Adult survivors of child abuse

This chapter explores the possible presentations and management in general practice of adults who experienced abuse as children. This includes people who experienced physical, emotional or sexual abuse, and people who experienced neglect or grew up in situations of domestic violence.

Note that this chapter focuses on people who have experienced child abuse and neglect. The Centers for Disease Control and Prevention has more information about the effects and management of other kinds of adverse childhood experiences.

Definitions, health consequences, identification and management of child abuse in children are outlined in detail in Chapter 9: Child abuse and neglect, including mandatory reporting requirements regarding children.

Child abuse and neglect often occur in multiple forms, and they frequently have long-term effects on victims/survivors. A number of state investigations into institutional child abuse, and the National Royal Commission into Institutional Responses to Child Sexual Abuse, have established that child abuse and its impact can remain hidden for long periods. Many victims/survivors have been unable to disclose, or if they have, were often not believed, either as a child or an adult.

Effects of child abuse on later life

The Australian Institute of Health and Welfare estimated that ‘there would have been 26% less suicide and self-inflicted injuries, 20% less depressive disorders and 27% less anxiety disorders in 2015 if no one in Australia had ever experienced child abuse and neglect during childhood’.¹

Child sexual abuse is associated with a range of adverse outcomes in adulthood, including substance misuse, mental health issues, suicidality and chronic disease.⁴

There is some evidence to suggest that non-sexual childhood abuse is also associated with a range of mental health outcomes, drug use, suicide attempts, risky sexual behaviour⁷ and with physical health outcomes including arthritis, ulcers and headache/migraine in adulthood.⁴ Furthermore, multiple adverse childhood experiences are associated strongly with mental ill-health, problematic alcohol or drug use and interpersonal or self-directed violence; moderately with smoking, cancer, heart disease and respiratory disease; and weakly with overweight or obesity, physical inactivity and diabetes.⁸

We are starting to better understand the mechanisms underlying the effect of childhood abuse on long-term health (refer to Figure 13.1). Trauma is linked to a number of biological pathways, such as the hypothalamic–pituitary–adrenal axis (the stress response), neuroplasticity (how neural tissue changes in response to stress and therapy), serotonergic transmission, immunity, circadian rhythms and epigenetics.⁶

There is increasing research in the link between inflammatory conditions and early trauma, with potentially a bi-directional relationship between mental illness and inflammatory conditions, and strong heritable associations.⁹

Figure 13.1. The interaction of childhood adversity and biology¹⁰

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Along with other characteristics, such as a child’s sex or the psychosocial environment, particular genetic polymorphisms are associated with various outcomes following exposure to adverse childhood events. Exposure to adversity can itself lead to biological changes, including epigenetic, neurological and immune regulatory changes. These changes, in turn, influence adult outcomes ¹⁰
HPA axis (SHRP), hypothalamic pituitary adrenal axis (stress hyporesponsive period)

Reproduced with permission from: Berens AE, Jensen SKG, Nelson CA. Biological embedding of childhood adversity: from physiological mechanisms to clinical implications. BMC Medicine. 2017;15(1):135.

Some people who have been abused as children may have adopted strategies to enable them to ‘survive’, for example, smoking, alcohol and substance abuse, risk-taking behaviours,^{7, 11} physical inactivity and disordered eating. Other strategies can include psychological mechanisms such as dissociation (refer to Box 13.1), or behavioural disturbances such as self-harm. The younger the age of abuse, and the greater the sense of helplessness associated with it, the more likely an individual is to have dissociation.¹²

Although these strategies may have been necessary for the person in the past, many are risk factors for adult health issues, and in the long term can contribute to morbidity and mortality.

Research suggests that adults abused as children are at increased risk of further victimisation as adults.^{13, 14} This means that a patient’s current victimisation could be compounding their history of childhood abuse.

Those who engage in violent and criminal offending are significantly more likely to have a diagnosis of PTSD.^{15, 16} Trauma-informed therapies may have a role in treatment for violent behaviours.¹⁴ Refer to ‘Risk of harm to others’ below, and Chapter 5: Working with men who use intimate partner abuse and violence.

Adults who have experienced adverse childhood events, especially cumulative adverse events, are more vulnerable.^{8, 13} However, exposure to adverse events does not mean a child will necessarily experience negative outcomes. With the right support, children exposed to adverse childhood events may have increased resilience later in life.^{17, 18} Treating adult victims/survivors of childhood abuse may help not just the individual but also address the cycle of intergenerational abuse.^{17, 19}

A number of factors may be protective against mental ill-health and substance use in children who experience adverse childhood events. These positive childhood experiences include:²⁰

• opportunities to use their abilities (academic, athletic, extracurricular activity, leadership, work, hobby, household responsibilities and popularity)²⁰
• protective internal cognitive (eg neurotypical intelligence) or psychological functioning (eg temperament)²¹
• external contemporaneous supports such as being treated fairly, and kind supportive friends.²² (This may include professional services such as social or health services.²²)

GPs may have a role in promoting and advocating positive childhood experiences for their patients.  

Some groups are more likely to have experienced adverse childhood events, for example those from Aboriginal and Torres Strait Islander backgrounds, and those in families with a parent with alcohol dependence or who has a background of intergenerational abuse.

Prevalence

National prevalence

It is estimated that 2.5 million Australian adults (13%) experienced physical and/or sexual abuse during childhood.²³

Girls are more vulnerable to sexual abuse. Some studies in Australia estimate the prevalence of child sexual abuse at up to one in four girls and one in eight boys.¹ International studies show one in five women and one in 13 men report having been sexually abused as a child.²⁴

Children are most likely to be abused within the family or by people known to them.

Where family abuse occurs within the home, even if the abuse is not directed at the child, children are still vulnerable and may be affected by the abuse.

More on prevalence is discussed in the child abuse and neglect chapter.

Prevalence in general practice

Women with a history of child sexual abuse are more likely to utilise medical care at a greater frequency than women who have not been abused.²⁵ There is more robust data within tertiary level settings, specifically emergency presentations; there is some suggestion and anecdotal reports this is also applicable in the general practice setting. They may also have complicated presentations and not respond easily to treatment.²⁶

Some smaller studies in general practice demonstrate up to one-third of patients have experienced any adverse childhood event, with potentially one in four reporting symptoms also of PTSD.²⁷

As there is a level of under-reporting that occurs in relation to abuse, these statistics reveal that a substantial percentage of children and young people are abused. Consequently, a significant number of Australian adults who were abused as children may still be experiencing the ongoing effects of their abuse.

The role of general practice and the GP

Child abuse in all its forms often has long-term sequelae and health implications. Health practitioners should consider the need to address possible past experience of child abuse and neglect with adult patients who present with conditions such as mental health issues, suicidality, drug and alcohol problems, and chronic disease.

The effects of childhood trauma are something that belongs to the whole community. There is not an expectation for the individual GP to be responsible for solving or holding the entirety of the distress or journey. However, this chapter aims to empower the GP and support team to be able to do their part well – to ask, believe and listen.

A trauma-informed approach to patients by GPs can help minimise the risk of re-traumatisation and enable pathways to recovery through appropriate referrals to health practitioners with specialist skills in supporting adult victims/survivors.

Good trauma-informed care is team based. Those who work in this area should consider accessing peer support, mentorship or supervision.

The therapeutic relationship

Disclosure only occurs in a relationship of trust.²⁹ However, trust may take some time to develop, as adult victims/survivors of child abuse have been abused, rather than cared for, in prior relationships of ‘trust’.

Patients who have been abused tend to have a very negative sense of self and for many, shame is often predominant. This makes it more difficult for them to care for themselves, seek help and follow advice, a pattern of interaction that may impair the therapeutic relationship. A history of re-traumatisation from health services may complicate further health interactions.

The GP’s own beliefs and experiences can influence interactions and become part of the challenge of working with adult victims/survivors. The prevalence of trauma in the population means that GPs may have their own trauma histories and may need information on how to stay safe and healthy.

GPs approaching this work with an attitude of trying to ‘fix’ a patient or problems can foster impatience and dissatisfaction in both parties. It is a more helpful attitude to ‘sit’ with distress and the recovery journey and recognise the patient’s autonomy in their care journey. More on this is discussed in ‘Telling the Story’, later in this chapter.

Working with boundaries

People who have been abused as children have often had their boundaries violated. All workers and practitioners engaging with victims/survivors, including GPs, need to model clear boundaries.

So those patients feel and are safe, GPs must be respectful of a patient’s physical and emotional space. Intrusion on a patient’s boundaries may replicate aspects of prior abuse, which can be re-traumatising.

Maintaining a clear role as a GP while the patient seeks help from a counsellor, psychologist or psychiatrist further models good boundaries and helps provide the comprehensive model of care many victims/survivors need. This is the model of working as a team to care for adult victims/survivors (or patients).

GPs can make an important contribution, but they may not always be able to provide everything a patient needs. Some patients might be in counselling or might need therapeutic support but are unable or unprepared to access it. Either way, patients with a history of child abuse are likely to be facing a number of challenges and will often require support. A listening empathic ear, respect and validation coupled with a sense of hope and optimism for future recovery are invaluable.

Identification

How a person who has experienced childhood trauma may present

Patients who are victims/survivors of child abuse may present to general practice in the following ways. These conditions have been found to have a much higher incidence in this group:^{4, 7, 25, 30}

• anxiety, panic attacks
• chronic depression
• obesity
• chronic gastrointestinal distress
• eating disorders
• personality disorders  
• multiple somatic symptoms
• drug and alcohol abuse/smoking
• suicidality
• chronic pain
• sexually transmitted diseases
• self-harm.

Understanding the presentation

A victim/survivor of childhood trauma may present with complex PTSD (CPTSD).³¹ Figure 13.2 represents the complex symptomatology that may occur in an adult victim/survivor of childhood trauma.

Figure 13.2. A model of complex post-traumatic stress disorder with potential general practice interventions⁵

Reproduced with permission from: Su WM, Stone L. Adult survivors of childhood trauma: Complex trauma, complex needs. Aust J General Practice. 2020;49(7):423−30.

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Hypervigilance, re-experiencing and flashbacks can mimic paranoia or other anxiety disorders. Flashbacks may also be associated with depression, nightmares or sleep disturbance, perceptual disturbances or anxiety at times of sexual activity. Strong physical or emotional responses can present as somatic symptom disorder or stronger responses to physical illness or treatment.

The overly ‘resilient’ individual who throws themselves into work, can be just as much a manifestation of ‘avoidance’ as a person who copes with disordered eating, substance use and gambling. It may become maladaptive if the apparent ‘helpful’ strategy also avoids emotional and interpersonal difficulties. Conflict within the doctor–patient relationship occurs when the person is misunderstood or misheard with their presentation.

Survivors often report low self-esteem and difficulties with trust, particularly when the abuse has occurred from betrayal from a trusted figure. There can be a sense of false culpability related to their own abuse. These feelings can be further eroded by the cognitive impairments of concentration and memory that can occur with those who are experiencing heightened distress. Some of these people did not have a reliable model of attachment in childhood, and this can interfere with normal processes of interpersonal interaction into adulthood.

Underpinning these symptoms is often profound shame. This is discussed in greater depth in the Trauma-informed care in general practice chapter.

The complexity of presentation may explain why some victims/survivors accumulate multiple diagnoses, including depression, anxiety, panic disorder, psychosis and borderline personality disorder.²⁶ Many patients experience stigma and discrimination from these diagnoses, notably borderline personality disorder.

Anecdotally, it has been suggested that some adult victims/survivors appear to have experienced little or even no effect from the abuse; however, many will be profoundly affected in many aspects of their lives. Without the right treatment, these effects can last their whole life. Many elements influence how well a victim/survivor copes, including the type(s) of abuse experienced, its frequency and duration, the person’s family life, the response to disclosure, and adult experiences of abuse and violence.

Events that may trigger or pre-empt presentation

PTSD is characterised by flashbacks of the prior traumatic events, which might occur at any time.³¹ Certain events are more likely to trigger symptoms of distress.⁵ For victims/survivors of child abuse, these may include:

• marriage
• the birth of a child³²
• themselves or their child reaching a certain age
• the death of the perpetrator (eg family member)³³
• watching a television program relating to incest
• a particular place or smell.³⁴

How to ask about past child abuse 

Most patients will be unlikely to disclose their traumatic experience to health professionals unless they are asked. Yet health professionals may not ask, because of an overestimation that it will lengthen or complicate the consultation.^{35, 36} or a mistaken belief in the futility of treatment for adult victims/survivors, or barriers to access additional care.

Patients do believe that GPs are able to help with their symptoms,²⁷ and they are receptive to being asked sensitively about adverse childhood experiences. Asking insensitively can re-traumatise the victim/survivor (refer to Box 13.2 and Box 13.3).

Advice for asking questions about childhood trauma is shown in Box 13.3.

To optimise patient care, GPs and all the healthcare team need to keep the possibility of trauma in mind in all presentations, to case-find or ask if there are clinical indicators and respond appropriately when patients do disclose a history of abuse.² This may include validation, hearing the story and collaboratively addressing concerns.

Many behaviours and comorbidities associated with trauma (refer to earlier section titled ‘Effects of child abuse on later life’) are stigmatised. When health professionals are not educated about the purpose of these strategies, they often perceive the patients as being manipulative or attention seeking. A trauma-informed lens enables health professionals to understand patients’ presentations in the context of their lived experience and respond appropriately. Asking about family relationships when they were children and the abuse of alcohol by their parents may provide clues.

Health professionals may be able to help by providing a safe space in which the person can discuss their needs and which over time, can help establish trusting relationships. This can be valuable for the adult victim/survivor.

More on this is discussed in the Trauma-informed care in general practice chapter.      

Management

Figure 13.3 outlines management strategies for adult victims/survivors of childhood trauma, including how to approach consultations with patients.

Telling the story

Sometimes the challenge is the consultation itself. This may be because of difficulty understanding the story or telling the story, or the GP hearing the story.

GPs may have their own trauma stories, which can affect the doctor–patient interaction. They may also have preconceptions of what constitutes ‘recovery’ for the patient, or of what the ‘problem to fix’ is. If the GP and the patient’s agendas don’t align, the patient may disengage. Financial and perceived time constraints have further impact.

Listening to the patient’s story is critical. Allowing their distress to be present as part of the journey can be powerful and engaging, and meaningful therapeutically. Patients can initiate their own solutions that are person-centred and individualised.

Adult victims/survivors, particularly those with the most severe trauma, may have never had relational or personal strengths in the first place and may have to ‘learn’ rather than ‘re-learn’ coping strategies. Dissociation may mean they are still learning to connect with thought, feelings and identity even before they are in a place to work on their emotions. Consider dissociation when the story or reason of presentation doesn’t all fit together (refer to Figure 13.3). It may be that there is paucity of information, discrepancy or emotional incongruity to presentation – either too much reactivity or too little.  

Hyperarousal (or hypo-arousal) can indicate the material is emotionally triggering. It is particularly important during these times to ensure the person is safe in the process.

Just as not enough empathy can interfere with patient engagement, sometimes too much empathy can too. It can leave a person stuck in the emotional quagmire of distress without allowing them to move on. Acknowledge distress, but also focus on ensuring that the patient conveys appropriate information and is listened to.

In a practical sense, this may mean that you may need a checklist to ensure crucial elements of the story are not missed – sometimes information may not follow a sequential or logical sequence, or be overwhelming in its detail. When listening to the story, be aware that the specifics of the trauma may be less important than just knowing it exists and its effects on the individual. This may take multiple sessions, so it is important to set expectations for this, particularly the more complex the issue.

The consultation can sometimes be derailed by emotional dysregulation (refer to Table 13.1), or relational difficulties, either within the consult or influenced by interactions with family or friends. A person who has experienced childhood trauma is more vulnerable to subsequent trauma, so may also present with acute stressors or distress.

As health professionals, we sometimes forget that part of the whole story includes social, cultural, economic and psychological influences. These are part of the pieces of the story we need to listen out for, and become part of the story that can enrich, support or hinder recovery.

Figure 13.3. Roadmap to recovery: A flowchart for the management of adult victims/survivors of childhood trauma⁵

Reproduced with permission from: Su WM, Stone L. Adult survivors of childhood trauma: Complex trauma, complex needs. Aust J General Practice. 2020;49(7):423−30.

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Reproduced with permission from: Su WM, Stone L. Adult survivors of childhood trauma: Complex trauma, complex needs. Aust J General Practice. 2020;49(7):423−30.

Specific interventions for common symptomatology

Table 13.1 summarises interventions that may be helpful for symptoms commonly seen in people who are victims/survivors of childhood trauma.

Reproduced with permission from: Su WM, Stone L. Adult survivors of childhood trauma: Complex trauma, complex needs. Aust J General Practice. 2020;49(7):423−30.

Managing risk

The unfortunate reality is that trauma is a risk factor for suicide³⁷ and self-harm,³⁸ and a history of child abuse may put some people at higher risk of harming others.³⁹

Managing adult victims/survivors of child abuse, as for all survivors of trauma, should include an assessment for and management of these risks. Refer to Chapter 5: Working with men who use intimate partner abuse and violence and Chapter 7: Trauma-informed care in general practice.

For more information on suicide prevention and management, including safety planning, refer to Sane Australia’s suicide prevention and recovery guide and Suicide prevention and first aid: A resource for GPs.

Therapy and treatments

Psychological therapy

There is a moderate level of certainty in the evidence that any psychological therapy will reduce PTSD or trauma symptoms, depression and anxiety in adults who have experienced child abuse. Trauma-focused therapies appear to have a larger effect size on symptom levels of depression and dissociation, but not anxiety (refer to the White Book technical report for more information.)

It is therefore recommended that adult victims/survivors of child abuse are offered psychological therapy to reduce PTSD, depression and anxiety.

Appropriate treatment options to consider with the patient may include individual counselling/therapy, referral to specialist service, therapeutic groups and self-help groups.

Sometimes choice of therapy is based on accessibility, for example, access to specialised services or long-term psychotherapy. Many victims/survivors have increased vulnerabilities that may further compound access difficulties. GPs can fill the gap where services don’t exist, or advocate for localised services. Understanding the processes and principles of trauma-informed care may be crucial to ensure that the GP is providing the best care within the limits of their capacity.

For some adult victims/survivors, sharing their story and psychotherapy can be an important part of the process. For others, it can be re-traumatising. Fitting the therapy to the person and their stage of recovery is important. Emotional distress may occur with specific triggers, during transitions and during recovery. Emotional distress does not necessarily mean relapse. Supporting the victim/survivor to elucidate antecedents to the distress and develop strategies for emotional regulation may assist. Care should focus on self-empowerment and choice.

For patients who have been disempowered in childhood as a result of their abuse, the trauma-informed principle of being able to choose from a range of treatment options is an important part of their care.

Being open and non-judgemental to therapy options is important. However, the evidence for some therapies is still emerging, and the primary principle should still be to do no harm. This is particularly important for therapies where there is controversy and potential risk. Therapies that are under debate include retrieved memory, dissociative identity disorder and more novel therapies involving the use of psychoactive substances. Emerging therapies with low risk, such as exercise and social integration, are reasonable to promote, although further research into these areas is still necessary.

Pharmacotherapy

In principle, pharmacotherapy assists with emotional regulation, but it should be used as an adjunct, not as the whole of therapy for a victim/survivor of complex PTSD.⁴⁰  

Self-care for the health professional

Many of us do compassionate work due to a sense of altruism, but can get burnt out when the systems around us don’t support us.

GPs may find that at different stages of their professional development, they may have the capacity to ‘hold’ a person with complex needs, to contain and facilitate the individual to develop strategies to manage the emotional distress, and share the care with other health professionals who have expertise in this area. GPs may find that their level of involvement within the care team may evolve as their skills and situation does.

As discussed previously, the effects of childhood trauma belong to the whole community. There is not an expectation for the individual GP to be responsible for solving or holding the entirety of the distress or journey. However, this chapter aims to empower the GP and support team to be able to do their part well – to ask, believe and listen.

Good trauma care is team based. All team members involved should have access to peer support, mentorship or supervision. Refer to Chapter 8: Keeping the health professional safe and healthy: Clinician support and self-care for more information on self-care strategies.

Certain procedures and investigations – for example, cervical screening – may be especially challenging for some patients. Providing a choice about having or not having these procedures is empowering for people who have previously been disempowered.

It may be appropriate to use the concept of ‘continual consent’ if you think a patient may feel uncomfortable with a particular procedure or investigation. Using this technique, the doctor talks through a procedure, letting the patient know what they are about to do. Throughout the dialogue, the doctor asks the patient if they are comfortable and happy to proceed. This provides the patient with the freedom to stop the procedure at any time.

Survivors may present with physical symptoms that need to be explored, but some of these may be triggered by or stem from the actual abuse. Examples include a sore throat, gagging related to former oral sex, or pelvic pain. Such possible symptoms of prior abuse need to be kept in mind, as does the need to minimise any potential for re-traumatising patients with particular sensitivities.

Resources will vary from one area to another, and it is often difficult to find sufficient, adequate or appropriate resources. Information from Blue Knot or the professional support line (1300 675 380) may be of assistance. The Blue Knot professional support line has a referral database of practitioners and agencies with expertise and experience for working with adult victims/survivors of child abuse.

Referrals could be to:

• another GP with training and experience in supporting adult victims/survivors
• a psychologist or psychotherapist with experience and training in working with adult victims/survivors
• an appropriately trained and experienced social worker or counsellor
• a sexual assault service, if it is resourced to see patients who have experienced childhood sexual assault
• a psychiatrist with experience and expertise in working with adult victims/survivors.

Check with the patient whether the gender of the therapist is of concern to them, and if so, which gender they would prefer to see. It is ideal to provide a choice of referrals and give the patient the option of returning should the referral not be suitable. It is also important to offer to continue to see the patient in the role of GP while the patient is in counselling/therapy.

John, aged 35, presents to his GP with his wife, Judy, and 5-month-old son, James. Judy says that she has been asking John to see a doctor for some time as she is worried about his anxiety. He has seen a locum doctor, who prescribed benzodiazepine. John found the medication helped with symptoms but made him feel sluggish. He has also found over the past few weeks that he needs to take more to get the same effect, and he feels more unwell when he doesn’t take it. Judy says, ‘I don’t like him taking the medication; it seems to make him more withdrawn and unhappy.’

John is reluctant to talk, but with encouragement from Judy says that he is really stressed at work. His job as a computer analyst has always been busy, but lately he is feeling very overwhelmed and is worried he is not performing well.

He is irritable and finds himself ‘flying off the handle’ more easily. His colleagues at work have asked him a few times if he is okay. He has had some disagreements with his boss. He says that, while he has generally interacted well with his boss, he isn’t a very good manager and that this has recently been bothering him. He is finding it difficult to get to work in the mornings and dreads getting out of bed.

Judy says she has noticed that John is not sleeping well, and he agrees, saying that he is having trouble getting to sleep and wakes early, feeling tired. He has bad dreams that often wake him and he then finds it hard to get back to sleep. These symptoms started about four to five months ago.

John reveals that his father had a problem with alcohol and was violent towards John’s mother. He left the family home when John was nine years old, and John has had little contact with him since. John appears to become increasingly distressed through the consult and says, ‘There was some stuff that happened to me when I was young. I thought I’d dealt with it, but it seems to be haunting me now. My mum did her best, but she couldn’t keep me safe and my dad didn’t care enough’.

John says he worries about his son and fears for his safety. He says, ‘James just seems so small and I’m worried I won’t be able to protect him from the world’.

Over a number of consultations, John discloses that as a child he was sexually assaulted over a number of months by a neighbour. This abuse only stopped when John and his mother moved house. Despite his early childhood trauma, John appeared to manage life well, completing his tertiary education, working full time and creating a close nurturing relationship with his wife and close friends. The life stage of becoming a father appears to have triggered symptoms consistent with PTSD, related to his past trauma. The prescription of benzodiazepine, while providing some short-term relief, has led to dependence and tolerance and it has not treated the underlying cause of the distress.

Discussion

This case illustrates a scenario in which the effects of past abuse appear to have been triggered by having a child. This has presented as nightmares and anxiety. John seems also to be having some problems with authority figures – his boss at work, for example – and this would be consistent, as abuse occurs in situations of inherent power imbalance.

The benzodiazepine, while providing short-term symptom relief for his anxiety, has not addressed the true cause of the symptoms, which at the time was not identified.

John is ultimately helped by sessions with a psychologist. As he works through his abuse issues, he comes to understand what was contributing to his anxiety and how it was linked to the birth of his son. He is able to stop using the benzodiazepines.

Susan is 21 years of age and living in a country town. She presents to your practice requesting a cervical screening test (CST). When you take her history, Susan reveals that she broke up with her most recent partner because she was dissatisfied with the sexual relationship: she says she doesn’t enjoy sex, feels uncomfortable and finds it very hard to relax. She asks you if this is normal. Her reason for wanting a CST is that she has been talking with her friends about women’s issues and they seemed to think that regular tests were a good idea. Although she is not sexually active at the moment, she says she would feel happier to have a full check-up.

As you perform the examination, Susan is extremely tense, and performing the vaginal examination is difficult. You stop the examination, concluding that to proceed would be detrimental to Susan. Susan is upset and once she is dressed, you reflect to her that the examination was anxiety provoking. She calms down and says that she will come back in a couple of weeks now she knows what is involved. Before she leaves, you inquire about any past unpleasant sexual experiences. She repeats that she doesn’t enjoy sex, but that she can’t remember anything of a frightening or threatening nature.

One week later, Susan reappears at your surgery saying she has been disturbed since the attempted CST. She is having strange dreams and has a feeling that something happened when she was younger. She grew up on a small property out of town. After some discussion she says she thinks something happened with her older brother and some of his friends, but the memories are unclear. She is obviously distressed.

You consider the following to be the most likely diagnosis for Susan:

• sexual dysfunction
• child sexual

You explore some options for counselling or therapy with Susan, either individually or in a group, and discuss whether she wants to see a counsellor at the local sexual assault centre, or an allied health practitioner with expertise and experience in supporting patients with past abuse.

Susan opts to see a counsellor at the local sexual assault service. As the waiting period is three months, you offer to see Susan weekly for support. She agrees and you are able to work with her to help her feel safe and improve her capacity for self-care. You discuss strategies that might provide some relief to her sleep disturbance, explore her diet, exercise and self-care, and assess her supports by way of friends and relatives, encouraging her to reach out to those she trusts and with whom she feels safe.

Nine months later she comes to see you for a CST. Although Susan is slightly tense, she can relax sufficiently for the examination to be performed successfully. Susan is relieved and says that in counselling she has been feeling that she is making good progress, and being able to have a CST is indicative of her progress as well. She thanks you for your involvement.

Refer to resources nationally and in your area.

• The hidden factor: the effects of child abuse on adults – this DVD is a resource for GPs and other health professionals. Three women tell their stories of abuse to give doctors and other health professionals a better understanding of the factors that helped with the healing process. Available for loan to RACGP members from the RACGP library: email library@racgp.org.au, or phone 03 8699 0519.
• A whole person approach to wellbeing: Building sense of safety – book by Australian GP psychotherapist, Dr Johanna Lynch, Routledge, 2021.
• Practice guidelines for clinical treatment of complex trauma – a guide from the Blue Knot Foundation.
• Australian guidelines for the prevention and treatment of acute stress disorder, post-traumatic stress disorder and complex PTSD.
• The body keeps the score: Brain, mind and body in the healing of trauma – book by psychiatrist Bessel Van der Kolk, which explores different models of trauma therapy, Penguin 2015.
• After abuse – by Victorian psychiatrist Dr Gita Mammen, this book outlines types of treatment and may be helpful to GPs trying to find an appropriate referral or seeing patients in a counselling role, ACER Press, 2006.
• Better Access Initiative – the MBS item relating to the GP Mental Health Treatment Plans may be useful for patients wanting to initiate ongoing mental healthcare.
• Victims services – these are state/territory-based services, funded by the Department of Communities and Justice, to support those who have experienced crime, including family and domestic violence. They provide counselling and financial assistance.
• Primary Health Networks – may provide training and education, and coordination and collaboration with local services.
• Living well – a website for men who were sexually abused as children or who have been sexually assaulted as adults.
• See what you made me do: Power, control and domestic abuse – book by Jess Hill, Black Inc Books, 2019.