Trauma Background
SAMHSA Definition
Trauma results from an event or circumstances experienced as physically or emotionally harmful, with lasting adverse effects on functioning, mental, physical, social, emotional, or spiritual well-being.
SAMHSA, 2014Who is affected — Individual events
- Physical or sexual assault / abuse
- Intimate partner violence
- Military service & combat exposure
- Military sexual trauma
- Natural disasters
- Severe injury or sudden-onset illness
- ICU hospitalization
- Witnessing serious injury or death
Who is affected — Population & systemic sources
- Human trafficking
- Refugees
- First responders
- LGBTQ+ individuals (higher risk)
- Historically marginalized populations (elevated risk from systemic trauma)
- Intergenerational / historical trauma
- Healthcare workers (especially post-COVID)
Trauma may not be consciously recalled, but symptoms may still present.
Adverse Childhood Experiences (ACEs)
>50%
US adults with at least 1 ACE
61%
report ≥1 ACE (CDC, 2015–17, n=144k)
16%
report 4 or more ACEs
Health Associations (ACEs)
Hughes et al., Lancet Public Health 2017 — 37 studies, 253k participants:
Moderate association
Smoking · heavy alcohol use · poor self-rated health · heart disease · cancer · respiratory disease
Strong association
Mental illness · sexual risk-taking · problematic alcohol use
Strongest association
Problematic drug use · interpersonal and self-directed violence
Felitti VJ et al. Am J Prev Med 1998 · Hughes K et al. Lancet Public Health 2017Framework — The Four Rs
The Four Rs of Trauma-Informed Care
SAMHSA Concept of Trauma and Guidance for a Trauma-Informed Approach, 2014Realize
Trauma is widespread and affects patients, families, and staff.
Recognize
Know the signs: hypervigilance, avoidance, dissociation, somatic symptoms, delayed care.
Respond
Integrate trauma awareness into policies, procedures, and every clinical encounter.
Resist re-traumatization
Actively avoid practices that replay experiences of powerlessness or violation.
Observer vs. Reactor States
Courtesy Trauma Informed Oregon
Observer
"The individual can watch themselves and consciously figure out their emotions and behaviors. They think about what is in their control and what is not, and respectively make an informed decision on what to do next."
Reactor
"A person will act immediately in response to a feeling, letting emotions control them. Sometimes this might be good, but most of the time, it's more beneficial to see the situation from all angles before taking action."
Reflection: How may both states exist in the practice of medicine?
Trauma-Sensitive History
Opening scripts
Sample opening
"Would it be okay if we talked about what happened?"
Alternative opening
"This can be challenging. What would be helpful to talk about?"
Core principles
- Safety
- Trust
- Choice
- Collaboration
- Empowerment
- Cultural sensitivity (race, gender, identity contexts)
Key approaches
- Give patients space to tell their story — without pressuring retelling of traumatic events (that can re-traumatize)
- Explore timing, duration, perpetrator, and current contact with perpetrator when relevant
- Always assess current safety
- Inquire about safe relationships (past and present) — protective factors matter
Normalizing script
"Many people have experienced difficult things in their lives — it can affect health in many ways."
Reframing identity
"You survived something very difficult."
After sharing, briefly explain how trauma and chronic stress affect the body — this can be genuinely therapeutic.
Avoid encouraging long retelling — brief acknowledgment and forward focus is usually more therapeutic.
Responding to disclosure
| Do | Avoid |
|---|---|
| Be comfortable with silence and pauses | Rushing to fix or problem-solve |
| Reflect and summarize periodically | Pressing for graphic details |
| Normalize the experience | Language that implies blame |
|
Validate
"That is a completely understandable reaction." |
Promising confidentiality you cannot guarantee |
|
Highlight resilience
"You have found ways to cope." |
— |
| Briefly explain biology: chronic stress affects every organ system — and there are real pathways to recovery | — |
Physical Exam
Before the exam
- Check non-verbal cues (muscle tension, flushing, dissociation)
- Sit/stand at eye level with patient
- Set an agenda: explain exam type and expected duration
- Ask about comfort and concerns
- Offer a chaperone
- Ask permission before beginning the examination
Asking permission
"Is it okay if I begin the examination now?"
During the exam
- Use simple, depersonalized clinical language
- Announce each step before touching
- Ask permission again — even if already given
- Stay within patient's eyesight
- Attend to draping and modesty
- Be efficient
After the exam
- Express thanks for cooperation
- Share findings clearly
- Ask if they have questions
- Check in emotionally if you noticed distress
- Collaborate on next steps
Clinical language — what to avoid vs. use
Elisseou S et al. MedEdPORTAL 2019;15:10799 · Gorfinkel I et al. CMAJ 2021
| Avoid | Use instead |
|---|---|
| "Look at your…" | "Inspect the…" |
| "Touch / feel your…" | "Examine / evaluate the…" |
| "Swallow for me" | "When you can, please swallow" |
| "Relax" | "Some find it helpful to take a slow breath" |
| "Your bed / stirrups" | "The exam table / foot rests" |
| "That looks good" | "That looks healthy / normal" |
| "I want to…" | "I'm going to…" |
Sensitive exam considerations
Pelvic / cervical
- Offer a mirror so patient can see the procedure
- Allow patient to insert speculum themselves
- Utilize self-collection for cervical cancer screening
Genitourinary (XY anatomy)
- Ask patient to hold penis/testicles
- Always offer choice of gown and draping
General principles
- Remind patient they can stop at any time
- Check in at each step
- Drape as fully as possible
- Allow patient to control gown adjustment
- For anxiety: consider lorazepam 0.5 mg one hour prior (verify medication is appropriate)
- General anesthesia is an option for very severe trauma history
IPV Background
What is IPV?
Intimate partner violence describes any violent behavior — including physical or sexual violence, stalking, and psychological aggression (including coercive acts) — by a current or former intimate partner.
It occurs on a continuum of frequency and severity, from a single episode to chronic, severe episodes over years. It can occur in heterosexual or same-sex relationships and does not require sexual intimacy or cohabitation.
VHA Directive 1198, January 2018Outcomes Associated with IPV
1 in 5
US homicides are committed by an intimate partner
Associated conditions (morbidity)
- Cardiac · GI · nervous system · chronic pain · reproductive
- Major depressive disorder (MDD)
- PTSD
- Substance use
- High-risk sexual behavior
Keep these associations in mind during clinical encounters.
IPV Screening
2025 USPSTF Recommendation
Screen for IPV in women of reproductive age.
Clinician note: Confirm current full text of recommendation when documenting.
Single-Question Screening Tool
NEJM — Screening question
"Are you afraid of your partner or anyone else?"
If You Suspect IPV — Ask
- IPV is common and underrecognized
- Asking helps patients recognize IPV — asking is itself an intervention
- There are many ways to open the conversation
Responding to "Yes"
Use empathic language
Slide courtesy of Andrew Goodwin, LCSW, Portland VA, with adaptation
Empathic scripts
- "We would like to help."
- "The abuse is not your fault. It's wrong for one person to hurt another person."
- "Unfortunately, you are not alone. Many of our patients have experienced abuse."
- "I'm sorry that you have to experience that."
Avoid judgmental & directive language
Do not say:
- "You need to leave this relationship."
- "This is not acceptable."
- "You need to get to a shelter right away."
5-step clinical response
- Assess risk of imminent danger
- Treat symptoms and injuries
- Document — after obtaining consent
- Connect with Social Work / Mental Health for additional education and resources
- Schedule follow-up