As the gynecology field moves through 2021, providers must realize that the patient landscape is changing. The #MeToo movement has empowered more survivors of sexual violence to speak up about their experiences; groups like the International Urogynecological Association (IUGA) are expanding educational sessions for physicians on treating transgender patients; and the OB/GYN field is re-examining existing healthcare disparities in a new light.
Here are five critical areas that gynecologists and their staff need to be aware of in order to be prepared to provide meaningful, quality care to their most vulnerable patients.
1. Racial Disparities Are Real
According to the American College of Obstetricians and Gynecologists (ACOG), Black women experience gonorrhea, infertility, unintended pregnancy, preterm birth, fetal and maternal death and death from breast cancer and diabetes at higher rates than women of any other racial or ethnic group. Only in the category of cervical cancer does another group, Hispanic women, experience a higher mortality rate.
It is vital for providers to recognize their role in racial health disparities so that they can also see themselves as part of the solution. While the reasons for disparities are complex and not entirely known, providers may unknowingly contribute to them through unconscious bias and assumptions. For example, a physician may attribute diabetes or pelvic inflammatory disease to a patient's behavior, rather than viewing the condition as a product of complex genetic and situational risk factors.
Awareness is the starting point for providers to address racial and ethnic disparities within their own patient base. OB/GYNs must educate themselves on health disparities as well as provide affected patients with educational materials and screening opportunities.
2. Treating Survivors of Sexual Violence
ACOG recommends that OB/GYNs regularly screen patients for a history of sexual violence, as this can affect how patients perceive and experience gynecologic care. Survivors of sexual assault may be reluctant to address health concerns with their physicians, or might even neglect their healthcare entirely. ACOG also suggests that physicians be aware of the health consequences of sexual assault and intimate partner violence, including unintended pregnancies, sexually transmitted infections and mental health challenges. Physicians have an "essential role" in talking to their patients about "healthy, consensual and safe relationships," according to Futures Without Violence.
ACOG also advises that physicians should practice trauma-informed care with survivors of sexual violence. According to the Trauma Informed Care Project, this framework emphasizes "understanding, recognizing, and responding to the effects of all types of trauma" and is essential for patients who have experienced sexual assault, including in childhood. If a patient has a history of sexual assault, exploitation or childhood trauma, physicians should ensure it is documented in the patient's chart and appropriately coded.
3. Understanding the Needs of LGBTQIA+ Patients
Lesbian, bisexual and asexual women, as well as gender-nonconforming patients, experience distinct barriers to care. Individuals who have been stigmatized or discriminated against due to their gender, gender expression or sexual orientation may approach the medical community with hesitation. The Fenway Institute reports that LGBTQIA+ individuals are less likely to have health insurance, often experience discrimination from healthcare staff and sometimes encounter health professionals who lack knowledge or experience in caring for this patient population. These barriers to care contribute to LGBTQIA+ health disparities, such as higher rates of reproductive cancers among bisexual women.
ACOG recommends that OB/GYNs take concrete steps to help LGBTQIA+ patients feel welcome and respected. Practices should use inclusive, neutral terms on office registration forms, such as "domestic partner" or "spouse," and should not assume the gender of any partner or partners during sexual health interviews. Additionally, practices should post nondiscrimination signage in public areas such as waiting rooms; the Fenway Institute reports that LGBTQIA+ people actually look for these signs to know whether a practice is sensitive to their concerns. Finally, providers should be prepared to offer health education information specific to the LGBTQIA+ population, such as a listing of community resources, and to educate all staff members on appropriate and respectful conduct.
4. Numbers of Transgender and Nonbinary Patients Are Growing
In 2016, the Williams Institute estimated that there are around 1.4 million transgender adults living in the United States. According to a 2015 study published in the Journal of Women's Health, however, 80 percent of gynecologists surveyed had not received any training during residency on transgender patient care. How can providers close this knowledge gap?
A review published in the journal Federal Practitioner recommends that physicians and staff start by learning appropriate terminology and making it a habit to ask patients about the pronouns and name they use on intake forms. A patient's legal name may not change as they begin the process of gender-affirming treatment, but they may have a different chosen name, which should be documented in their chart. Providers should also educate themselves on the basics of gender-affirming care, such as the effects of hormone replacement therapy on the body, through offerings like IUGA's conference sessions or the World Professional Association for Transgender Health Standards of Care.
The Federal Practitioner report stresses the importance of performing screenings and examinations appropriate to the reproductive organs present and explaining to the patient why exams may be necessary. Transmasculine people and trans men, for example, may have pelvic pain that is best evaluated through ultrasound. Practitioners should approach pelvic exams with caution to avoid traumatizing a patient; adjustments such as substituting transrectal or even abdominal ultrasound for transvaginal ultrasound may help OB/GYNs avoid triggering gender dysphoria or other distress in their trans and nonbinary patients.
5. Respecting Patients' Moral and Religious Beliefs
Every patient has the right to receive appropriate care that respects their religious or moral beliefs. Gynecologists should be aware that in some religions, special attention is given to gender and physical contact. For instance, female patients who are followers of Islam or Orthodox Judaism may refrain from touching men who are not family members and might consider exams by male physicians to be inappropriate.
No one expects a physician to be familiar with every religious or cultural practice, but it is important to remember that providers' ignorance of these issues can cause stress and discomfort for patients. Physicians can address this by simply asking the patient for their preferences, beginning with intake forms. It is the physician's obligation to suggest appropriate care in all cases, but the patient retains the right to object to care.
Under federal law, physicians and other healthcare staff may be allowed to refrain from care to which they are "conscientious objectors," except during emergencies. ACOG suggests that practitioners who hold beliefs that prevent them from providing reproductive or other care should inform patients of their options for accessing it elsewhere. If possible, these physicians should either work with a colleague who does not have the same objections or should have an efficient referral system in place.
The common themes in providing patient care for diverse populations are awareness, sensitivity and education. It is important for physicians to maximize the quality of care and patient satisfaction they provide, especially for patients who might be reluctant to visit a gynecologist. To attract and retain a greater diversity of patients, practices need to put in the extra effort to ensure that all individuals feel valued and cared for.
