CONSIDERATIONS FOR PERSON-CENTERED CARE
CHALLENGING ASSUMPTIONS ABOUT SEXUAL ORIENTATION
While it is good practice to elicit sexual orientation for SOGI (sexual orientation and gender identity) data collection purposes, people of all sexual orientation experience pregnancy, and sexual orientation does not always match sexual behavior and practice. Providers should avoid assumptions about sexual orientation or sexual practices, provide the same approach to pregnancy counseling to all people regardless of sexual orientation, and offer contraceptive and sexual health services that are relevant to the person’s sexual practices.
GENDER IDENTITY AND PREGNANCY
Everyone has a gender identity—an internal understanding of their gender—and thus, people across the gender spectrum may require sexual, reproductive, and pregnancy-related care. “Cisgender” is used to describe someone whose gender identity aligns with their sex assigned at birth. “Transgender” or “trans” is an umbrella term for people whose gender identity does not correspond to the sex assigned at birth or with the expectations associated with that sex (Transgender Law Center 2011). Trans and gender diverse (TGD) people are clinically underserved, and face barriers to routine health care and transition-related care such as a lack of insurance coverage and mistreatment by health care providers (James 2016).
TGD people with ovaries and a uterus can experience pregnancy if they engage in sex with a partner who produces sperm, even after social and/or hormonal transition. Menstruation is an unreliable marker for fertility. Testosterone may be used for masculinization in TGD patients and may lead to amenorrhea but should not be considered contraception as there can be breakthrough ovulation resulting in pregnancy. (Light 2018, Light 2014). All hormonal and non-hormonal contraceptive options may be safely used by TGD patients and do not interact with testosterone.
In order to provide gender-affirming, person-centered care, providers should create a space that is welcoming, use inclusive language, that consider the potential physical and emotional trauma specific to this population when performing physician exams (Bonnington 2020). TGD people attempt abortion without clinical supervision at higher rates, highlighting the importance of reducing barriers by implementing gender-inclusive care and the need for providers to be trained on support after self-managed abortion (Moseson 2022). Note that a person’s name and gender identity may not be accurately reflected on their identification, medical record, or insurance documents. Avoid making assumptions about anatomy and identity, and practice trauma-informed care, considering high rates of negative and traumatizing experiences with accessing gynecological and general health care. Also consider that many clinics are still gendered spaces that may not be comfortable or acceptable to patients, and making changes to clinic decor, clinic name, and paperwork can help create a gender-inclusive space.
- Pre Pregnancy Counseling for People of All Genders
- Euki App
- Sam’s MAB Zine
- Transgender Law Center. “10 Tips for Working with Transgender Patients”
- Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, UCSF Center of Excellence for Transgender Health
- Human Rights Campaign- Glossary of Terms
- WPATH: Standard of Care
- Chapter 7 Content: Contraception across the Gender Spectrum
COUNSELING FOR PEOPLE WHO USE SUBSTANCES
Substance Use Disorder (SUD) is a treatable, chronic illness. However, people with SUD face profound stigma, barriers to care, and even criminalization when interfacing with the medical industrial complex. Understanding this stigmatization and numerous injustices people who use substances face can help us understand how people choose to engage with the healthcare system, as we know people with SUD have higher rates of unintended pregnancy, sexually transmitted diseases, infertility, and mortality related to pregnancy; and lower rates of contraceptive use (Zwick 2020).
Clinicians can help reduce these health disparities by supporting people who use substances. Reproductive care should be provided alongside comprehensive preventative, harm reduction, and primary care services. This does not include urine toxicology, which is not medically indicated before providing contraceptive or abortion care, does not diagnose acute intoxication or a use disorder, and is an expensive test with false-positive and negative results which can have serious consequences (Kale 2021). It is also important to note that SUD, in itself, does not impair one’s ability to make medical decisions. Any person who can understand the risks and benefits of a procedure is able to consent. Counseling should also include that chronic substance use can cause oligo or amenorrhea so pregnancy may occur even when periods are infrequent (Flannagan 2020). For people with SUD who want to conceive, trauma-informed care and medication for addiction treatment should be considered to support people in having safe and healthy pregnancies. Additional resources:
- California Bridge Program
- Substance Abuse and Mental Health Services Administration
- Substance Use Disorder and Family Planning Care Webinar
- Ch 5: Considerations for People who Use Opioids
COUNSELING FOR PEOPLE WITH DISABILITIES
A disability can be defined as a long-term physical, mental, intellectual, or sensory condition which substantially impairs a person’s full participation in society on an equal basis with others (United Nations 2014). Approximately 15% of people worldwide and 25% in the U.S. are living with some kind of disability, of whom <5% experience significant difficulties in functioning (WHO 2020, CDC 2020; note differences likely represent reporting issues).
People with disabilities have similar sexual and reproductive health needs as the general population however, they are less likely to receive contraception counseling, sexually transmitted disease testing, cervical and breast cancer screening, and prenatal care (Taouk 2018). People with disabilities are at higher risk of sexual coercion, assault, and of contracting HIV. They face significant barriers in access including lack of provider training, provider bias, harmful stereotypes (e.g. that they are not sexually active or are unable to get pregnant), and inaccessibility in health care facilities and equipment (Taouk 2018).
People with disabilities are active health care participants and have medical decision making capacity unless a severe cognitive impairment is present. In those cases, it may be appropriate to facilitate supportive decision making, which is an alternative to guardianship allowing people to choose someone they trust to assist with making decisions regarding specific topics (NDRN 2019).
Many guardians will request contraception or even permanent sterilization for people with cognitive impairment, either for hygiene purposes or to avoid pregnancy. In cases of mild to moderate cognitive impairment providers should request the person be seen without their guardian to best assess their personal wishes. Permanent sterilization of people with severe cognitive impairment is always an ethical dilemma and providers should seek guidance from an experienced ethics committee when faced with such requests (ACOG 2016).
- Assume intellectual and medical capacity. Do not mistake speech impairment for intellectual impairment; motor disorders alone can hinder articulation.
- For adolescents/young adults with mild to moderate cognitive impairment, conduct sexual health screening questions without the parent/guardian present if possible.
- Advocate for inclusive facilities and equipment in waiting and exam rooms for people using wheelchairs or other mobility equipment, and for those who have larger bodies. Plan ahead and move things to accommodate.
- Consider purchasing at least one mechanical exam table with adjustable height and padded leg rests (not foot rests).
- Ask each individual how they want to be assisted in transferring and/or positioning on the exam table.
- Allocate extra time for visits so that the person’s needs are appropriately addressed.
EARLY PREGNANCY LOSS
If a pregnancy loss or threatened pregnancy loss is diagnosed, be sure that the person understands the diagnosis, implications, and various management options. Reassure them that most pregnancy loss is caused because the pregnancy was not developing correctly, not because of something they might have done, thought, or wished for. Do not assume how the person will feel. Some people feel relief, others sadness or guilt, and others may have concerns about their health or fertility. People may also feel a number of emotions simultaneously. See Chapter 8, Counseling Tips for Early Pregnancy Loss.
Multiple pregnancies currently makeup approximately 2-3% of all pregnancies but occur at higher rates with assisted reproductive technologies and increasing maternal age. Miscarriage and complication rates are higher among multiple pregnancies. It is common to discover previously unrecognized multiple gestations during the ultrasound evaluation. Some patients may want to know if they have a multiple pregnancy, others may not. Anecdotally, this information may occasionally change a person’s decision in either direction. Unless local law requires viewing or describing ultrasound findings, routinely ask each patient, prior to the ultrasound examination, if they would want to know about multiple gestations, so you can honor their wishes. Selective reduction may be an option in some settings.
CONTRACEPTION COUNSELING IN THE SETTING OF ABORTION CARE
It can be helpful to offer contraceptive counseling while remaining aware that some people prefer not to discuss contraception at the time of abortion (Matulich 2014, Kavanaugh 2011). Patients from historically marginalized communities may feel coerced to use contraception in abortion settings (Brandi 2018), making it particularly important to give enough time to think about choices. Advanced notice of method availability has been shown to acceptable, and provides abortion patients more time and knowledge for decision-making (Roe 2018). Those who do desire contraceptive counseling report wanting to hear about methods that are easier to use and more effective than previous methods and want to leave the clinic with a method (Matulich 2014). See Chapter 7: Evidence-Based Contraceptive Guidance.
Reproductive coercion (RC) is common. Internationally, nearly 20% of respondents in family planning clinics reported previous pregnancy coercion and 15% reported birth control sabotage by a partner (Grace 2016, Silverman 2014). RC may include explicit attempts to pressure a partner to have sex without a contraceptive method, either explicit or covert interference with contraceptive methods, or attempts to control outcomes of a pregnancy. RC can come from intimate partners, family members, clinicians, or community members. These actions limit a person’s reproductive autonomy and compromise their ability to make decisions around contraception, pregnancy, and abortion. While many clinical settings have integrated intimate partner violence screening tools, it may be challenging to identify subtle acts of power and control in relationships.
In addition to asking generally about your patient’s support people, you might ask them if anyone has tampered with or prevented their contraceptive use or is pressuring them to make a decision about this pregnancy. Offer support and resources if they are being coerced.
It is not uncommon to encounter patients who have experienced sexual trauma such as sexual abuse, rape, incest, or human trafficking (National Center for PTSD) . These individuals may have had little control over the abusive situation and may feel especially vulnerable and powerless.
Some groups are particularly at risk of sexual trauma. Transgender individuals as well as those with disabilities are 2-3 times more likely to be raped (Office of Justice Programs 2014, Basile 2016). In addition, victims of human trafficking are often forced or tricked into working in dangerous conditions or having sex with others against their will. Trafficking occurs in every country. It is estimated that 80% of trafficking victims are people capable of pregnancy, over 50% are children, and 40% are within the person’s country of origin (NCADV 2014). Many victims of sex trafficking do not recognize that they are the victims of trafficking and may simply believe they are in a bad situation, relationship, or job, and are often at high risk of unplanned pregnancy (Lederer 2014). It is important to screen for sex trafficking and have a planned response to assist.
If a patient discloses they have been raped, consider supporting them by suggesting:
- “This isn’t your fault. No one ever deserves for this to happen to them.”
- “I’m so sorry that happened to you.”
- “Thank you for telling me; you’re brave to do that.”
- “I want you to know that you are safe here.”
If any patient is interested in reporting a sexual assault, access the sexual assault service providers most familiar with your local reporting laws and counseling. Consider developing and instituting forensic policies and procedures
Self-sourced medication abortion (SSMA) refers to the act of obtaining abortion pills outside of the clinical setting for the purpose of ending a pregnancy (e.g. from online sources or available over the counter in some countries). This is sometimes referred to as self-managed abortion (SMA), though self-managed abortion includes any method of self-managing, such as herbs, medications, substances by mouth or vagina, and deep abdominal massage.
Self-sourced medication abortion is known to occur in countries worldwide irrespective of the legal climate surrounding abortion (Moseson 2019). Reported reasons include perceived greater bodily autonomy, distrust of medical providers and/or institutions, social stigma, cost, distance or lack of access to abortion care, and legal restrictions. For some it is preferred while for others, it is their only option. While self-managed abortion is not new, medication abortion and therefore self-sourced medication is becoming more common, and studies show that it is simple, safe, and effective (Jones 2019, Moseson 2022 and Moseson 2021).