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Hello, everybody and welcome to tonight's Stash webinar. My name is Alice. I'm a GU SPR in Birmingham and also one of the stash education leads for this year. Um I'm also here with my co Sarah. She'd like to introduce herself. Hello, everyone. My name's Sarah. I'm 1/4 year medical student from Holy York Medical School. Grand. So um we've got Doctor Rachel Caswell with us this evening. Who's gonna give us a great talk? So, Sarah, if you'd like to introduce her via biography, happily, um Doctor Rachel Caswell is a consultant physician in sexual health and HIV at the university hospitals, Birmingham NHS Trust. She studied medicine at Trinity College, Dublin and Public Health Masters at the London School of Hygiene and me um and tropical medicine. Um Her research focuses on improving healthcare responses to sexual violence and abuse. Thank you very much, Sarah. And um hello to everybody on the webinar this evening, I am going to start and share my um slides. Can you see that? Yes, brilliant. Ok. So um I'm going to talk about trauma informed care. Um And I really wanted to emphasize about self care this evening. Hopefully, you will receive the email earlier in the day. Um But I will be talking about trauma informed care, but particularly I'll be talking around sexual violence and abuse as that is the one of the main associations as to why I particularly look at trauma informed care in gu medicine. This topic is quite difficult for um all of us and particularly difficult um for particular people that has impacted either directly or indirectly. So please do take time out of this talk if you need to. Um I'd also say I'm gonna mention a list of organizations that you can get in touch with. Um I realize that actually the webinar is um throughout the UK, I suspect rather than just around this area. But if you struggle to get hold of local support services, you can also um reach out to me um or I guess also to Alice as well and happily put you in touch with the local um services if you need. I also really wanted to mention about self care throughout your career because I think this is something that we all should um be doing and be aware of. And I say that particularly around the talk and about trauma informed care because I think part of being trauma informed is also about looking after ourselves. And I think it's really important in terms of being able to care for patients is when we are in a good place ourselves. So part of self care. One thing that I really liked, I saw somewhere was ABC and I do admit that's basically because I can remember it, but I think it is also really uh useful points that they've got under each um A B and C. So A A is for awareness. So do you recognize how you feel when, or how you react when you start to feel stressed? Do you sort of realize what you're becoming like or how you're feeling? And I guess if you don't realize it's quite hard to do anything about it or if you're not self aware in that way and take a step back and realize that you're starting to feel overwhelmed then and things can escalate B is for balance, taking care of yourself. And that's, you know, thinking about doing other things rather than just work and really being quite proactive about putting those um into action and, you know, doing exercise, meeting up with people um taking time to relax whatever it might be for you. And see, I actually think is the most important or at least it is for me and that's around connections. And I think it's about having um a support network, whether that be family or friends or colleagues that are um that you spend time with and that you invest time with. So I'd really encourage everybody to kind of think about that. Um As well. This talk will cover aspects of gu medicine that made me consider trauma informed care and trauma informed approach. And I will talk about forensic medical examination. I will talk about sexual um violence and the link to GU medicine for me. And I will also talk about a service that I set up called the Ask Abuse Survivors Clinic within GU Medicine Clinic. Talk about what trauma in form care is and why implement it. I'll think about a different medical model of care. We'll show a short video that explains trauma informed care much better than I do. And then also I'll think about how all of this relates to a sexual health clinic and how it links to the clinic in our area in terms of responding to sexual violence in um a way that is trauma informed and hopefully safer and more supportive for survivors who attend the clinic. So going to the first part aspects of gu medicine that made me consider being trauma informed while I was a trainee in GU medicine, I also worked as a forensic medical examiner. Um and that was seeing patients who had presented usually via the police um after sexual assault and were wanting to have a forensic medical examination. This was outside of the NHS. Um and I was doing that alongside my gu work and it really sort of opened my eyes for that er to the to the world of, of forensic medical examinations and and also to the um to this of challenges and difficulties that clients were um having to face and were overcoming in the community. And also then requiring this link after the forensic medical examination to gu clinics and how challenging that was and the difficulties that were um faced by them after the medical examination to access sexual health care. And it made me think about people who are coming into our clinics um who have been subjected to sexual violence, either being referred from after a forensic medical exam or you know, anybody just walking in and just wondering about how we offer care, how we provide care in that setting and how do we do it well. And as part of that, I thought it would be useful for busy sexual health service to set up a clinic that had a bit more time, a bit more experience in terms of being able to respond to disclosures of sexual violence. Um and also to offer some additional services like cervical sampling. Um and, and also we have um support organizations who work alongside us in that clinic. So all these sort of aspects made me consider about how our service looked. And at the time, I didn't really know what trauma informed was. I hadn't really heard those words, but I guess I was thinking really about how to provide a safer place for survivors of sexual violence. Um to come into no trauma is not, is obviously not just limited to sexual violence. And there are lots of different types of trauma and there's, you know, a whole list here and within any health care setting with any walk of life, um, people will have been er, subjected to lots of different types of trauma potentially and this can happen over the whole lifespan, it can happen in childhood. And we talk about aces um adverse child childhood experiences and then we talk about um, multiple or single occurrences of trauma as well. So, trauma, it is quite complex um and affects people in different ways. And then what is trauma informed care? Well, it's thinking about what uh not what is wrong with them. If somebody's, you know, being difficult in the clinic, not thinking, oh what's wrong with them but thinking, you know, what do they need or what's happened to them that they're, they're acting like this. It's not about treating the trauma. So if you end up working in, you know, ed, uh you trauma informed care should also be applied there. It should, it's not about offering counseling, it's not about therapies for trauma, it's about creating a safe space. Um And it's creating a, a place where that person feels as safe as possible where they're not being retraumatise or, or triggered or reminded of their trauma in some way. And it's about understanding the impact of trauma, how common it common it is so sort of realizing and accepting that it's um a common thing that patients that you will be seeing in clinic will definitely have experienced. And it's about thinking, how do I make this uh this service better for them and safer for them and more accessible. And it's about more than just doctors doing trauma informed care. So it's about the whole service. So it might be to do with the layout of your waiting rooms. It might be to do with your reception staff. It might be to do with what words you use on a leaflet or your website. And just to reflect back to the medical model of care, which I don't, I mean, I was at med school a very long time ago. So maybe things have really changed. But the medical model looks at what is wrong with the person. And so what's the disease and how do we fix that? And that's very different from the trauma informed approach. Um, so this traditional medical model has a paternalistic that the doctor's the boss, the doctor's the one that holds the power. Um, and that patients are reassured and told what to do and what investigations they need and they're not part of that decision process. Now, you have to kind of reflect that some individuals and families prefer this and, you know, maybe there's some situations where you couldn't, you know, understand that in a, you know, emergency life saving moment. Um, but I guess when it comes to something like the types of trauma that I've mentioned before that this kind of paternalistic approach isn't helpful and, and actually can be quite detrimental to the to that therapeutic relationship that needs to be there er in the cases of um trauma. And so this approach looks very different to that paternalistic approach. And instead in trauma informed care, we have choice, safety, empowerment, trust and collaboration. So that relationship between doctor and patient is one where they're working together, where they're trying to come up with a plan that feels safe and, and feels right for that individual. And so that will, that control sits back with the patients. And they've got a choice about what happens and it might not always be what the doctor thinks is the right choice, but it's what feels right for that person and safe enough for that person right now. And they've been empowered as in, they know the decisions, they know the consequences of whatever decision they decide to take about their care pathway, but it feels right and unsafe for them and trust is obviously very important. So in many of the um the situations that uh um I see that, that the trust, their trust has been really um very severely hurt by people who they really should have been able to trust and therefore having trusting relationships with other healthcare professionals in other situations is very difficult. And so being very mindful of that and trying to ensure that you're upfront, you're very clear, you don't overpromise um is very important in a trauma informed approach. So the impact of trauma, what are the outcomes? Well, we know that the there can be negative mental and physical health impacts. So the trauma that's experienced over a lifetime can really impact people in lots of different ways. And for example, people can present or find it actually difficult to present to health care services after trauma or they might present in ways where they get angry very quickly. Or um they find it very difficult to uh maybe wait in the waiting room, for example. And I guess it's us recognizing that these, these can be the consequences of previous trauma. It's also important to recognize that coping skills that might be used that, that, you know, to us appear um very harmful or um not, you know, in, in that patient's best interest, like for example, excessive alcohol use are actually a way of coping and, and just to say to somebody, well, you know, reduce your alcohol intake or whatever is actually not particularly, it's not gonna be particularly helpful in that they need some alternative way of coping. They need um a different strategy rather than just taking something away. And so in cases of trauma that, you know, I'm referring to, it needs to be um sort of, I guess understood a little bit further and it's a little bit more nuanced. Um And that support needs to be there for them. I'd also say that uh I don't think it's or, or the other way, I think it's really helpful to, to be clear about hope and also to be clear about the strength of individuals after trauma. It's important not to make assumptions about how people will be after this type of trauma. Some people are incredibly strong, courageous and indeed the people who come to clinic and um disclose and access care in my view are extremely courageous. And I think it's important to recognize that and acknowledge that. So what I was gonna do is show a clip of trauma informed care and this was um or this was presented by a Scottish group, but I think it explains it really well. And what I would say is in the first half it talks about or it actually shows how people react and why they react like it. And I think it's really good, um a really good way of sort of thinking about different ways people can present um because of their trauma. And then in the second half, it shows how healthcare professionals and other professionals can change the way they practice so that um it's more trauma informed and so that people feel safer and what amazes me is that it's really basic what the changes are like. It just might be a few extra words or taking, you know, an extra few minutes of time. Um So in some ways, it feels like so little and there's such soft things to do in a way, but they make such a huge impact. So let me show you whenever mom went away, he would come into my room. He said I made him do it. And then it meant he loved me. It always made me feel powerless, ashamed. I never knew when an argument would turn into a fight. I was always scared. Always in edge, always had to be ready to defend myself. My late husband was very controlling. Always put me down, told me what to wear or cook. He'd get angry if I didn't do things right. I had no choice or control. It made me feel useless. I had no confidence in the end. So I zoned out pretended it wasn't happening. It's so difficult to trust people. Now I just freeze and float away in my head when I feel powerless. Now I just get angry a lot. I feel like I went to fight. Sometimes I worry, I'm just like him. I find it difficult to do things myself and I get really nervous when I have to talk to new people. I avoid them when I can. What we went through was traumatic because we were harmed physically emotionally and felt like we were in real danger. Dramatic experiences can be things that happen once a serious accident or assault or it can be where traumatic things keep happening. Like physical or sexual childhood abuse or domestic abuse or relationships where you can't be yourself, where you put down or bullied, it can make you feel powerless, trapped or betrayed the signs of confusion, shame or fear can be overwhelming. Especially if there is no one you feel able to tell. Even after it's over, it's harder to get on with life and feel safe. Trauma is more common than most people think. Almost one in five adults has experienced physical or sexual abuse in their childhood. And more than a quarter of all women have experienced domestic abuse. Some people recover after traumatic events, some people aren't affected as much. Having good safe, supportive relationships with other people can really help. But lots of people continue to be affected by trauma. Sometimes long after it happened for most of us traumatic or adverse childhood experiences. Like these affect our body's response to stress, affecting our physical health as well as our mental health. The impact of trauma can also make it harder for us to learn and to realize a full potential. One of the most worrying things about the experience of trauma is that it can make us avoid people and places even if they are there to help like doctors, teachers, social workers, carers, colleges councils, community centers, employers advisors, because most trauma experiences happen in relationships with other people, we can find it difficult to trust people or feel safe and sometimes the way we react to help ourselves, feel safe, pushes people away. And makes it even harder to get the help we need. It's like your brains learn survival tricks to get us through the trauma at the time. Like priming us for danger, making us run away, shutting down. When we feel upset, it might look like we have a short fuse, like we're unfriendly or we're just about absent anything however small that reminds us of that trauma can set off our own unique trauma response to protect ourselves, making us avoid the people and places that we need the most like you. But there are things you can do to help me trust you enough. So I feel safe and I don't shut down or avoid you. You can offer me a different relationship that doesn't remind me of the one I had when I was a kid, one where I feel safe, I feel empowered and I have choice and control over what happens to me one where we work together and I can trust you. This is called being trauma informed in the way you work. Being trauma informed means thinking about what will make me feel safe. It might mean offering me choice over the sex of the person, offering me care or support, especially if it involves intimate care or examinations. Unfortunately, your usual care worker heather off sick will be sending someone else instead. Do you have any preferences about who comes instead? Well, I'd feel more comfortable with someone I've met before most importantly, I, I'd like a woman. Oh, how about June? She's worked with us for three years. If there's anything you'd like her to do that? Heather normally does just ask trauma informed means, empowering me to have control and take an active role in what happens to me. We know some people don't like coming to the dentist. So is there anything that you're worried about or scared of? I can tell you each step I'm doing so. There are no surprises if you'd like if you need me to stop, how will you tell me trauma informed means helping me to trust you by being clear about what will happen, doing what you say you will do when you said you would do it. Unfortunately, our advisors are running about 30 minutes late. I'm so sorry about that. Are you able to stay or can we make another appointment for you? Many of us at work will have had our own experiences of trauma in our own lives or we might witness or hear about it in the course of our work. So the same principles apply to all of us, we all need to take care of ourselves by making sure we're safe and connected to the people and activities that matter to us. Can you think of anyone you've met or worked with recently that a trauma informed approach would have made a difference to? Are there any trauma informed changes you might make that could make a difference. So if you offer me safety and choice, if you collaborate with me and empower me and help me trust you, then you will help me work with you. Even if I only meet you. Once, even briefly, you can give me a different kind of relationship. One where I feel valued and valuable, connected and safe. And when that happens over and over again with everyone that I meet, I can learn that it's safe to make connections with people. It is those connections that we all need to access life chances and reach our full potential. OK. So I find that um uh a very um helpful explanation and with good examples. Um And obviously, there were quite generic examples for lots of um different types of services. And in this next part, now I'm going to focus more on my work and um that's within a GU clinic. And for me, it was really around my background of working with survivors of sexual violence that really made me think about what we're doing within sexual health services. Um that, and it really made me stop and reflect about how we were offering care and how that might be done differently. So I'm gonna talk a little bit about sort of an overview of sexual violence and why um it's one of the topics within uh GU clinic that's particularly important and particularly important that we do get our responses right? This first picture is of the iceberg and it's to do with the fact that we only hear or within a healthcare setting or perhaps it's to do with police reporting, we only hear the tip of the iceberg and we know this huge underreporting of sexual violence. Um, people don't disclose and don't feel able to, some of the statistics that are out there show that it is really common and within the UK, this is England and Wales. Um, you can see figures there from the crime survey, 20% of women, 4% of men experience sexual violence from age 16. And some of the information then from rape crisis show that for example, five and six women who are raped don't report and the same is true for four and five men. So there are lots of statistics out there showing that it is very common and that includes within sexual health services. So this, this one study showed that 17% of female attendees reported sexual violence in one in one service. Er, and that's published and then within our service, which is called Umbrella in Birmingham and Solihull. Some audit data showed that there was one adult a day and one child per week attending to look for uh, healthcare after sexual violence. So it really is, it really is a huge, um, a huge issue issue, but also something that really does present to us within health care and we need to make sure that we're, we're ready to respond. And so why do people come to sexual health services after sexual violence? Well, it is seen that sti testing is a priority for people after sexual violence. But also there are different um other types of healthcare offer that we can make. For example, post exposure prophylaxis for HIV hepatitis B, vaccination, emergency contraception, pregnancy testing examinations. And we also it's also really important to have good links with other services that people come and can be signposted or referred directly to other services. Such like such as counseling, also need to be mindful of safeguarding social and legal advice, forensic collection, police reporting. So all those aspects that the sexual health services can uh link people up with. So thinking about trauma informed care and this improving our response making our our um sexual health services safe and supportive for people. So it's three kind of areas that I look at trauma informed approach with ba basically overlaps with everything else. But it's specifically, I also think about opportunity for service users to safely disclose past sexual assault. And I also think about training to include tackling rape, myths and victim blaming. So the first point of those three opportunity for service users to safely disc disclose past sexual assault. So we use um in our service what's called routine inquiry. And that means asking everybody who attends about um sexual violence. So if it's safe to do so. And so, and we really ask about whether they want to hear about the support that is available for survivors. So it's not something um that they have to answer. Um And it's, but the offer is there and we do bring it up. And what that does is that it makes people realize that um that we don't hold to what uh for example, stereotypic rate looks like. So everybody's asked, asked those barriers are overcome, the barriers to disclosure, disclosure are huge and they do really impact on people's. Um people feeling able to disclose what's happened to them within our clinics. So you can see here, we I've broken it down into individual service and society levels, this disclosure. So at individual levels, people can really feel a sense of self blame for what had happened or they might minimize what's happened. Um And kind of think, oh, it was just once or it's not that big a deal. Um The self blame might be because they blame what they did or their actions or their non actions. Um People also can feel embarrassed about what happened and just feel like they don't want to, to say anything. People can be fearful of what's going to happen next if they do say something. And then at the service level, people um within healthcare services do get burnt out and, and I think if people are listening to trauma again and again, sometimes their response isn't as good as what it might be. Um and that's one barrier to disclosure where people at uh healthcare professionals are obviously putting up their own barriers to listening to disclosures. There also can be not enough time in clinics and being aware of how to create time and how to have good links onto counseling services. So that that role is not taken um on by the doctor is important. There might be things like um a traditional health care practice. So people might be kind of acting in that medical model, that kind of paternalistic model and that is a barrier to safe disclosure. And then at the societal level, there are um issues like rape, myths and stigma and silence that surround um sexual violence and disclosure. And it makes it very difficult for that individual to come and um feel confident and um able to disclose what's happened. And so it's really important, I think for us within sexual health services to make sure we've got that space and we're clear that we've got that space that if people do want to um talk about what's happened and access care and um and think about, you know, onward steps. If that's what they want at that time, then we were able to do that. And I think it's important that we think about the service as a whole trying to set it up in a way that makes it that safe environment for people to disclose to. And I did spend some time thinking about whether well is disclosure, it is telling somebody um helpful or not. So we're asking everybody in clinic, is that going to be, is that a good thing or is it not a good thing? And I, and there is, there are studies and there is work out there that looks at different aspects of just disclosure. And I would say that disclosure has to be done in the right way. So within a sexual health service, certainly just asking people about it is not ok. And it needs to be done in a, in a way where it is trauma informed, where the healthcare staff are trained in how to ask, when not to ask how to respond. And that response you can see here is the first column, negative and unhelpful responses are to be avoided. So for example, blaming or controlling or minimizing or distracting about the disclosure is very important to avoid and there are positive helpful responses that are really important and that survivors have talked about being key after a disclosure. So, um validation is very important, providing emotional support um in terms of, you know, there is support for you, you are not alone, et cetera. So I um did a survey to look a national survey to look at people's opinions on routine inquiry within sexual health services. And there were over 2000 respondents and the majority of respondents felt they were in favor of the use of routine inquiry um, but you can see here, but here even more interestingly within that survey, there were those who had, um, a history of sexual violence were actually more in favor of routine inquiry. So I thought that was, um, very encouraging. Really were, um, the survey was an anonymous where with this, um, more people who had, um, been subjected to sexual violence did want it, um, asked about and spoken about. Now it doesn't, certainly routinely inquire, it doesn't mean that people have to disclose or anything else that should be, remain in their control and be their choice. But it's interesting that people do want it um spoken about. So just highlighting the fact that um there needs to be a trauma informed response to the disclosure of sexual violence by healthcare professionals and healthcare professionals need to know how to respond, not only to validate drugs, that means um acknowledging what's said, not just rushing on to sorting it out. Um So validating a means, acknowledging what's said, um acknowledging the courage it's taken and making sure that person doesn't feel alone and fe and making sure they feel supported. Um And then being aware of the follow up onward referral pathways and having those um in hand, so that it's not, it's not a disclosure and not sure what happens next. Um And also having a bit of time in clinic to um pause and let that person um have a moment after after disclosure and not rushing on to the next patient. And then the second point that I made, there was about considering trauma informed care in the health service and making sure that everybody's involved. So I did mention about reception staff and certainly the people I have interviewed in the past have been really um really clear that reception staff and admin staff have a huge impact on their healthcare experience. So people who are coming into a healthcare service and um who have a bad first experience with the person, whoever they meet at the door, um start to feel quite nervous, don't feel safe. And and I think it's really important that um ha reception staff and admin staff are involved in the training of trauma informed care as well. And also every aspect should be considered within the service. So it's about, for example, people brought up in our service, they didn't like queuing um down the street before the clinic doors opened, um which you can understand also about booking um appointments. And for example, some people wanted to be able to speak to somebody to ensure they had a appointment booked. Whereas others very much wanted to have a walk in option, whereas others wanted to be able to book in online without speaking to anyone um and to have a to have a clinic appointment. So it's just ensuring that people do have choice. One of the things about not speaking to somebody and being able to book in is because people are very worried that they're going to be asked why they're attending, why they need to be seen. And if they do mention what's happened, they are afraid they're going to have to retell their story about um the sexual violence. And that can um bring up a lot of memories, be very distressing for people and you know, should be avoided in terms of staff training. Um We have input from a third sector organization to give some expert advice and training around the topic of sexual violence, which is useful and then staff staff supervision. So that's about um taking care of staff as well and making sure that there is that support for them. So I've just got some examples of trauma informed care within our service and it depends what the service you're working in, you know what it's doing, what it looks like. But some of these are quite specific to sexual health, but some of them can just apply anywhere. So it needs your health care practice needs to be predictable. So when you see a patient or you know, when they're walking through the doors, it's quite important that people know what's gonna happen next or during an examination. Like in that video, it's important that people again know what um is likely to happen during the examination. They know that they can say um stop if they want to, websites are really useful. So we have a umbrella website that um so explains the different services that are offered within sexual health. And I think, well, I think ours could be better, but I do think that the wording in that and the way um services are the, the way we communicate with the general public through the website is really important and we can use words of support in that for survivors of sexual violence to know that they will be seen and supported and not judged and believed. Um So I think it's important to get our communications right. I think trust as mentioned throughout this um talk is really key for trauma informed care. So one example I've got is stating the limits of confidentiality. What's not good is if you ask um people about um you know, previous experiences of abuse and you know, they, they tell you lots of things and then you suddenly say, well, actually, I'm gonna have to tell other people about that and there might be good reason for that. Perhaps there's vulnerable adults or perhaps there are Children who are potentially at risk and you need to safeguard. But those limits of confidentiality need to be stated before, um you ask or before the patient um starts to, you know, so tell you all these, all these things because if not, that trust is broken and that's very damaging for that relationship with that particular healthcare professional. But also going forward can be very damaging with their future engagement with healthcare waiting times is another one. So, you know, lots of clinics run late but actually communicating with people in the waiting room going out, especially for people survivors. Um It's really important to communicate because they may be very nervous waiting in the waiting room for their um clinic choice control and collaboration. So offering tests and explanation about tests. So I don't think we, we we do investigations or we manage patients. I think it's really important to offer investigations and offer tests and offer treatment. I think it's important to empower people. So they know um you know, if they decline what they're declining and et cetera, but I think it's about offering um explanation about why you're asking questions even. So if you're risk assessing somebody to see if they need um um HIV prophylaxis, for example, rather than just asking them lots of very uh sort of intimate or possibly distressing questions without them understanding why I think it's important to explain why you're asking. Um And if and if it's something that's happened years ago, then I just don't think you need to ask. And so going into the details of what happened is not and then retelling it to us is not something that's going to benefit them and their health as we're not um counseling them, that kind of um detail would be something that would be appropriate for a counselor to do in a safe way where it's in a controlled um space for that um patient rather than us in our clinic room when we're doing our F TI screen. So for example, sometimes if it's something that's happened maybe relatively more recently, and um you want to ask about testing and you know, you've got test swabs that can go from vagina from the back passage or from the mouth. Instead of saying, well, what happened in terms ie you know, where do you need a swab from? I will say things like this. These are the tests that we have. These are the three places that we can test from. Which ones would you like? Or would you like all three? Um rather than making them um put, putting them in a place where they have to, they feel like they have to answer about what happened. I also sometimes people, well, sometimes people just refuse, they just say not ready for any type of test. I can't even face anything like that. And that's, you know, completely fine because there's definitely no way that I want to leave them feeling retraumatise after their visit. And sometimes I'll rearrange a visit when they'll come back. Um If that's what they want, sometimes we can offer home test kits which they can do the testing at home and feel it more in control at that. Um In that way. Also, I mentioned about kindness and humanity and it's quite interesting because in the interviews that I've done with patients in a research setting. This is the key, um the key thing that they find the most important aspect of their care. So they find it really important that they can connect with the doctor. Now, what this doesn't mean is that you're kind of, you know, emotive and, you know, huggy or, you know, uh you know, crying with them, that's not helpful because I guess in some ways that's kind of offloading our own feelings onto them. But really, it's about showing your kindness. Um maybe in words or in time um or, or, or in the sentences that you use and that they find um they reported to me that they find those things really helpful and that connection where you were treated like a real, the patient was they felt they were treated like a real human being and not just another number in the clinic, it's very important. Um There are some obvious things about uh re not traumatizing. So for example, um some patients were would request um uh being tested or being examined in a certain position or they would uh want certain people to be present for that examination. Um are for example, um they might have an advocate that they want there to support them. And so there are different things that we've changed in our clinic to, to allow people to feel safer and to that environment to feel safer. So, in conclusion with this trauma informed, I think sexual health services should be environments where people feel as safe as possible. It's not like we can create a completely safe or a completely not re traumatizing environment because clearly we ask a lot of personal questions and within sexual health. And sometimes as, as much as we try not to um cause distress or re trigger, sometimes that does happen. And I think it's also then for us as healthcare professionals to be aware of that potential and sometimes just to stop. And if we look at a person and we see that they're becoming distressed and becoming upset, just to stop what we're doing and just say it, it looks like you're finding this very upsetting or distressing. Shall we, shall we stop for today? Should we make another appointment or would you like me to carry on? I think I've mentioned about trust and how important that is. I've mentioned about choice control and collaboration and some of that can sometimes feel quite uncomfortable because we might not do the tests or give the treatment or do the examination that we really wanted to. But I think it's all about an informed discussion and consultation with that person. And the last point of those three was about health care, professional training in order to create this safe and supportive environment. So people can clearly fear specific aspects of the medical checkup. After sexual violence, people can have flashbacks or really vivid memories of what happened and sometimes this can be triggered by um medical examination, like the t of swabs like a genital examination. And so to be mindful of that, um and to make sure that this um staff trained within the department are all aware of that, um so that we can um some of the things that we do in clinic are um make sure that people of time, make sure people are, are are consented for an examination, that is what they know is happening and they're consenting for that to happen today. We also make sure that we've got some way um of people to indicate to us that they don't want to continue during it. So sometimes people can't speak and saying stop might not be what they can do in that moment, but they will hopefully be able to say, OK, if I don't want to go ahead, this is what happened or just checking back in with the patient and as you're going along, just checking with them that they are um OK to continue. Also grounding techniques can be helpful. So, um bringing people back to, you know, where they are in the room, maybe it's the noise around them, maybe something um happening in the in the clinic that you can hear or perhaps it's the um sensation of feeling that the couch in their hands um and just bringing them back to where they are here. And now because sometimes people can really get um caught back up in those vivid memories and it's helpful to bring them grounded back to where they are. And also I really feel it's important that healthcare professionals are trained um to recognize rape myths and victim blaming in their own practice. So, um just because we've gone through medical school or whatever healthcare professional training we've done doesn't mean that we don't hold to these views and sometimes it's inadvertently so we don't really realize that we're doing it and, and I think it's really good to be challenged. Um, and in some ways, I think it's much better to be, to recognize that you are holding to some of these rape myths and victim blaming. Um, and then be able to challenge yourself. Um, so that in your practice you're not holding to it. So rape myths, for example, um, women shouldn't go out alone at night if they don't want to be raped. Um, however, in the UK, 80% of female rape cases, the, it's the victim. Survivor is raped by someone she knows. And in 45% of cases it's by a partner or ex partner. So it just shows, you know, how to warped. These, um, these, these myths are, um, and you can see how that's obviously a huge barrier for patient to come in and say it's, you know, she's been written by her partner and particularly then if the doctor goes on to, to not really understand that or, or not quite get what she's she's saying and this is the last page. Um But I'm really sorry, I now realize that um it's, it's majority are based in the West Midlands. However, I would say that the women's aid and the men's domestic abuse support are national. And um again, if there is specific information that anybody wants to have personally, um I'm definitely, you're very welcome to um get in contact with me if that, if that would be of help. Thank you. Amazing. Thank you so much, Doctor Caswell for that. Um Incredible and very inspiring talk as always, um There was um a few questions already coming up, so I'll start with the first one. So this was from Kai. So how should you handle a situation in which a patient would prefer not to be treated by a clinician with a protected characteristic due to trauma? So, II don't know if there is a right answer to these things, but I'll tell you what I would do and that's about all I can do. So, um We, we um definitely um try to make sure that the person, the patient feels as safe and supported as they do in the clinic. So the most frequent request that we get would be to be examined by a female. And or for example, there could be a health care assistant who's a chaperone who will be present in the room, who the patient would say I'd prefer a female or I'd prefer them not to be here at all. And I will um respect that and make that a safe place for them. Sarah, do you want to ask yours? Um Yes, please. So um you gave an example earlier about um upset patients in waiting rooms and s that made me think about how sometimes when people have strong emotions, it can be taken very personally by staff. Do you have any advice that we can use to kind of influence our colleagues to be a bit more trauma informed in their approach? Especially from like a student perspective where you're like where the people that you witness are a bit more senior than you are. Yeah. Goodness that is tricky. Um Yeah, it is, it is about being trauma informed. Um I think, um, well, we certainly, I think it's become, being trauma informed, has become increasingly um talked about within the NHS. So the NHS, er, now the, the government actually has put out definitions on the website only in the last couple of years, never there before. So North America had it years ago and, and you know, everybody was talking about trauma informed care but UK much more, well, Scotland way ahead of the game and then England kind of catching up. Um but II mean, I think it is more talked about, I think there will be more training and I think people will be, you know, will be, become increasingly aware of it. Um, do I, what can you do at that time? I guess it's what it's very difficult, isn't it in that moment? Um, hopefully there will be training. I actually find a lot of, kind of senior, um, doctors are often very good at handling, um, kind of, uh, conflict or whatever. They think they've seen it so many much they realize, I mean, it's not personal and, you know, they get that I do see other staff who struggle with it more and clearly react to it. And I think for me then for me, but I realize I'm not in the same position as a, you know, a student. Um But I think for me, I feel like, you know, me kind of stepping in and going, trying to solve it or just taking a step back and basically acting out how I think it should be handled sometimes in the moment it's not right thing to kind of pull somebody away and do whatever you're trying to sort out the situation, aren't you? But I think often people learn by the way you do things by watching. So I guess that's how I would do it. Thank you. Um There's just been another question in the chat from George mcnaughton. Um They say I really struggle with trying to help manage expectations and explaining what will happen. I'm an A&E and Ob Gyne with very chaotic departments and high likelihood of me being called away. Um, so leaving people for much longer than I hoped or someone else having to examine them. For example, I try not to promise anything timing wise, but I do want to give them clear plans as to what will happen next. Any ideas as to how to manage this, the, yeah, I find that hard exactly what you're asking because it sounds like you're just really, really busy and there's not much, I mean, you, you sound like you are doing what you can in terms of um explaining to people. Um and, and letting them know what will happen. So I'm not, I it sounds like you are doing what you can, you're not leaving people in the dark, you're not just, you know, leaving them disappearing off. Um I guess that there are staff alongside you that work with you. They're also aware of the importance of this. I think communication is probably the, the biggest, most important thing that you can do. Um But it sounds like you are doing it, whether the people you work alongside are also doing that, I guess is the only other thing I would think about. It sounds like you might, yeah, you need to look after yourself with all of that as well because um that's hard working at that intensity. And then there's a question about how do we implement this in the case of individuals who have learning differences or a death, for example. Um, and they've said in, in terms of, we offer chaperones for examinations like breast exams and cervical swabs. But in this case, if there's trauma, they might not want an addi, um, an additional individual in the room. S uh, ok. I see a little bit as well. Um, so just leaving out the first of all, the bit about, um, learning differences or death, just leaving that bit in terms of chaperones, um II, and again, don't take my word as you have to just work out what's right. But for me, um, there are some patients who do not want anybody there who don't want to be chaperoned. So we, we always have a chaperone in our sexual health clinics. Um, but there are sometimes people say to me who, um, have experienced trauma that they do not want anybody else in the room. Um, and I will respect that sometimes people want an advocate, so not somebody from the NHS or it might be a friend and that's fine. I'll take the name of them. Those things happen pretty rarely, but I do respect them. Um, I have to admit I'm not very good at doing swabs at the same time as speculum exam and getting it all in the right place um, with all the slides and everything. But I do my best. Um, in terms if, if, what if, if, what I'm understanding here from this, for example, if you're worried about somebody's capacity. It's very different, that's a whole different talk for some other evening. If that's what you're getting at in terms of chaperones, um, if it's in terms of you not feeling comfortable, so you don't feel happy doing the examination without a chaperone present, then I think that you should not do the examination without a chaperone present. Um, and that, um, and that's, yeah, that's something to discuss and, and, and work and work out, I guess, um, with that patient. But, um, yeah, sorry, Stephanie, I'm not, I'm not quite sure if I'm quite answering your question though. I just have another question if that's ok. Um, I was wondering, are there ways that we can individually impact more, like hard rules that maybe aren't trauma informed? The thing that comes to mind is, um, like, do not attend, like sometimes you have three strikes and you're out. But, um, as we know, there are some people who are more likely to not attend than other people. So, in our now world of sexual health, I'm not sure we have that rule ever. So, so, um, so maybe that's, um, is that with other, within other departments? Is that? Yeah, I mean, that's a really good example, isn't it? And, um, and, and, and I guess you can really see both sides of that so you, you can see how I, and I guess to me it's about supporting that person attending, that's what it comes down to because the, the do not attend to strike out, like, say you get made it to 10 and they didn't attend for 10. That's clearly not the answer. So I guess it's about really understanding about ha having that discussion. Do they know what they're coming for? Do they know why they're coming? Do they know? Do they understand what's gonna happen? Are they afraid? Are they, can they not get there by transport? I mean, there's so many other factors aren't there. Um, and to me it's probably about thinking about those and addressing those and, you know, frequently, I guess in terms of, um, HIV clinic, um, I think, you know, there are people that don't attend for investigations and I end up, you know, we don't, there are, sometimes it feels like three strikes and they're out from other departments but I end up having a conversation with the patient and saying, you know, what, what is it, why, w what is it that's creating the barrier here? I don't say it like that. But, but that's essentially what I'm asking them and, you know, often it'll be fair, often they don't understand what they were being referred for in the first place and I think those are the things to address. Mm. Yeah, that makes sense. Thank you. Yeah, you're thinking more in terms of capacity. Yeah. So, so that, that's, that is difficult. Um, Stephanie, I guess, I guess, I mean, the same thing, the chaperone thing is to my mind somehow slightly secondary still in that scenario. So in, in terms of capacity, do they have capacity to be examined? You know, are they, do they have capacity to do the for them to accept the test is that, you know, is it there's a lot more to think about, especially when it comes around to, um you know, obviously when it comes around to sexual violence and things like that, we're thinking about capacity to consent, um or not a lot of things to kind of tease out and in some ways the examinations, the kind of least of the concerns and, and all, you know, that swab is, is, is um sort of a slightly less important point. I tend to find that um people, the vast majority of people will accept a chaperone. It's very rarely that people will say no, thank you. I don't want a chaperone. And in this situation, I suspect they'll be quite happy to have a chaperone. Um The, the people who, who decline or don't want it are people who usually, sometimes people have a lot of trauma um and just find it really, really difficult to trust somebody else. Um Yeah, great. Well, that brings us to eight o'clock. Um The feedback link is on the chart if everyone doesn't mind filling that in. Um And thank you so much to um Rachel and Sarah for tonight and we'll see you all next month for another webinar, take care everybody.