CHAPTER 2 TEACHING POINTS: COUNSELING & CONSENT

EXERCISE 2.1: Pregnancy options counseling and screening

Purpose: The following exercise is designed to review pregnancy options counseling. Consider using role-play in the following scenarios.

1. One of your patients presents with an unexpected positive pregnancy test during clinic or in the ED. How would you approach this?
   • If a pregnancy test is being discussed or requested in advance, some providers will ask patients what result they hoped for. Once you have given the result, wait for the patient to respond. If it’s not clear how they’re feeling, or what they want to do, you can ask open-ended questions:
     • “How do you feel about this result?”
     • “What do you know about your options?”
     • “What would it be like for you to continue a pregnancy/have an abortion at this time?”
   • Explain that because symptoms can be vague, a pregnancy test may be suggested for pregnancy capable people; obtain consent. Explain the result was positive, meaning they are pregnant. Ask if they had at all suspected that they might be pregnant.
   • Your role is to listen, support, and ask questions. A patient may clarity one way or the other, and may not need (or appreciate) full options counseling.
   • If they need time, ask if they’d like to explore more with you, whether now or at another visit, or if they’d rather discuss it with a trusted person. Consider giving them space to imagine their life now and a few years from now, and to reflect on how each outcome might change those circumstances. For a more comprehensive exploration of thoughts, feelings, dreams and goals, offer them the Pregnancy Options Workbook.
   • Video Resource: Decision Counseling for the Positive Pregnancy Test (IERH).

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2. When you ask a patient what questions they have, they want to know if an abortion will affect their ability to have children in the future. How would you respond?
   
   • Uncomplicated uterine aspiration and medication abortion has been shown to have no effect on a person’s future reproductive health, including the ability to get pregnant or have a healthy pregnancy. There is no increased risk of infertility, spontaneous abortion, or pre-term delivery.
   • Available data suggest that multiple abortions pose little or no increased risk compared to a single procedure.
   • You might say “There is a lot of misinformation out there about this issue, so I want to reassure you and be very clear – abortion is extremely safe and will not affect your ability to get pregnant in the future if and when you want to”.

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3. A patient is leaning toward adoption, but is trying to decide, and wants to know more about the process and options. How would you respond?
   
   • Giving birth and raising a child are two different things. It is important to consider what both would be like for you
   • A birth parent can think of adoption as a way to select parents for the baby, as opposed to giving the baby to adoptive parents.
   • Birth parents may feel sadness about relinquishing a child, even if they feel it is the best decision for them. Feeling sad does not mean that the decision is wrong.
   • Introduce differences between open and closed adoptions, and give resources and local/national referrals as appropriate. Please see Chapter 1: Adoption Facts Section.

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4. While you are explaining the protocol for a medication abortion to a patient, they mention that their boyfriend “absolutely cannot find out about this.” What concerns does this raise and how can you explore this further?
   
   • Use open-ended questions to explore the relationship dynamics, as there may be reproductive coercion or intimate partner violence occurring.
   • “Tell me a little more about your relationship, and how your partner might feel about the pregnancy.”
   • Validate and normalize the patient’s feelings about the situation and remind the patient that you will support their decision no matter what.
   • Validate and normalize the patient’s feelings about the situation and remind the patient that you will support their decision no matter what.
   • You can explore options for birth control that their partner would not know about or be able to control.
   • If intimate partner violence is a concern, make a safety plan.
   • Offer to refer the patient for further counseling around these issues if needed.

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5. You receive a phone call from a man who would like to schedule a medical abortion for himself. What questions should you ask during counseling and intake?
   
   • Transgender patients can experience desired and undesired pregnancy, even if amenorrheic from hormone use, and may need abortion services.
   • Hormone therapy is not a contraindication to medication abortion. If a person decides to continue their pregnancy, they should connect with their prescribing provider to discuss any recommended changes in hormone therapy.
   • Work to create a safe gender-affirming environment by asking about pronouns and preferred terms for specific parts of their body or their menstrual cycle. Make sure all staff and providers are aware of language to use.
   • As with all patients, ask standard questions to accurately date the pregnancy and ensure that their decision is free of coercion.
   • Ask, if relevant, whether they are interested in contraception. Counsel that people can ovulate on testosterone even if amenorrheic. TGD patients can safely use any form of birth control they might like. Some may want to avoid estrogens, due to the potential for either undesired feminizing side effects or increased VTE risk.

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6. You have a 19-year old patient who has been to the clinic for several abortions in the past and their first abortion was when they were 14. They are always accompanied by an older male relative. You are concerned they may be the victim of sex trafficking. What questions might you ask? What should you do if you find out they are the victim of trafficking?
   
   • Make sure to see all your patients privately for a few minutes at the beginning of each visit to assess for intimate partner violence and reproductive coercion.
   • Ask about their relationship to the older man; look for cues that they might be deferring decision making to them.
   • If they indicate (either through verbal or non-verbal cues) that they feel trapped in the relationship, ask about what might be keeping them—assess for fear of violence or other negative consequences of leaving.
   • Ask about work: are they being forced to work, is payment ever withheld based on performance? Are they being coerced into sleeping with other people?
   • If the answers to any of the above questions lead you to think they are a victim of human trafficking, explain what human trafficking is, that you think they may be in a situation where they are being trafficked. Offer support and access to confidential resources. If the victim is a minor, immediately call child protective services.

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EXERCISE 2.2: Counseling around clinical care

Purpose:

Discuss what you might do or what you might say to a person in each of the following situations when you come into the procedure room.

1. As you enter the exam room you hear the patient’s partner criticizing them for “acting stupid” and telling them angrily to “just shut up.” The partner is looking at the wall and ignores your efforts to introduce yourself.
   • It is essential to talk to the patient without the partner present. Explain that you routinely do an exam with the patient alone and have the partner go out to the waiting room.
     • Ask the patient about the tension you observed and how they are feeling about the decision.
     • A domestic violence screen is appropriate, and you should know the reporting laws for your state or country.

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2. When you come into the exam room and ask the patient how they are feeling, they start crying uncontrollably. They have their head turned away from you and do not make eye contact.
   
   • Crying can be normal. Check in with the patient about how they are feeling. “It’s ok to cry and to have feelings. Is there any way I can help you now?”
   • The patient may be afraid, or experiencing sadness or loneliness, but could still be sure of their decision. Alternatively, they may be unsure, or feeling pressured and trapped.
   • Make space for the patient to discuss their feelings while also not assuming that they do want to talk. You may add something like, “We’re here to make sure that we’re providing the best care for you. Would it be helpful to talk about how you’re feeling about this decision today? Would you like to tell me more about what you’re experiencing?”

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3. The patient is a 14-year-old who has experienced sexual trauma and is 7 weeks pregnant. Every time you attempt to insert the speculum, they raise their hips off the table.
   
   • Ask if the patient would like to continue with the aspiration procedure or if they would like to consider other options. Continue checking in with the patient about their decision to proceed.
   • Offer, “I’m sorry this is uncomfortable. Would any of these options help? How would you feel about inserting the speculum yourself or raising the head of the exam table?
   • Offer to practice a Kegel, pushing their hips downward, or visualize softening or melting of muscles downward during the exam. Reinforce that they are in control of their own body, and give suggestions about what they can focus on to help keep the procedure safe.
   • Consider asking for a staff person to provide dedicated support. Talking about other topics may help with comfort.
   • Have the patient tell you when they are ready for each step of the procedure. For example, ask them to tell you when to tell you when they are ready for the speculum insertion and when to advance the speculum beyond the introitus. Consider using a pediatric speculum.
   • If the patient continues to have discomfort, consider topical lidocaine. If they are available at your location, consider anxiolytics, pain medication other than NSAIDs. Consider a referral out for deep sedation.
   • Familiarize yourself with the mandated reporting laws in your state. Most states require reporting for any minor (<18 years old) who reports sexual abuse or if the partner is significantly older than the minor. For state laws: http://aspe.hhs.gov/hsp/08/sr/statelaws/statelaws.shtml.

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4. You are about to see a 22-year-old G0 patient with a mild motor and cognitive disability. They arrive in the clinic in a wheelchair with a parent. During intake, the parent states that they would like to discuss birth control that will assist them with periods.
   
   • Counseling on reproductive topics for adolescents and young adults with disabilities can be complex given possible medical comorbidities, intellectual disabilities that may raise concerns regarding consent, and the involvement of families or caregivers who may seek to support such decision-making (Ernst 2020). It is important not to assume that people with disabilities are not sexually active or do not wish to be.
   • Assess intellectual competence. Do not mistake problems with speech for intellectual incapacity; this patient’s motor disorder may hinder articulation.
   • If possible, conduct part of the interview alone to discuss sexual health screening questions, the patient’s own priorities, and comfort with a supportive decision-making role of the parent.
   • Allocate extra time and consider special issues for the visit so that the patient’s needs can be appropriately addressed.
   • If an exam is needed, consider using a mechanical exam table with leg rests, and always ask the patient how they would like to be assisted in transferring, and discuss alternative positions for doing a gynecologic exam or procedure.
   • For more in depth information on contraceptive counseling in patients’ with disabilities, see Ernst 2020, ACOG 2016, this helpful video (University of Michigan 2017), and Chapter 7: Contraceptive Counseling.

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5. You have just completed an aspiration (for abortion or early pregnancy loss) for a patient at 8-weeks gestation. The patient asks, “Can I see what it looks like?” How would your response differ at 12-weeks gestation?
   
   • Normalize the request. While you do not need to know the reason for their request, it may be helpful to clarify what they are interested in and set expectations. Sometimes a patient is asking to see the tissue; sometimes they are interested in what you do with the tissue. You may say “That’s a common question. Tell me more about what you’d like to know.” Patients often have an inaccurate image of what an early pregnancy looks like and are reassured by what they see. Some may be curious, and some may want time to mourn or pray.
   • Before 9 weeks it is difficult to visualize fetal parts. You can say, “The pregnancy may look like a blood clot or a cotton ball.”
   • For later gestations, consider asking tactfully what the patient expects to see. Alert the patient that the fetus may not be intact and that some recognizable parts will be visible, and confirm they still want to see.
   • If you are asked about fetal tissue donation and a tissue donation program exists at your facility, let them know that it is entirely voluntary and in accordance with ethical and legal standards. Federal law requires a separate consent, that there be no patient payment or control over what the tissue is used for, and no changes to how or when the abortion is done in order to obtain the tissue.
   • If the patient is still sedated after moderate or deep sedation, address the request after the patient’s procedure is safely completed, they are alert, and in a private area.