Touching Invisible Scars

It was the stories about bodies that got Carol Stalker and Candice Schachter thinking: the stories they had heard from female survivors of childhood sexual abuse. The chronic pelvic pain, chronic headaches, lower-back pain, and gastrointestinal disorders that had no medical explanation; the deep distress that dental treatment could cause them; the extreme sensitivity they felt to touch – and, above all, the unease they experienced, edging toward panic, when healthcare professionals came near them.

Stalker had heard these stories as a social worker doing therapy with women who were sexual-abuse victims at the London Health Sciences Centre, in London, Ontario. Schachter, a physical therapist, had been a volunteer in a London sexual-assault clinic. Subsequently, they both went on to academic careers: Stalker as a professor of social work at Wilfrid Laurier University (WLU) in Waterloo, Ontario, and Schachter as a professor in the school of physical therapy at the University of Saskatchewan, in Saskatchewan.

The stories of the London women they had worked with stayed with them. The question that lay at the back of their minds was: How would these people, who had suffered so much injury to their psyches, respond to physical treatments? Schachter had the idea to do research with the survivors of child sexual abuse who had been referred to physical therapy, and she became the principal investigator of their subsequent study.

The Study of Suffering

For Carol Stalker, whose approach to research, frontline social work, and life can be summed up in one word: action, the search for the answer was both a symbolic and a concrete step forward out of the shadows that still envelop childhood sexual abuse.

In 1985, a decade before Stalker began her academic career, just as the women's movement was beginning to make the public aware of the issue, Stalker and another social worker started a therapy group for childhood sexual-abuse survivors in London. They were instantly overwhelmed by the number of women asking to join the group.

The darkness in Stalker's own life gave her a special empathy with the pain of the women she was working with. Her father suffered from serious depression; her two sisters (twins) were developmentally delayed; her marriage had ended, leaving her a single parent. Her Master's thesis, interestingly enough, was on the epidemiological aspects of mental illness and social disintegration in London.

The research material, about women at the time, who had been sexually abused as children was thin to the point of being non-existent. Stalker quickly became fascinated by why some women survived sexual abuse with seemingly little damage, while others never climbed out of the ruins of their lives. She became intrigued by the physical pains many adult survivors felt.

In 1988, Carol began work on a doctorate in social work – funded by research awards she won both in Canada and the United States – at Smith College, in Northampton, Massachusetts. Her PhD thesis examined how women adapted to childhood sexual abuse. After she started teaching at WLU in 1994, Stalker began designing courses in, and writing prolifically on, childhood sexual abuse.

Survivors Speak – Therapists Listen

Eli Teram, a WLU social work professor with expertise in research methodology who knew both Stalker and Schachter, brought them together in the late 1990s and was involved in all stages of the study. The result: an academic collaboration that produced the Canadian government's Handbook on Sensitive Practice for Health Professionals – now mandatory instruction for physical therapy students across the country and included in the Canadian Medical Association's clinical practice guidelines.

Stalker describes the handbook as a bridge between mental and physical health workers. Its subtitle is "Lessons from Women Survivors of Childhood Sexual Abuse." It is written in plain, down-to-earth language. And woven through the statistics and background information on sexual abuse are the voices of the real human beings who come for treatment to the offices and clinics of professionals Stalker calls "touch-therapists," which include doctors, nurses, physical therapists, and dentists. There is the 60-year-old woman with a recent hip replacement who could not explain to her exasperated physical therapist why she was unable do the exercises that required her to spread her legs; the woman sitting in a curtained cubicle feeling terrified that at any moment a stranger would pull back the curtains; the woman saying how hard it is to go to a dentist because her childhood abuse had involved oral sex.

Stalker, Schachter, and Teram began by conducting in-depth interviews with survivors of childhood sexual abuse who had been treated by physical therapists and other touch-therapists, such as chiropractors. They selected only women who had also sought help from mental health professionals (on the grounds that these patients would have a greater awareness of the issue and have support if the interview proved upsetting). They then brought small groups of the women together with small groups of physical therapists to talk about the interview results.

What emerged – powerfully – from the discussions were the feelings survivors had about the attitude of some of the therapists, the tone of voice the therapists used, the medical model of control: "I am telling you to do this because I know what's good for you." It was that relationship, the women said, that triggered their past trauma, caused them to panic. It was sudden touches that they didn't expect, procedures that they didn't understand.

"It was reminiscent of the abuse experience when they were being controlled, told to do things, forced to do things," says Stalker. And, if the healthcare professional gets frustrated and annoyed with the abuse survivor who doesn't follow instructions, more stress is added to the relationship.

One in Four or Five

The incidence of childhood sexual abuse among women is between 20% and 30%; among men – on whom less research has been done – it's possibly as high as 15%. At the start of each year, Stalker lays those bleak statistics before her WLU students. She looks around a class of between 20 and 25, most of them women, and she tells them: "The odds are that five of you have been victims of what we're about to discuss."

In fact, the suspicion – although solid supporting studies still need to be done – is that healthcare professionals see even higher percentages among their regular patients. Stalker said research indicates a clear link between physical pain experienced by abuse victims and post-traumatic stress disorder (PTSD), the syndrome that causes the mind to replay past traumatic experiences, especially those from childhood. People with PTSD tend to have an exaggerated startle response. Many suffer from severe sleep-deprivation that, in turn, leads to long-term health problems. Stalker said studies comparing people with histories of childhood sexual abuse to those without histories show the former have far greater utilization of the healthcare system and a much greater incidence of chronic pain.

Collaborative Treatment

Stalker, Schachter, and Teram designed the handbook to be a workable tool for healthcare professionals with tight schedules, one which would not require them to venture into areas beyond their expertise. They knew that the busy professional, confronting a patient who inexplicably will not let herself be touched, has neither the time nor the knowledge to probe deeply into the patient's state of mind.

Accompanying the handbook is a model consent form developed collaboratively by survivors and physical therapists. "This is the message we're trying to get to health professionals, [to take] a more collaborative approach, an approach where you really try to partner with the client or patient," says Stalker.

The handbook does not advocate that women should disclose their past abuse to touch-therapists. It asks therapists to be sensitive to patient responses that may appear irrational and make the link to a possible history of sexual abuse. It asks them to explain their treatment procedures as they go along, to tell their patients where they are going to touch them and why, and to stop treatment if they sense a patient's discomfort and suggest, perhaps, that the patient may wish to talk to their family physician or other professional about their anxiety.

The consent form (which could more accurately be called a contract between therapist and patient) explains to the patient that she will have to wear shorts and a T-shirt during treatment and that the therapist will need to observe her body, touch it, and move parts of it. It says the patient can have a friend or relative in the room with her, and she can, at any time, ask the therapist to stop the treatment.

Finding Solutions

Since co-producing the handbook, Stalker has been invited to China to give sexual-abuse workshops. She has given workshops for women throughout Ontario on self-image and assertiveness. She carries on a social work practice in addition to academic life. She is remarried, happily, to an elementary school teacher.

She describes the handbook as "action research" – a clinical best-practice guideline for healthcare professionals. "Basically, we're just trying to educate them." It's how Carol Stalker likes to do things: see a problem, come up with a solution.

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