Most health care professionals choose their careers because of a genuine desire to help people. They want their clients to benefit from the services they offer. Because touch can affect survivors of sexual abuse so strongly in unexpected ways, understanding the potential effects of touch on this client population is essential for all health professionals.

When we understand these effects and apply this understanding to the way we touch in the health care setting, the unexpected and delightful result is that survivors of sexual abuse can heal completely from the most previous assaults. I have had many clients who suffered horrific years of consistent sexual abuse and who are now recovered and free in a way they never knew was possible. One case of remarkable recovery is Danielle. In her childhood, Danielle had been abused consistently in the most violent and invasive ways. At 30, when she started on her healing journey, she was fragmented, in excrutiating physical, mental and emotional pain, and in a black hole of despair. Now, she functions at top level in her life, free from the clutches of the past, and enjoys each day from the perspective of not only having survived, but also having evolved to a level of existence that is joyous and meaningful. Every touch adds or subtracts from such potential.

Sexual abuse is a form of negative touch. The physical impact of sexual abuse is not only the beginning of long-term, deeply embedded harm that occurs for the victim. Complete recovery is not a linear process. Healing is complex. It requires time and a comprehensive approach that addresses all the layers of injury - physical, mental, emotional and spiritual. Recovery is most likely when health care is designed to recognize and address the particular needs of this client population. Even years later, the best intended therapeutic intervention can and many times does, exacerbate the already painful injuries, thus becoming part of the problem. The method of delivering health care is critical to how the person responds.

Sexual abuse affects the emotional, mental, and spiritual aspects of the person. It is like a thief, violently robbing the spirit and thrusting the person into a state of shock, fear and grief. Lifelong changes are set in motion. The abusive act interrupts the natural developmental flow of the person, no matter what phase of life they are in. It injures the heart and soul. Common stresses can feel like matters of life or death. Life can become profoundly difficult and frightening. Life will never be the same. It can, and often does, take a lifetime to completely recover.

All health care professions function according to the basic principle extracted from the Hippocratic Oath [1], Do No Harm. This is easier said than done when delivering health care to survivors of sexual abuse. The effect of treatment is unpredictable if there is no understanding of the many possible ways this client population may experience touch. The intended results can quickly turn into unintended, unwanted consequences. At worst, well-intended efforts may cause the client to re-experience the results of the past abuse and undergo trauma once more. The client might feel alienated by this and discontinue treatment, without saying that anything is wrong. Or, the healing effect of the therapy may delayed or negated. Even worse, the client may blame the practitioner for the trauma experience in treatment. The client may not realize that the effects of past abuse have been triggered and are causing the current distress. These are only some of the possible devastating consequences that can occur. Navigating this sensitive arena requires an in-depth study of survivors in the health care setting. Unfortunately, training in the health care professions does not currently address these issues adequately.

Not All Touch is Equal

How people receive and experience touch is unique to each individual. A procedure such as a blood test may feel routine to one person, but invasive and risky to another. A massage may feel wonderful to one person but threatening to another. The negative touch sexual abuse survivors have experienced affects their perception of all touch, even touch that is designed to soothe or benefit. Most survivors of sexual abuse have issues that arise when they receive health care and because of this, many assiduously avoid any health care involving touch. At the other extreme are those who seek invasive health care procedures obsessively and replay the pattern of invasion over and over in controlled environments. Others merely suffer silently through - and after - their health care.

Consider the circumstances of several of my clients: Jean has never seen a gynecologist in her life. She is 57 years old. Carol had a serious automobile accident with injuries to her nervous system. She saw a doctor but would not go through with the medical diagnostics needed to determine treatment. Muriel was sexually attacked. She has not reported the incident, nor received medical care, nor talked with legal counsel. Barbara has had countless cosmetic surgeries, the most extensive including breast enlargement and liposuction. She complains of horrible effects on her well-being after each procedure yet is planning the next with the same breath. Sharon has regular check-ups with her doctors and follows their suggestions to the letter. After each visit she feels traumatized and deeply confused. Richard gets sick often and it takes him much longer to recover from common ailments than most people. What do all of these clients have in common? Their history of sexual abuse. Each of them has profound issues regarding touch. Their history presents serious obstacles to receiving the health care they need in a way that they can receive it.

A Working Definition of Touch

The medical definitions of touch have a narrow scope which primarily addresses the physical. Taber's Cyclopedic Medical Dictionary defines touch as "To perceive by the tactile sense: to feel with the hands, to palpate." The American Medical Association Complete Medical Encyclopedia defines touch as "One of the five senses. The sense of touch relates to the body's ability to sense vibration, pressure, temperature, and pain."

In The American Heritage Dictionary, the definition of touch is expanded to include other ways the word is actually used in our language. We find that it has many applications that relate to other senses, and to aspects of the human system other than the physical. Sample excerpts include, "To bring one thing into contact with something else: To put in touch with; To have an effect on, to move emotionally: Her sadness touched me deeply; A mild attack: a touch of the flu; A characteristic way or style of doing something: the right touch."

These definitions fall short of what a practitioner needs when delivering health care, especially to survivors of sexual abuse. We need a definition that recognizes touch as something that occurs in the context of a relationship between the giver and the receiver. Our definition also needs to offer a comprehensive viewpoint specifically applicable to the health care setting.

The foundation of my work includes the following five working hypotheses:

1 What touch conveys is dependent on how it is used and how the recipient interprets it. Touch is a non-verbal language. Touch, like all languages, can be learned and used intentionally.

2 Touch permeates all parts of the person being touched. Touch has the potential to impact the physical, energetic, mental, emotional, psychological, and spiritual components of the human being.

3 We make contact in many ways. Physical touch is the one we are most aware of. Other ways we make contact include mental, emotional, spiritual and energetic connections. The health care practitioner must be aware and intentional when using any form of touch.

4 Touch is interactive and takes place in the context of the therapeutic relationship between practitioner and client. The therapeutic relationship is as important as the technique or procedure used.

5 Touch is an integral part of the healing process. The practitioner's approach to touch largely determines the quality of touch the client receives. The quality of touch used to administer health care techniques and procedures strongly influences the direction, pace and success of the healing process.

The Language of Touch

How is touch like a language? Speech is a form of communication that we express through the medium of sound and receive through the sense of hearing. Touch is a form of communication that we express through the medium of physical contact and received through the tactile sensors in the skin. The type of speech can be Italian, Chinese, Hebrew, Gaelic, and so on. The type of touch can be a handshake, a pat on the back, a massage, or a chiropractic adjustment, to name a few. Like spoken language, the language of touch can be ambiguous and is always interpreted by the receiver. Touch, like speech, is always more effective when it is well intended, given by a person skilled in its use, and received by a person who has granted permission.

Intentional Touch

All touch communicates something, whether intended or not. A mother holds her baby close - both relax and she pours love into her child. The baby receives the message that it is loved, cared for and safe. A happily married couple embraces. They both receive messages of love, comfort and affection. Two friends that have not seen each other for a long time smile and shake hands when they meet. They both receive the message that they are glad to meet again. These examples are natural expressions of one human towards another in a healthy relationship.

Touch can be random, automatic, or intentional. This does not necessarily depend on the training, experience level or motivation of the practitioner. The health care delivery system that I have developed takes into consideration all of the factors that shape the way people make contact and respond to touch. This system's approach surrounds and guides the use of techniques.

Whether touch is intentional, automatic or random, there are several factors that shape the way the receiver responds to it:

1. Practitioner's approach

2. Client's history

3. Practitioner's training and experience working with survivors of sexual abuse

4. History or lack of history between the client and practitioner

5. The current emotional state of the client and the practitioner

6. The field or environment in which touch occurs

7. Social and cultural factors

8. The survivor's brain interpretation of the touch

One or more of these factors play a part in these examples:

Sarah was molested as a child. The person who molested her threatened to strangle her if she screamed or told anyone. He put his hands around her throat while telling her this. In her 40's, Sarah suffered a neck injury and was referred to a physical therapist for treatment. The first time the physical therapist worked on Sarah's neck, her neck muscles tightened. The physical therapist interpreted this as Sarah trying to help with the work. She made a seemingly innocent joking remark to Sarah while her hands were on Sarah's neck. Sarah froze. The way Sarah tells it is: "I was suddenly six years old and his hands were around my neck again. I was frozen with terror." It took Sarah many months of therapeutic intervention to understand, come to terms with and heal from the retraumatization. With professional assistance, Sarah used the material that surfaced from this experience to heal from the original trauma and emerged stronger and more whole. Afterwards, Sarah said, "I was convinced that physical therapy was not for me and that my physical therapist was rough and uncaring. Now I realize that the physical therapist did not know that my needs were specific when being touched." When Sarah was strong enough, she was able to give the physical therapist feedback. Her physical therapist was grateful to have this brought to her attention and Sarah started treatment again, this time with an excellent start of a therapeutic relationship that gave her a say in her care. Factors influencing this situation were:

• Sarah's history
• Practitioner's lack of awareness to Sarah's history
• Practitioner's lack of training and experience working with survivors
• Lack of history between Sarah and the physical therapist

Gary has a history of having being bullied and sexually assaulted during a two year stay in prison in his early 20's. He is 65 years old. Recently he went to a chiropractor to get relief from lower back pain. Each adjustment gave him immediate relief, but within an hour of treatment, his back hurt worse and he felt enraged and full of resentment. His generation was taught not to question the authority of health care practitioners, and not to make waves. So he continued to go to the chiropractor and did not tell him about his reactions. At first Gary thought there was something radically wrong with himself. With professional assistance, he realized that the adjustments were tapping into old, unprocessed trauma from his early life. Gary says, "It never occurred to me that the problem was not my inability to heal, but rather the need to find a practitioner who understood how early trauma plays into the healing process." Factors influencing this situation were:

• Gary's personal history
• Practitioner's lack of training and experience working with survivors
• Practitioner's lack of awareness of Gary's history
• Social and cultural factors

Harriet was raped 20 years ago. Now 45, she has been on medication for depression for five years. It is not uncommon for a woman who has a history of sexual abuse early in life to begin to experience depression 20 or more years later. Her medication can be difficult to regulate and at times when it needs adjusting her perspective can be skewed. Until her medication is balanced, receiving health care is risky because she may perceive those around her as wanting to hurt her. She may not verbalize her fears, but may instead isolate herself and suffer silently. There are subtle signs she will display during the health care that only a practitioner trained in the nuances of touching those who have experienced sexual abuse would recognize. Harriet says, "When I feel paranoid, I am too afraid to be visible, so I stay as quiet and unobtrusive as I can. It is painful, but feels very necessary to my survival. Sometimes I feel like I will be killed if I speak up." Factors influencing this situation were:

• Harriet's brain's interpretation of the touch
• Practitioner's lack of training and experience working with survivors
• Harriet's current state

Touch is Interactive and Takes Place in Relationship

In the therapeutic environment both the client and the health care practitioner have expectations, hopes and agendas. These remain hidden for the most part in the collective expectations set up by the culture and its systems. For example, if a woman sees a physician for an exam, she expects the physician to perform certain tests to determine the state of her health. What happens when the style of touch and the decisions communicate something other than what the patient expects and considers acceptable? The patient may feel as if something unacceptable took place or may leave with unmet expectations. A patient with a history of sexual abuse of sexual abuse may leave in considerable distress, experienciing some combination of confusion , dispair, fear, memory loss, disorientation or a feeling of having been misused or tricked. The physician, on the other hand, may be completely unaware of having done anything that had this effect. Physicians are trained to perform the exam in a specific way in order to obtain accurate data. If the patient manifests unusual reactions to the exam, the physician may even feel the patient's reactions are unacceptable patient behavior and not within the scope of obligation to the patient.

The touch that a physician performs is guided by that physician's training. There is no guarantee that the patient and physician have the same expectations, yet each assumes that they do. It is likely that neither person's expectations were communicated to each other.

The Impact of Touch

For survivors of sexual abuse, even well-intended touch can trigger unconscious interpretation rooted in past trauma, unrelated to the present circumstance. Let's revisit Jean's situation. At 57, she realizes that having a check-up for her reproductive health is wise. However she is terrefied of medical procedures in general. Recently she had a very bad experience with a physician that reinforced her fears. After the appointment Jean felt abused. She left the office confused, in despair, and angry. She sought professional help. It was only when she processed the incident did she realize that it was the resemblance of the physician to her abuser and the resemblance of his office to the room that she had been abused in that triggered her reaction. While the physician was giving her treatment, Jean unconciously regressed and re-experienced the trauma of her childhood sexual abuse. A developed therapeutic relationship, started at intake, and carefully nurtured throughout the appointment and all future appointments would have prevented this situation. It is important to take the time to invite information from the patient and use this information respectfully throughout the treatment.

Conclusion

Touch is a language. All languages communicates and there are two sides to every communition. To deliver health care to survivors of sexual abuse effectively and safely, it is essential to be aware that this language of touvh does happen in the context of the therapeutic relationship. And, whether one is a massage therapist, a nurse, or an acupuncturist, it is paramount to understand that survivors of sexual abuse are extremely sensative to interactions with others. Time spent with them must be preceeded and interlaced with development of trust and respect. The therapeutic relationship that offers safety and clear boundaries will significantly lower the risk for both client and practitioner and increase the liklihood that healing will occur as effectively and speedily as possible. One's overall approach to touch is as important as the actual service provided and the goal is to provide quality health care which maintains a safe environment and consideration of survivor's needs so that the past traumas are not triggered. With attention to the therapeutic relationship and the approach to touch, not only will the practitioner prevent problems, but you offer the client a profound opportunity to heal completely and to emerge as a clearer, healthier person.

*The names of all clients have been changed to protect their privacy.

Donna C. Cerio, MsT, HHE, PhDc has been a Health Care Practitioner and Educator since 1979. Donna is the developer and primary instructor of the Intentional Touch certification program. This is a training for health care professionals who want to specialize in working with sexual abuse survivors. Visit www.thecerioinstitute.com & www.intentionaltouch.com for more information.

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Recently published work by Donna C. Cerio: The Wounded Client: Guidelines for Working with Survivors of Sexual Abuse - Massage Magazine, November/December 2003 (Issue 106)