When gynecologist Florencia Greer Polite of Penn Medicine asked a patient in her mid-60s about her first sexual encounter, the response gave Polite pause. “She said, ‘Time of first consensual or non-consensual intercourse?’”
The patient was one who Polite had seen for routine gynecological care a few times, but this interaction included a discussion about human papillomavirus (HPV). Exposure to HPV can happen during a person’s first sexual encounter, so Polite needed clarification—though she treaded lightly. “I said, ‘Let’s talk about the difference in those two dates,’ and the patient said, ‘My first consensual intercourse was in my 20s, but I was raped when I was 8.’”
For Polite, who sees patients ranging in age from early adolescence to post-menopause, such conversations have become more common in recent memory. They made her start to ponder what responsibility she and physician colleagues have to support patients who have endured sexual assault. She also wondered about the role doctors should play in teaching patients, particularly younger, inexperienced patients, about the meaning of consent.
“It started becoming clear that there are many women dealing with trauma that happened years before,” she says. “It’s also become clear that we’re a sacred space, a no-judgement zone. That’s what an obstetrician or gynecologist should be.”
During the Senate Judiciary Committee hearings for Supreme Court Justice Brett Kavanaugh and the testimony by Christine Blasey Ford, these ideas that had long simmered below the surface for Polite moved front and center. She felt that the educated physician perspective was missing from the discourse, which focused instead on the idea that because a certain amount of time had passed, Ford’s recollection of what had happened wasn’t reliable.
“Who’s to say how long someone will remember one of the most traumatic incidents in their life? They may remember things that are so specific, like what underwear they were wearing, who was in the room, and where,” Polite says. “The idea that because of time alone, you can’t trust someone’s memory, I was like, where are the people advocating for the patient? Where are the physicians? We were told, ‘This is a legal matter, stay in your lane.’”
So Polite and colleagues Rhonda Graves Acholonu of the Children’s Hospital at Montefiore and Penn Medicine alumna Nzinga Harrison of Eleanor Health did just that—by writing a commentary about the matter for the July issue of Obstetrics & Gynecology. In the paper, they argue that beyond the responsibility physicians have in terms of the medical, legal, and mental health aspects surrounding their patients and sexual assault, they also have something the researchers call “social responsibility.”
“The first tenet of our social responsibility is prevention. We need to recognize acquaintance rape as the public health crisis it is,” they write. “Preventive medicine is a mainstay of clinical medicine and certainly should include prevention of sexual assault.”
Part of that means education about consent—when it’s given, when it’s not, and how to tell the difference, as well as how to make certain your own intent is clear. When Polite talks with high school students about the subject, she often shows a movie clip of a boy and girl together at a high school party. The girl has been drinking and is throwing herself at the boy. He is completely sober. Polite then asks the room whether a sexual encounter between these two, should it come to pass, would be consensual.
“We do it in a debate style. One side of the room says yes, the other side of the room says no,” she explains. “We eventually get to the point I know we’re going to get to, which is that someone says the girl is wearing a short skirt and she came to the party looking like she wanted to be touched.” It’s important for the conversation to lead here because then Polite can hammer home the point she’s trying to make: Consent means paying attention to what someone is saying rather than making prejudgments based on societal norms.
She can then get into more detail about this important communication. “Consent is something that has to be actually stated,” she says. “‘I am consenting to X, Y, and Z.’ Somebody has to be without the influence of drugs or alcohol, they have the right to give it and to take it away, and it’s something that’s per event only.”
In the clinical setting, Polite aims to convey the same points to her patients. She has also changed the way she discusses the subject, particularly once she knows that abuse has occurred.
“The trust piece is huge, so first we settle into a space of, I believe you, this is a safe environment,” she explains. Then she apologizes to the patient that something like this has happened, before asking a few, gentle follow-up questions. “I no longer fire off questions. That can be jarring and may make the patient think we don’t believe her.”
The goal of this work—the paper, the new methodology in the clinical setting—is to spark conversation among physicians in all specialties, to reframe how they see their role, and to remind survivors of sexual assault that their doctors can offer them a support system, survivors like the patient of Polite’s who waited more than five decades to share her story.
Florencia Greer Polite is an associate professor of clinical obstetrics and gynecology in the Department of Obstetrics and Gynecology at the Perelman School of Medicine at the University of Pennsylvania. The Obstetrics & Gynecology paper was titled, “A multispecialty perspective on physician responsibility to sexual assault survivors.”