Station 84
Priya Kapoor
Age: 32 years old female
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Acknowledge that the patient has brought a very personal and difficult issue and thank her for trusting you. For example, thank you for sharing something so personal with me today, Priya. I can only imagine how difficult this must be to talk about. Please be assured that we will do our best to support you. Are you comfortable talking about what happened 8 months ago?
- Show respect and sensitivity by informing her that you will be asking numerous personal questions regarding her sexual history. This shows good interpersonal skills and helps prepare the patient for the discussion.
- Ask how long she has been experiencing difficulties with intimacy
- Ask what happens during attempted intimacy, for example, whether she experiences fear, anxiety, physical pain, or involuntary tightness. This is to help differentiate an emotional trauma response from secondary vaginismus.
- Ask if sexual intercourse was comfortable prior to the traumatic event.
- Ask if she has had any medical review, STI screening, or forensic examination after the incident.
- Screen for symptoms of PTSD by asking about nightmares, flashbacks, intrusive thoughts, feeling constantly on edge (hypervigilance), or feeling emotionally numb or detached.
- Ask about her mood, sleep, appetite, concentration, and general functioning.
- Ask about suicidal thoughts or self-harm ideation.
- Ask how her symptoms have impacted her relationship, emotional wellbeing, ability to work, and day-to-day life.
- Ask about her social history, including smoking, alcohol use, and any use of illicit substances. Enquire about her occupation, who she lives with at home, and what support network she has around her.
- Ask about her ideas, concerns, and expectations regarding what might be going on and what kind of help or outcome she is hoping for from the consultation.
- Give a diagnosis of Post-Traumatic Stress Disorder (PTSD) with secondary sexual dysfunction.
Example of explanation to patient
Priya, thank you again for being so open and honest with me today. From what you have described, it sounds like the trauma you experienced has had a deep impact on your emotional wellbeing, your relationship, and how you are coping day to day.
These kinds of symptoms, like feeling emotionally distant, avoiding intimacy, having flashbacks, or feeling tense, are not uncommon after a traumatic event like the one you went through. What you are describing is something we call post-traumatic stress, and I want to reassure you that you are not alone, and that support is available.
Are you happy for me to talk through some of the ways we can support you, Priya?
One really important step we can take is to refer you to a mental health specialist. They can assess you fully and offer you trauma-focused treatment, such as talking therapy or a treatment called EMDR, this involves gentle techniques using eye movements to help process traumatic memories in a safe way.
Does that sound okay so far? Would you like me to go ahead with that referral?
In addition, there are some support charities who are very experienced in helping people who have been through traumatic experiences like yours. One of them is called the Birchall Trust. They provide emotional support, counselling, and can connect you with others who have been through similar situations. I can share their details with you if that feels helpful, would that be alright?
You also mentioned that this has affected your relationship with your husband. We do have access to counselling services for couples, where both of you can receive support together. These therapists are trained to work specifically with couples dealing with the impact of trauma. Is that something you and your husband might be open to exploring?
While we are waiting for the specialist support, I should also let you know that medication is another option that some people find helpful. These are usually antidepressants, and while they can take around four weeks to start working, many people find they help with anxiety, low mood, and intrusive thoughts. They can have some side effects, like mild stomach upset, but we would support you closely if you chose to try this. Is that something you would be open to discussing further?
Lastly, you mentioned that this has been affecting your work. If you feel that you are struggling to cope, I can provide a fit note to give you some space and time for yourself. What are your thoughts on that?
Management
Management
- Acknowledge the trauma and validate the patient’s feelings; reassure her that her reactions are understandable and that help is available.
- Offer referral to mental health services for specialist trauma-focused psychological support, such as trauma-focused CBT or EMDR (Eye Movement Desensitisation and Reprocessing).
- Offer referral to sexual violence victim support charities (e.g., Birchall Trust, if local), where she can also access counselling services and support tailored to survivors of sexual assault.
- Offer referral to couple’s psychosexual counselling if she and her partner are open to exploring this.
- Offer to provide a fit note if her symptoms are affecting her ability to cope at work.
- Discuss and inform the patient that medication (such as an SSRI) is also an option while awaiting assessment by the specialist team. Explain that these medications can take time to work, with most people starting to notice benefit after around 4 weeks.
- If drug treatment is initiated, arrange follow-up within 1–2 weeks to assess response, monitor for side effects, and provide support.
- Safety net: Advise the patient to seek urgent medical help if her mental health worsens, including if she experiences suicidal thoughts, or feels unable to cope.
Learning point from this station:
This case highlights the importance of recognising the psychological and physical consequences of sexual trauma, particularly how it can impact intimacy, emotional wellbeing, and relationships.
Secondary vaginismus and post-traumatic stress disorder (PTSD) can occur either independently or together following sexual assault. Understanding and distinguishing between psychological trauma (such as PTSD) and physical responses (such as vaginismus) is essential to ensure the patient receives appropriate, trauma-informed care.
PTSD is primarily psychological. The individual may experience fear, anxiety, flashbacks, and avoidance behaviours related to sexual activity or touch. The patient says things like “I feel afraid”, “I avoid intimacy”, “I get flashbacks”, “I cannot trust anyone”
Management focuses on:
- Trauma-focused CBT or EMDR
- Support from sexual assault or rape crisis services
- Psychosexual counselling
- Possibly SSRIs for mood or anxiety if indicated
Secondary vaginismus involves involuntary physical contraction of pelvic floor muscles, making penetration painful or impossible. It is often related to psychological triggers but manifests physically. The patient says things like “It hurts”, “It will not go in”, “My body tightens up”
Management includes:
- Psychosexual counselling and pelvic floor physiotherapy
- Desensitisation techniques and graded exposure
- Medication is not always needed unless co-morbid anxiety or depression is present