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. A person you see for care presents with an unexpected positive pregnancy test during a health center visit or in the ED. How would you approach this?
   • If a pregnancy test is being discussed or requested in advance, some clinicians will ask people what result they hoped for. Once you have given the result, wait for them to respond. If it’s not clear how they’re feeling, 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 why a pregnancy test is indicated and obtain consent. Explain the result was positive, meaning they are pregnant. Your role is to listen, support, and ask questions. A person may not need (or appreciate) full options counseling.
   • If they need time, ask if they’d like another visit or if they’d rather discuss it with another trusted person. Consider giving them space to imagine their lives 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, 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 what questions an individual has, they want to know if an abortion will affect their ability to have children in the future. How would you respond?
   
   • Uncomplicated medication and procedural abortion has been shown to have no effect on future reproductive health, including fertility or future risk of spontaneous abortion or preterm 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. An individual 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.
   • If you are considering continuing the pregnancy and parenting, what support would you need to make this possible?
   • You can choose an open adoption, which allows more space to be involved in the child’s life if desired. Thinking through the level of involvement you desire is important before talking through your plans with prospective adoptive parents.

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4. While you are explaining the MAB protocol, a patient mentions that their boyfriend “absolutely cannot find out about this pregnancy.” What concerns does this raise, and how can you explore the situation further? What assurances can you give them, and what support may you want to offer them?
   
   • Use open-ended questions to explore the relationship dynamics, as reproductive coercion or intimate partner violence may be occurring. “Tell me a bit more about your relationship and how your partner might feel about the pregnancy.”
   • Validate and normalize their feelings about the situation and remind them that you will support their decision no matter what.
   • Explore the MAB process and how to support confidentiality from the boyfriend.
   • Explore contraceptive options their partner would not know about or be able to control.
   • Explore MAB options that will allow them to access abortion without their partner knowing.
   • If intimate partner violence is a concern, make a safety plan.
   • Offer to refer 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 an abortion for himself. What questions should you ask during counseling and intake?
   
   • Transgender people 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 menstrual cycle. Make sure all staff and providers are aware of the language to use.
   • As with all people, 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 people 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 are seeing a 19-year-old who has been to the health center for several abortions in the past. 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 individuals 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, and 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 and 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 (CPS).

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EXERCISE 2.2: Counseling around clinical care

Purpose: Discuss what you might say to the person in each of the following situations.

1. As you enter the exam room, you hear a partner criticizing the person 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 individual without the partner present. Explain that you routinely do an exam with the person seeking care alone and have the partner go to the waiting room.
     • Ask them about the tension you observed and how they feel 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 room and ask how the person is feeling, they start crying uncontrollably. They turn their head away from you and do not make eye contact.
   
   • Crying can be normal. Check in with them about how they are feeling. “It’s ok to cry and to have feelings. Is there any way I can help you now?”
   • They may be afraid, experiencing sadness or loneliness, but could still be sure of their decision. Alternatively, they may be unsure or feel pressured and trapped.
   • Make space for them to discuss their feelings while not assuming they want to talk. You may add something like, “We’re here to ensure that we’re providing the best care for you. Would it be helpful to talk about how you feel about this decision today? Would you like to tell me more about what you’re experiencing?”

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3. You have just completed a uterine aspiration for someone at 8 weeks gestation. They ask, “Can I see what it looks like?” How would your response stay the same or differ at 12-weeks gestation?
   
   • Normalize the request. While you do not need to know the reason for their request, clarifying what they are interested in and setting expectations may be helpful. Sometimes, a person asks to see the tissue; sometimes they are interested in what you do with it. You may say, “That’s a common question. Tell me more about what you’d like to know.” People often have an inaccurate image of what an early pregnancy looks like and are reassured by what they see. Some may be curious and 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 tactfully asking what they expect to see. Alert them that the fetus may not be intact and that some recognizable parts will be visible, and confirm that 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 following 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 to obtain the tissue.

   If they are still sedated after moderate or deep sedation, address the request after the procedure is safely completed, they are alert, and in a private area.

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4. A person at < 14 weeks by LMP presents with bleeding to your health center. Which history questions are beyond clinical relevance and should be avoided to protect them from potential criminalization?
   

• • Avoid asking questions or documenting about medications or other means used to initiate bleeding or abortion, as management of bleeding is equivalent.
  • Avoid questions or documentation about immigration status, substance use, sex work, or employment unless immediately clinically relevant.
  • Encourage these practices among colleagues and trainees, as well as such protocols within your institution.