counseling here if that would be helpful, or is there anything else\u0026hellip; you want me to know so that I can best care for you that I can put in the chart?\u0026rdquo; (CNM) Another professional discussed broaching the conversation of a patient\u0026rsquo;s previous experiences by inquiring about possible triggers. This healthcare professional stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSometimes it is, are there any triggers you have that I should worry about? Because then it's kind of broad, that doesn't necessarily mean sexual triggers. It just means, you know, overall life triggers. Or are there any experiences that you have that you think might make any part of labor and delivery a little bit more challenging for you, kind of again, with those open-ended questions, not necessarily directing it at sexual assault. (Doula)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e This interviewee outlined how healthcare professionals may approach sexual assault history by situating probing questions within conversations on how to best care for the patient while also showing respect for any sensitivities the patient may have. This interaction allows the professional to delicately collect necessary information for appropriate care while simultaneously building trust with their patient. Another way healthcare professionals may build trust with their patients is how they react to the information they have received. One interviewee shared how she responds to patients after they have revealed sensitive information, \u0026ldquo;We'll write it on the birth plan\u0026hellip; and we'll say we don't want to talk about this at the bottom. Here's this disclaimer\u0026hellip; these are their triggers don't say some things\u0026hellip; don't say a certain phrase.\u0026rdquo; (Doula) When speaking on how to ease the process of obstetrics and gynecological exams, one professional shared, \u0026ldquo;I try to be really vocal through like all of that component for sure.\u0026rdquo; (CNM) Another shared similar experiences when performing physical examinations, \u0026ldquo;really letting the woman kind of guide that\u0026hellip; and what that looks like and letting them just tell me what's okay and what's not okay, versus me saying, I'm going to check your cervix now.\u0026rdquo; (CNM) These healthcare professionals highlight their strategies for sensitivity when working with victims of sexual assault. In addition to providing cautionary care, some professionals took it further to ensure their patients felt supported. One interviewee shared their approach:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e I make sure that every woman knows that you have to give consent for everything. If somebody's saying I'm going to check your cervix. Now you can say No, thank you. And it doesn't matter if they get shi**y about it. If they get hostile with you, you ask for a new nurse until you find one that is willing to respect your wishes. (Doula)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother professional echoed these thoughts saying:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBeing clear that they know that they can always tell someone to stop any sort of exam\u0026hellip; pointing out parts of the process that they can ask to lead instead of having like a provider\u0026hellip; physically do like for pap smear, it's a really good example of that, like, patients don't maybe always know that they can insert their own speculum if they want, like that sort of thing. (CNM)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFocus group participants discussed cautionary approaches to care, which highlighted similar attitudes previously expressed by professionals. One participant shared, \u0026ldquo;Maybe just\u0026hellip; having the exam itself could trigger stress for them\u0026hellip; just always re-stating exactly what they're about to do, what the patient should feel, what the patient will experience and just being very, very thorough.\u0026rdquo; (FG2)\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eHealthcare professional-induced trauma.\u003c/span\u003e As healthcare professionals discussed precautionary care, they also discussed patient outcomes when sensitivities are not considered. One interviewee outlined how a patient may feel if experiences are ignored, \u0026ldquo;I think it's to find out if they've\u0026hellip;ever been assaulted, to know their comfort level. Because, you know\u0026hellip; you don't want them to feel like they're being re-assaulted.\u0026rdquo; (NP) Additionally, another healthcare professional shared, \u0026ldquo;I mean, that caused a lot of women to suffer post-traumatic stress from their birth\u0026hellip; it isn't even about that she had a C section it is about she was violated.\u0026rdquo; (NM, NP) These two professionals\u0026rsquo; thoughts emphasize the necessity of precautionary care to address sexual assault so that patients feel respected in their healthcare experiences.\u003c/p\u003e \u003cp\u003eFurther driving this point, one interviewee explained to researchers their patient had been previously pressed into an unwanted C-section, \u0026ldquo;the birth of her previous child was the worst day of her life.\u0026rdquo; (Doula) This professional continued to tell researchers the patient\u0026rsquo;s second birthing experience required another C-section, and outlined how the birthing process played out:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eShe went through the C section, entire section with headphones and her hands over her eyes. She refused to look at her babies, she wouldn't look at them in recovery. And that's not because she's a bad mom. It's because she had horrible PTSD from a previous birth experience. And not understanding things like that can be devastating to these moms and it can have an impact on their ability to care for their infants. (Doula)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen appropriate and cautionary care is ignored, it can lead to additional painful experiences, increasing patient distress. One interviewee also emphasized the impact professionals\u0026rsquo; insensitivities can have on a woman during the birthing process. This professional spoke specifically on women with previous sexual assault history and their birthing process, \u0026ldquo;Those women tend to want a more hands-off pushing stage, because if there's a bunch of hands inside them, touching them, rubbing them stretching them, it can cause rape flashbacks or sexual trauma flashbacks\u0026rdquo; (Doula) Another interviewee added to this saying, \u0026ldquo;The way that a clinical care provider treats a woman in labor can have a huge impact on her life forever. And she doesn't understand that.\u0026rdquo; (Doula) These narratives demonstrate the weight of ignoring patient sensitivities, priorities, and preferences in their healthcare experiences. In a focus group discussion, one participant echoed the healthcare professionals\u0026rsquo; attitudes when sexual assault experiences are ignored, \u0026ldquo;I mean yeah because you can throw somebody back into traumatic moments by doing things like if they don't know.\u0026rdquo; (FG1)\u003c/p\u003e \u003cp\u003eIn addition to the discussion of healthcare professional-induced trauma, interviewees spoke of patient consent and the distrust they may have toward professionals for forcing services. Some participants highlighted how their colleagues ignore patient choice. Two separate professionals shared similar sentiments on cervical exams for women with one stating, \u0026ldquo;I don't think these physicians realize what they're doing to these women and that they are abusing them or, you know, going and doing a vaginal exam, all these unnecessary vaginal exams on women that the women think that they have to submit to.\u0026rdquo; (Doula) Another healthcare professional shared with researchers:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI have a lot of clients who will deny cervical exams to check for progression of labor, one because it really doesn't get that much useful information. The cervix isn't a crystal ball, you can go from zero to 10 in five minutes, or you could go from nine to 10 in six hours\u0026hellip; Sometimes it can, you know, in certain situations, but as a rule of thumb, checking somebody dilation every two hours, isn't really that beneficial or evidence-based\u0026hellip; for those clients, they because the feeling of somebody else going inside their vagina can be very triggering to them. (Doula)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdding to this, one interviewee shared, \u0026ldquo;They tend to deny cervical exams. And then there's this hostility with the providers, if they're not understanding well, \u0026lsquo;I want this information,\u0026rsquo; and the client then not feeling comfortable enough to say, \u0026lsquo;well, this is why I don't want this.\u0026rsquo;\u0026rdquo; (Doula) These healthcare professionals stress the significance of patient consent and choice when interacting with any patient whether they have a history of sexual assault or not, as these deliberate acts could inflict harm and create a culture of distrust. In one focus group, the discussion of unreceptive professionals presented itself when one participant described being asked about a history of sexual assault, \u0026ldquo;that question [about sexual assault history] caught me off guard and then I had like a very traumatizing experience too, because the doctor was like aggressive with it. And, you know, I feel like how the question was asked would have definitely changed that experience.\u0026rdquo; (FG6) These narratives highlight the importance of interactions with patients, patient choice, and the way healthcare professionals approach screening and services.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eImpact on overall care. \u0026ldquo;Some of them won't even go seek healthcare.\u0026rdquo; (NP)\u003c/h2\u003e \u003cp\u003eHealthcare professionals described the impact a patient\u0026rsquo;s history of trauma has when providing care, and the long-term implications that stem from it. Focus group participants continued to describe the discomfort that can arise in healthcare after previous traumatic experiences.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInfluence of trauma on health.\u003c/b\u003e As professionals discussed the impact sexual assault may have on a patient\u0026rsquo;s healthcare it became apparent that unaddressed trauma appeared to impact overall health. Many interviewees discussed patient discomfort and hesitancy in seeking care while also citing the limits trauma places on care:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt prevents them from coming in or, you know, kind of limits them on contraception options\u0026hellip; they'll usually tell us, some people will talk about it. Some people will just say, \u0026lsquo;you know, I've had trauma in my past and I do not want to come into the office.\u0026rsquo; (Clinical Pharm Specialist)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHealthcare professionals also described the amplified discomfort patients with previous sexual assault experience may feel due to routine reproductive health examinations. One interviewee also mentioned the mental health toll, \u0026ldquo;yeah panic attacks. Either like feeling uncomfortable with exams, who's in the room you know who touches them, cares for them?\u0026rdquo; (CNM) One professional emphasized the distress certain forms of contraception may have for victims, \u0026ldquo;let's say the NuvaRing most women with trauma regarding like their vagina don't really want to remove and insert something you know, like, regularly from their vagina, vulva, so I think it definitely can affect like how quick they are to seek care.\u0026rdquo; (CNM) This interviewee continued to explain, \u0026ldquo;If they feel like they're going to be required to, you know, have a vaginal exam or something breast exam, that kind of stuff, too. I'm sure, it\u0026rsquo;ll be traumatic as well.\u0026rdquo; (CNM) These professionals clarified the impact sexually violent experiences have on a patient\u0026rsquo;s health by citing hesitancy seeking care, and the fear connected to examinations. Healthcare professionals further emphasized this point noting the physical health implications of sexual assault trauma. One interviewee stated, \u0026ldquo;they would come in a lot with you know, decreased libido problems or they would be concerned that their thyroid wasn't working right or whatever, because they just had this aversion to having sex and they just didn't like sex because they had had a bad experience.\u0026rdquo; (NP) For this professional, knowing a trauma response was impacting the patient\u0026rsquo;s health was important in delivering adequate care.\u003c/p\u003e \u003cp\u003eHealthcare professionals continued to list the impacts sexual assault experiences have on healthcare; some citing issues related to pregnancy, such as \u0026ldquo;they may not want to breastfeed or so or like having cervical exams may be very uncomfortable for them\u0026rdquo; (Doula) and:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSome of it is a power thing to a lot of women that I've seen that are domestic abuse survivors are more apt to want to have unmedicated births because they feel like it's a challenge. It's an empowering thing. They can say they did something really hard. And it kind of makes them feel better about themselves makes them feel stronger. (Doula)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eProfessionals\u0026rsquo; experiences with patients highlight the impact traumatic experiences have on a patient\u0026rsquo;s health, the services they seek, and how care may be delivered. Focus group discussions also revealed how sexual assault can impact patient decision-making and overall health:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI know people who, like felt like they needed to be on some sort of hormonal birth control. Like they were sexually assaulted, and the person didn't use a condom or like, if they had a history of that happening and they didn't want that to happen again. They made sure they were on something that they could rely on. (FG6)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e The similarities between healthcare professionals\u0026rsquo; interactions with patients and the experiences voiced by focus group participants only further emphasize the overall impact sexual assault can have on obstetrics and gynecological health.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eProfessional Interactions.\u003c/span\u003e Healthcare professionals emphasized the importance of knowing about a patient\u0026rsquo;s history of sexual assault so they may provide better care. One interviewee shared, \u0026ldquo;these are things that can kind of clue you into, okay, there's something else here. It is surprising how many women in this context, once you build a relationship with them, will tell you.\u0026rdquo; (Doula) Yet some professionals noted not being equipped to handle the information, with one sharing:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think there's a lack of communication as far as you know, or education, I should say, as far as okay, once you ask that question, they say \u0026lsquo;yes\u0026rsquo; and then what, you know? what, what should we say? Or how should we say it? Or there's really no education for providers as what we're supposed to do, you know, once they say \u0026lsquo;yes\u0026rsquo; to that. (NP)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother professional shared how they utilize resources, \u0026ldquo;we definitely can be a supportive person to talk to, we always suggest we would refer out to a therapist if they weren't already utilizing one. But we have resources, you know, at our disposal to get them to the right person.\u0026rdquo; (Doula) In addition to offering resources and support, professionals may discuss other options in response to the information provided, with one interviewee noting:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI just kind of asked her, like, I would like to put some information in the chart so that people are sensitive to what has happened to you in the past. So, if there's any, you know, and I don't have to put I can put in there, whatever you want people to know, or don't want them to know, however you want me to put it in there just so that they like that you don't want lots of actual exams that you don't want to male provider, those types of things. (CNM)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn these conversations with professionals, it was described how and what issues of communication may arise when these situations go unaddressed. One explained the responses to patients who may have unreported trauma experiences:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eYou see fight or flight for those people in situations, but to a clinician are everyday things so they don't understand what's happening\u0026hellip; of course that it escalates because the clinician thinks they\u0026rsquo;re being ignorant or negligent or non-compliant or you know, and no, you have a terrified person. (NM, NP)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Within the focus groups, one participant discussed their thoughts on the importance of healthcare professionals in listening and communicating. One focus group participant shared, \u0026ldquo;you know what we can get from this is being really good at communicating with your patient. I think that's more vital than anything and just like trying to be really empathetic and focusing on like, making them feel comfortable but also in a way that's encouraging them.\u0026rdquo; (FG2) This participant illustrated the importance of patient-professional communication in these situations so professionals may establish relationships with patients to help guide the care they receive.\u003c/p\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eMale Healthcare Professionals.\u003c/span\u003e Interview and focus group participants frequently addressed male professionals\u0026rsquo; understanding of sexual trauma and how it presents itself in healthcare. An interviewee shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOne male provider I have talked to before and I used the term traumatic birth and he got really upset. He said, \u0026lsquo;I'll show you trauma. If the baby dies, it's trauma. If the mom has to have a hysterectomy, it's trauma\u0026rsquo; and he got really upset and I'm like, \u0026lsquo;No, I understand those things are trauma but what I'm telling you is there's traumas that you can't see, that you can't quantify. And you're not caring about those traumas, and those have an impact on life\u0026rsquo;. (Doula)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile this participant highlighted a lack of understanding this male health professional had, another shared a similar experience of misunderstanding: \u0026ldquo;I think honestly, he might have just thought it was like his eyes on the patient were enough of a screening.\u0026rdquo; (NP)\u003c/p\u003e \u003cp\u003eWhile discussing male professionals\u0026rsquo; understanding of trauma care, the narrative turned to the capacity of male professionals in addressing trauma when presented with it. One interviewee shared how a patient\u0026rsquo;s healthcare history suggested a possible trauma experience:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI recently had someone come to me for a pap smear, who had been seen at like a local community health center, mostly and kind of like jumped around a lot and her primary care, it was male, and his note said something like \u0026lsquo;she prefers a female to do her pap smear\u0026rsquo; and I like looked through history, and she had had an elective abortion at age 13. And so, like I started off the office visit, just, you know, saying it like, it's okay if, she was like in her fifties, like, it's okay, if you don't want to talk about this, but I just wanted to know, since part of this exam will be a pelvic exam if you've ever been sexually abused, and if that's something that I need to know about to be able to complete your exam. (CNM)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe healthcare professional continued to describe the response of the patient, reporting: \u0026ldquo;She had been and told me all about it, you know, as a child and the abortion that she had, and she told me that I'm the first healthcare provider who's ever asked her that.\u0026rdquo; (CNM)\u003c/p\u003e \u003cp\u003eWhile male professionals\u0026rsquo; understanding and attention toward sexual assault was often discussed, the comfortability that female survivors have with male professionals presented itself just as frequently. One interviewee shared, \u0026ldquo;She just admitted to me that she had been raped in the past. And she was asking if there were any male providers that I was, you know, just educating there, there were not.\u0026rdquo; (CNM) This professional also shared a similar experience with a different patient:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSo when you come in for labor and delivery, you know, is there anything that you do or don't want and it's like I don't want a man or I don't want a lot of vaginal exams, or I don't want you know, this this and this.... (CNM)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese narratives indicate the sensitivity surrounding male professionals when accessing healthcare. Focus group participants shared similar attitudes as well. One participant stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI'm sure that play like a huge part in like, whether they choose a female or male doctor. You know, if it's a woman who's been raped by a man like she's probably not going to want a male doctor, right and vice versa. Yeah. Huge role in future healthcare decisions. (FG2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Another participant shared their thoughts on male professionals, which echoed previous narratives on male professionals screening for sexual assault, \u0026ldquo;A man wouldn't think to ask that cause he's not a woman.\u0026rdquo; (FG3) Overall, there was an overlapping perception among this sample of both professional and non-professional participants that male healthcare professionals struggle not only to provide a safe environment for survivors to share their experiences but also to understand traumatic experiences and adequately address them.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eProfessionals and patients highlighted the absence of sexual assault screening within obstetrics and gynecological healthcare appointments and illustrated its need, including myriad ways professionals use their screening practices and tools. Participants also noted how professionals can use strategies during routine visits to prevent traumatic experiences. However, instances were also noted where professionals contribute to trauma through the care they provide. These experiences may create distrust among patients and professionals, thus impacting current and future care. Lastly, both interview and focus group participants noted how a history of sexual assault can impact patient-professional communication and rapport, including how a professional\u0026rsquo;s demographics influence the environment and care quality.\u003c/p\u003e \u003cp\u003eFindings revealed healthcare professionals\u0026rsquo; and non-healthcare participants\u0026rsquo; perceptions and experiences of the impact of sexual assault, including undisclosed sexual assault, on obstetrics and gynecological healthcare. These impacts spanned negative patient reactions during gynecological and obstetric care (e.g., panic attacks, discomfort), reduced follow-up, and impacts on healthcare choices (e.g., choosing not to breastfeed, preferring non-medicated childbirth, contraceptive choice). Prior research has identified reduced healthcare-seeking, follow-up, and suboptimal clinical experiences resulting from sexual assault history [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], which supports findings from this sample. Though extant literature identified the influence of prior trauma (emotional, physical, or sexual abuse) on contraceptive method choice and continuation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], healthcare professionals also described how sexual assault affected other healthcare decisions. This finding highlights the importance of screening for sexual assault by engaging patients in provider-initiated conversations to discuss patients\u0026rsquo; sexual assault history and outline potential needs before, during, and after a healthcare appointment, while ensuring comfort and consent.\u003c/p\u003e \u003cp\u003eBuilding trauma-informed care into obstetrics and gynecological healthcare that is intuitive to patient experiences, needs, and priorities may improve women\u0026rsquo;s care, health outcomes, and empower women in their gynecological and birth choices [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Doing so requires equipping healthcare professionals with the language and tools needed to regularly engage women in sexual assault screening in a patient-centered way. By developing and strengthening relationships, healthcare professionals were better able to identify possible sexual assault among their patients and broach conversations about it, as well as make women feel more comfortable sharing. This finding aligns with prior research on the importance of patient relationship on disclosure [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Providing possible screening verbiage and education for healthcare professionals on what to do after a disclosure is made and how to build this context into a patient\u0026rsquo;s care continuum is critical for enhancing obstetrics and gynecological healthcare experiences [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Prior work has identified strategies for developing trauma-informed care practice [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. For example, some women who experienced sexual assault by a man may desire a woman healthcare professional to avoid re-traumatization, building on prior research suggesting women select their providers to prepare for, navigate, and recover from healthcare experiences if they have experienced prior trauma [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. This is a contextual factor specific to each patient with a history of sexual assault but should be considered when identifying obstetrics and gynecological healthcare needs at the onset of an appointment to ensure a more positive care experience in the long term.\u003c/p\u003e \u003cp\u003eOne strength of this study was the inclusion of doulas. Doulas may be able to gain additional patient context that a healthcare professional can then use, with patient permission, to increase sensitivity to women\u0026rsquo;s needs in their birth experience. This aligns with prior work that found women may bring support people to appointments to help them navigate potentially difficult healthcare experiences [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Thus, opportunities exist to bridge the gap between routine trauma-informed care and current healthcare practice, in addition to building provider-driven trauma-informed care capacity, by including other types of healthcare professionals in women\u0026rsquo;s care teams. These healthcare professionals (e.g., doulas, clinical pharmacists) can also build these relationships with women and advocate, support, empower, and/or share information─ with patient consent─ during qualifying healthcare appointments to establish consistent, quality care.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Research\u003c/h2\u003e \u003cp\u003eResults should be interpreted in the context of some limitations. Results may not be generalizable across different populations, including other geographic locations or sociodemographic groups, though these findings may transfer to other contexts and samples. Because of the social nature of focus groups, some participants may not have shared their experiences due to desirability bias. Complete confidentiality could not be guaranteed due to the social environment, and the sample was a convenience sample; healthcare professionals also self-reported their behaviors, which may have led to social desirability and recall bias. Additionally, most professionals were white and female, which aligns with healthcare professional demographics in Indiana, but limits generalizability to other locations.\u003c/p\u003e \u003cp\u003eDespite these limitations, this study had many strengths. Qualitative methodology allowed for robust insight into rich experiences. Different healthcare professional-type and community healthcare settings allowed for triangulation of ideas and consistent themes across professional experiences. Varied recruitment strategies also assisted in enrolling healthcare professionals from different women\u0026rsquo;s reproductive healthcare sub-fields. Interview and focus group guides were reviewed by research experts and healthcare professionals. Future research should further identify what impacts healthcare professionals\u0026rsquo; decisions to discuss and screen for a history of sexual assault during obstetrics and gynecological healthcare appointments, beyond those identified in this study, and examine their role in sexual assault prevention and recovery. Additionally, future research should explore the acceptability of the sexual assault screening procedures suggested by participants in enhancing patient involvement in their obstetrics and gynecological healthcare appointments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eCommunity healthcare professionals serve a critical role in discussing sexual assault during obstetrics and gynecological healthcare appointments. Demonstrating listening, even when communication barriers exist, offers professionals one way to ensure patients feel valued, safe, and secure. Inquiring into sexual assault history and consenting prior to engaging with patients may allow professionals to personalize care and support patients who may be traumatized. Healthcare professionals should keep in mind patients may have prior negative healthcare interactions that impact their current views and behaviors. Thus, professionals should facilitate positive engagement for all via communication strategies, such as building quick rapport, refraining from abruptly ending conversations, validating experiences, and engaging in demonstrative listening. Community healthcare professionals may be one touchpoint for connecting victims to care and wraparound services.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eFindings offered insight into actionable and practical strategies for enhancing sexual assault screening and discussions in community-based obstetrics and gynecological healthcare appointments. Incorporating healthcare professionals\u0026rsquo; and patient experiences and preferences for sexual assault-related discussions during routine obstetrics and gynecological care can assist in sexual assault prevention and treatment efforts, improve patient-professional rapport, and yield better health outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u0026nbsp;\u003c/strong\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Purdue University (Approved September 27, 2019. IRB-2019-160). All participants gave written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u0026nbsp;\u003c/strong\u003eData and interview guide available by request. Please email Andrea L. DeMaria at [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. This research was partially funded by the Purdue University Office of Engagement and the Purdue University Health and Human Sciences Undergraduate Research Honors Scholars Program. Additionally, the study was funded by Purdue University internal funds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contributions:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAndrea L. DeMaria\u003c/strong\u003e: Conceptualization, Analysis, Writing, Editing, Supervision. \u003cstrong\u003eStephanie Meier\u003c/strong\u003e: Conceptualization, Data curation, Analysis, Writing, Editing. \u003cstrong\u003eHannah King\u003c/strong\u003e: Analysis, Writing, Editing. \u003cstrong\u003eHaley Siderowicz:\u0026nbsp;\u003c/strong\u003eAnalysis, Writing, Editing. \u003cstrong\u003eKathryn C. Seigfried-Spellar\u003c/strong\u003e: Writing, Editing, Supervision. \u003cstrong\u003eLaura Schwab Reese\u003c/strong\u003e Writing, Editing, Supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eThe authors would like to thank members of the Interdisciplinary Women\u0026rsquo;s Reproductive Health Collaborative at Purdue University who are not listed as co-authors for their continued support of the project. We would also like to acknowledge Natalie Murdock and Reese Mason for their work on the project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBlack MC, Basile KC, Breiding MJ, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report. Atlanta: National Center for Injury Prevention and Control CDC; 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith S, Zhang X, Basile K, et al. The National Intimate Partner and Sexual Violence Survey: 2015 data brief \u0026ndash; updated release [Internet]. Centers for Disease Control and Prevention.; 2018 [cited 2022 Jan 18]. 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Thousand Oaks: Sage Publications; 1998.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sexual assault, reproductive health, qualitative methodologies, USA","lastPublishedDoi":"10.21203/rs.3.rs-2082063/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2082063/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eNearly half of adult women in the US report experiencing sexual assault, with almost one-fifth reporting rape. For many victims of sexual assault, healthcare professionals are the first point of contact and disclosure. The purpose of this study was to understand how healthcare professionals working in community settings perceived their role in discussing sexual violence experiences with women during obstetrics and gynecological healthcare appointments. The secondary purpose was to compare healthcare professionals\u0026rsquo; perspectives with those of the patient to determine how sexual violence conversations should occur in these environments.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData were collected in two phases. Phase 1 consisted of 6 focus groups (Sept-Dec, 2019) with women aged 18\u0026ndash;45 (n\u0026thinsp;=\u0026thinsp;22) living in Indiana who sought community-based or private healthcare for women\u0026rsquo;s reproductive healthcare needs. Phase 2 included 20 key-informant interviews with non-physician healthcare professionals (i.e., NP, RN, CNM, doula, pharmacist, chiropractor) living in Indiana (September 2019-May 2020) who provided community-based women\u0026rsquo;s reproductive healthcare. Focus groups and interviews were audio-recorded, transcribed, and analyzed using thematic analyses. HyperRESEARCH assisted in data management and organization.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere were three resulting themes: (1) healthcare professionals\u0026rsquo; approaches to screening for a history of sexual violence varied depending on how they ask, what setting they work in, and type of professional is doing the asking; (2) healthcare experiences can compound traumatic experiences and create distrust with survivors; and (3) sexual violence impacts patient healthcare experiences through what services they seek, how professionals may interact with them, and what professionals they are willing to utilize.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eFindings offered insight into actionable and practical strategies for enhancing sexual violence screening and discussions in community-based women\u0026rsquo;s reproductive health settings. The findings offer strategies to improve by addressing barriers and facilitators among community healthcare professionals and the people they serve. Incorporating healthcare professionals\u0026rsquo; and patient experiences and preferences for violence-related discussions during obstetrics and gynecological healthcare appointments can assist in violence prevention efforts, improve patient-professional rapport, and yield better health outcomes.\u003c/p\u003e","manuscriptTitle":"The role of community healthcare professionals in discussing sexual assault experiences during obstetrics and gynecological healthcare appointments","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-10-03 14:41:20","doi":"10.21203/rs.3.rs-2082063/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-03-31T03:25:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-03-14T18:44:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"f9a3e618-b924-49d2-8db9-1c45b7aa68bc","date":"2023-03-09T16:28:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-03-03T10:38:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-03-01T18:22:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-09-29T06:19:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-09-29T06:11:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2022-09-19T18:25:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c86adf6c-5657-4f33-b41f-cba354600aa9","owner":[],"postedDate":"October 3rd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T20:59:49+00:00","versionOfRecord":{"articleIdentity":"rs-2082063","link":"https://doi.org/10.1186/s12905-023-02401-4","journal":{"identity":"bmc-womens-health","isVorOnly":false,"title":"BMC Women's Health"},"publishedOn":"2023-05-15 20:52:28","publishedOnDateReadable":"May 15th, 2023"},"versionCreatedAt":"2022-10-03 14:41:20","video":"","vorDoi":"10.1186/s12905-023-02401-4","vorDoiUrl":"https://doi.org/10.1186/s12905-023-02401-4","workflowStages":[]},"version":"v1","identity":"rs-2082063","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2082063","identity":"rs-2082063","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}