Recently, my mammography technician commented that women who have been sexually abused seem especially uncomfortable getting mammograms. She then shared her theory that those who have been abused avoid any number of screening tests due to the remnant emotional scars of the abuse. Was she right? And what's the risk to their health?

Being uncomfortable with medical exams and avoiding them is not uncommon for survivors of sexual abuse, responds Wendy Maltz, MSW, an internationally recognized psychotherapist and sex therapist in private practice in Eugene, Oregon. Maltz is the author of The Sexual Healing Journey: A Guide for Survivors of Sexual Abuse (Harper-Collins).

Abuse More Common than You Think

Most people are unaware of how prevalent sexual abuse really is, observes Maltz. As many as one in three women and one in five men report having been sexually abused as children. Depression, low self-esteem, problems with alcohol or drugs, eating disorders and sexual dysfunction all are possible consequences. Some women become socially withdrawn, while others may act out in dangerous lifestyles. When men act out, they are often more aggressive and controlling.

As my mammography technician suspected, medical exams also pose a problem for many survivors. While each person is unique and the phenomenon is not universal, many of Maltz's clients report avoiding not only mammograms but pelvic exams and colonoscopies as well. Due to sexual abuse involving oral penetration, some also have difficulty going to the dentist. Maltz adds that men -- who are typically uncomfortable admitting they are survivors of sexual abuse -- may have problems with urological and prostate exams. These people are potentially putting themselves in physical danger as well by not tending to their physical health.

Inadvertent Flashbacks

In certain ways, medical exams may replicate abuse, explains Maltz. During a mammogram, for example, a person who is viewed as powerful tells a woman to remove her clothing and position her body in certain ways. Even though the woman can theoretically say no to what is happening, embarrassment inhibits such a response. This is similar to abuse, in which a victim has little or no control over what is happening.

Added to this perceived power imbalance, notes Maltz, is the experience of being touched and sometimes inadvertently stroked in private places, which can cause unpleasant flashbacks. When you've felt helpless and scared, a certain body position or experience can activate a "felt" memory of sexual abuse that was locked away in the unconscious. Activating these memories can influence future decisions about health care.

What You Can Do

Since avoidance is not the long-term solution, how does a person work through issues about medical exams? Maltz offers a number of practical tips...

• Identify the problem. The first step is to recognize the problem for what it is. Identify your reaction and connect it with the early abuse. Maltz observes that many people will just say that they don't like being examined and refuse to go, not realizing they are uncomfortable with it because of what happened to them in the past.

• Do a little strategic planning. Once a person makes this connection, some advance planning is called for. Before committing to an appointment with a doctor, dentist or technician, Maltz recommends making certain that he/she will be sensitive to your special needs. When you call the office or medical facility, request to see a medical professional who is familiar with conducting exams on people with abuse histories. She adds that you don't have to give details about what happened to you -- it's sufficient to say that you experienced physical trauma or child abuse in the past that involved this particular part of the body. Don't think that you're a unique case -- as I said before, nearly one-third of the population has experienced abuse in one way or another, and the professionals are trained to deal with it sensitively.

• Get a helping hand. Prior to undergoing what you expect will be an uncomfortable exam, consider asking your physician to prescribe a mild tranquilizer. Or, if being accompanied by a trusted friend or relative would help you feel safer, see if this can be arranged. It can make a huge difference having someone there to hold your hand, remind you to relax and coach you to breathe slowly.

• Do not patronize offices that refuse to consider your needs. Maltz points out that professionals who have reputations for working with survivors know how to take things slow, explain procedures well, check in with the patient's mental state and offer more options with positioning and clothing than is usual.

• Schedule extra time. Given the extra time survivors need, it's a good idea to schedule a double appointment for an exam, advises Maltz. She cautions that you may be asked to pay more as a result... but these tests are an important way of taking care of yourself, and if you can afford the extra cost, it's worth it.

• Speak up. Don't be afraid to speak up about what you need. This is important to counter the negative legacy of abuse, in which victims are intimidated into silence. Maltz notes that the assertiveness skills you sharpen with these experiences can have positive reverberations for healing in general.

• Get therapy. More generally speaking, individual and group therapy can be very helpful in enabling survivors to resolve a wide variety of issues related to past abuse. Maltz recommends therapy for anyone with strong reactions to medical exams. Working with a therapist and talking with others who have undergone similar experiences can help you to move forward and take action to ensure that your special needs are honored.