Why does it take some people so long to get the care they need?
On a clear October morning, Bianca walked her standard poodle. Without warning, the dog yanked hard on the leash. Bianca felt a quick, tight pull in her right shoulder. It was warm and sore for a few days and then settled into a dull ache. Bianca found herself struggling with everyday activities like carrying groceries and lifting her toddler. Three months later, Bianca went to her doctor who confirmed that it felt "crunchy".
Why did it take so long for Bianca to get the care she needed?
Black women (like Bianca) and Native women are more likely to be sexual trauma survivors. Sexual trauma survivors are a group that sometimes avoids healthcare. When they do, a healthcare provider is often the reason.
Sexual abuse survivors have at least one person in their past who used power and control against them. A healthcare provider or professional is someone with more power and control than a patient or client. Because of past trauma, some sexual trauma survivors can feel suspicious or even fearful of their provider. This fraught-from-the-start relationship becomes more complicated when the provider is of a different race.
Dr Abigail Sewell has examined how differences in race and ethnicity influence trust in a provider (1). She found that African Americans and Latinx patients are less likely to trust the “technical judgment” and “interpersonal competence” of their physicians. Dr Sewell’s research also finds that racial minority patients say that their visits are “less participatory” and more “verbally dominant” with their provider than white patients do. These findings echo what I have heard for years from the Black women who attended the support groups I facilitated. Experiences including:
Being called unfair, projecting or misreading when sharing personal experiences;
Being instructed to step on the scale at a WIC appointment for their child;
Exposure to stereotypes ("what's your drug of choice?") or assumptions about being a drug addict when seeking pain relief;
Weight shaming and/or advising that their weight is reason for the issue, advised to lose weight;
Repeatedly being asked if they are pregnant or when they are going to stop having babies;
Touch by a provider without consent and/or without stated reason for doing so.
It should not need to be said that treating people in such a reductive way is dehumanizing. Shaming anyone for their experience or choices (although I would argue that one's weight is less a "choice" and more an amalgam of experience, genetics, and personal history) is not an effective way to help anyone change or become more healthy. For abuse survivors, however, situations like these can also be re-traumatizing. Because they re-enact the damaging power and control dynamic that was used against them when they were abused. For Black women specifically, however, these examples are one more way that simply by visiting a healthcare professional they are exposed to implicit bias or what I call racism.
Trauma survivors want to thrive and feel good. They want control in their own life so that they can feel normal, like everyone else. These desires show self-efficacy and support good health. So what can be done to help trauma survivors get the care they need?
One way to help survivors is to offer choice. A choice is a step that builds trust. An ask is a choice that shares power because it signals that someone's answer matters. That their answer will be taken into consideration. Choices are overt gestures of connection that build trust. Not telling someone to get on the scale but asking them if they would like to be weighed.
Another way to offer choice is to ask how someone would like to be addressed, "is it Elizabeth, Ms Johnson or Mrs. Johnson?" It's important, especially for white providers, not to assume familiarity or a relationship that isn't there. Another dynamic ask is: "what do you think the issue is?" Sometimes patient has an idea about the problem but is hesitant to say it aloud, especially unprompted. Asking "what do you think the issue is?" also reminds clients that they know their bodies best. It's a powerful way to assure a sexual trauma survivor that their body is not broken or damaged, that a survivor can and should trust what their body tells them.
Almost a year later, Bianca's shoulder is back to normal. She had several appointments with a physical therapist which helped not only mend her shoulder but also build confidence with a new healthcare professional. When I asked Bianca how things went with the physical therapy she told me, "Suzanne listened to me. And she helped me listen to my body in a way that I never have." Maybe next time, Bianca won't wait three months before seeking care.
I am talking about this and more at the “38th Annual Perinatal Conference: Gravidas at Risk” on November 19.
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1) https://pubmed.ncbi.nlm.nih.gov/26463531/
