Jennifer:
Thank you so much, Amy. Now, I’d like to turn this over to Rene.
Rene Andersen:
Good morning or good afternoon. This is Rene Andersen, and thank you Amy for such a wonderful lead in. My task today is to talk about how do we get and keep women engaged in caring for their oral health. The presentation’s going to offer concrete suggestions that help avoid common problems that prevent women form seeking dental care.
For women trauma survivors, pregnancy is a particularly challenging time. Most women experience joy, fear, doubting, anxiety, a sense of connection and disconnection. For women who have been previously victimized through childhood physical or sexual abuse, domestic violence, or sexual assault, this time of pregnancy is particularly fraught with either conscious or unconscious feelings. It can trigger feelings of trauma, including physical pain by an authority person and unbearably intense emotions.
Let’s look at the scope of this issue, the scope of the issue of violence in America today. Every 35 seconds, a child is abused or neglected in the United States.  In the past minute that I’ve been speaking, three children have been abused. Every six hours, a child dies from abuse and neglect, and almost 500 women are raped or sexually assaulted each day.
Women and girls are most likely hurt by someone they know intimately. Usually childhood physical or sexual abuse is perpetrated by a family member or a neighbor but someone that the family and the girls know well. For an adolescent girl, the greatest risk of harm is from someone she loves.
I’m going to skip this slide on men since we’re going to be talking about pregnancy. So, let’s get a look about violence and culture. More than half of lesbians report at least one incident of sexual coercion by a same sex partner. American-Indian, American native women are victims of violent crime including rape or sexual assault at more than double the rate of other racial groups.
Twenty one percent of Asian American women have a history of sexual abuse. We suspect that is a low report, and a study of South Asian women found in heterosexual relationships that 40% of participants had been sexually or physically abused by their current male partner.
What we know is violence is the norm and not the exception in women’s lives. It is universal, and we refer to this as the centrality of trauma. In 1998, I heard about the ACE Study, the Adverse Childhood Experiences Study, which was a collaborative effort of Kaiser Permanent and the CDC, and it’s the largest study of its kind, over 17,000 participants, and it examined the health and social effects of childhood experiences throughout the life span. Now, it’s interesting because the majority the participants were white, 77%. They were 50 or older. They had attended college. They had health insurance. They were at Kaiser Permanente. So, this is a group that we typically think would not be of great risk for physical and sexual abuse. The women, though, reported at least on childhood experience involving abuse or family strife, 66% of the women.
How did they define adverse childhood experience? Well, they defined it as childhood abuse and neglect, physical and sexual abuse, and growing up in a home environment where the mother was treated violently. There was substance in the family, a parent was institutionalized for criminal activity, a mental health diagnosis, or parental separation.
So, what happened? This is the way they described the consequences of adverse childhood experiences. When the experience occurs, there is a change in the body, which results in social, emotional, and cognitive impairment. Then, there is adoption health-risk behaviors, which are coping strategies. So, these are things such as when we begin to see kids drinking at early ages, doing drugs at early ages, promiscuity. These are adaptive strategies. This is how children begin to adapt to their lives and what happened to them. That’s a result of these health-risk behaviors. Let’s consider smoking one of those. Disease, disability steps in. So, people are most likely to develop lung cancer. So, there is a correlation between adverse childhood experience and lung cancer. We’ll look at a few examples of those correlative studies.
Social problems, if one of the health-risk behaviors is used to be sexually active at an early, this goes on, and one can become either as a street worker, or one goes on and gets STDs. Also, you can end up in jail, in prison, as a result of this correlated childhood experience. This all results in early death.
An ACE Score, we went over what those were before. It is physical and sexual abuse. It’s not how many times one was physically or sexually abused or how many times parents had psychiatric diagnosis or were in jail or prison, but each situation or condition is a score of 1. So, the higher the ACE Score, the greater the likelihood of long term health consequences, extreme emotional responses, health risk behaviors (Those are those adaptive or coping strategies), serious social issues, adult disease and disability, high health care costs, and poor life expectancy.
This is an example of [inaudible 1:03:55].
Jennifer:
So, I’ve seen a few questions. While we’re trying to get Rene back, I just want to let everyone know that I’ve gotten a few questions about Q&A, and we’ll certainly get to that at the end of the presentation. It seems there’s a possibility we may come to it sooner. I’m not sure why we’re unable to hear Rene at this time, but hopefully, she’ll come back to us momentarily.
However, we’ll go through some of the questions. This is, again. Okay. Rene?
Rene Andersen:
Yes, I’m back. I’m sorry. I lost connection.
Jennifer:
Alright, welcome back.
Rene Andersen:
Thank you. So, I’m going to go on and look at the ACE Score and intravenous drug use.  So, what we see here is the higher the ACE Score, the more likelihood there is intravenous drug us. So, a male child with an ACE Score of 6 has a 4600% increase in the likelihood he’ll become an IV drug user later in life. Up to 78% of drug injection by women can be attributed to ACE Score.
So, two important findings of the study. The adverse childhood experiences are vastly more common than recognized or acknowledged, and adverse childhood experiences have a powerful relation to adult health a half-century later.
Amy referred to the necessity. One of her recommendations is necessity for dental and medical offices to become trauma-informed. In order for a survivor to have the best experience in the office, staff needs to be trauma-informed. That is to better understand the emotional issues, the expectations, and the special needs that a person may have in a health care setting.
Now, I’m just going to be a little bit graphic. An adult who has a history of being abused as a child, for example, may have experienced being pinned down, which replicates the position that one is in in a dental chair. So, let’s look at Judith Herman’s definition of what it means to be trauma-informed. Trauma-informed means for a trauma patient to have the best experience in the office, they need to understand the emotion issues. We talked about that. So, they will always seek out ways they can feel more comfortable in health care settings.
Let’s look at trauma-informed principles. Trauma-informed principles are safety, trustworthiness, choice, collaboration, empowerment. So, safety. Safety and comfort are not the same thing. We don’t expect that trauma survivors will be particularly comfortable in a dental, but we do expect that they can feel safe. Safety is created by consistency and predictability. What physical safety may look like is the dental chair position so that the woman’s back is to the door, and if it is, is there a mirror on the wall across from the dental chair? So she can see who’s coming in. Physical safety might also be is the chair able to go up and down, and can she control that?
Trustworthiness. Do you do what you say you will do? Let me give you an example. I was in a dentist chair years ago, and the dentist and I, we agreed on a signal when the dentist would stop drilling when I was too uncomfortable. I gave the signal, and the dentist said just a few more minutes. That broke the trust between. If you have an agreement with the woman to stop drilling when she indicates stop, do so.
Choice. Do women have choice, a choice in terms of what the appointment is, which room they’ll be in, whether they have anesthesia or not, what kind of anesthesia they have. That is a conversation that you have in collaboration. Is the dental care done in collaboration between the oral health provider and the woman?
Empowerment. Is the women made to feel that she has power in this situation and can make those choices collaboratively, that she trusts you and feels safe?
These are the ways that you can help the woman feel safer and more comfortable prior to an appointment. These are concrete examples to prevent retraumatization, and by retraumatization, we mean reactivating the body and mind events that replicate the original trauma. Again, a little graphic, a woman on her back. Her mouth is open. She can’t talk. These all frequently replicate the original that is sexual abuse.
So, prior to the appointment, a reminder call inviting the patient to bring anything that might add to her being comfortable during the procedure, any music or book on tape or pillow or blanket that she finds particularly comforting. During the reminder call, encourage the patient to ask the staff any questions about upcoming procedure. Make the dentist available to her. Prior to the appointment, if a patient asks for sedatives for nerves, offer options and choice, meditation techniques. Does your office have a handout on breathing techniques? Non-narcotic medication can be prescribe prior to the visit. A CD on visualization or meditation on loan from the office. Again, she could perhaps check out the CD on visualization or meditation prior to her appointment.
Ways you can help a woman feel safe and more comfortable in the waiting room. Are the office chairs big enough and small enough to accommodate all sizes? Literature available in language other than English. Greet patients when they first arrive. Greet patients by name and have someone bring the patient to the operatory room.
More comfortable in your office. Offer a calming, soothing office environment. I was in the dental office a few months ago, and one of the news networks was on. It was covering a tragedy that had happened in the state, and there was a killing that had happened in the state. I was noticing other people in the office sucked into that television screen and noticing body reactions. People were getting more and more uncomfortable, twisting their body stiff. So, if you have a television on, turn it on to something that is not so jarring.