Trauma-Informed Reproductive Health Care for Underserved Populations LEARNING TO CARE FOR UNDERSERVED POPULATIONS

APRIL 25TH, 2024

My Career Path

Undergrad – Anthropology & Biology • Health Leads, global health experiences, Health4Chicago

Med School – Patient Centered Medicine • Domestic Violence Shelter, Homeless Shelter, global health


Residency – Internal Medicine/Primary Care/Women’s Health • Immigrant/refugee health, HPV vaccination in East African

communities in Seattle, global health experiences

Fellowship – Women’s Health Services Research • Anti-racism, trauma-informed care, postpartum care

Faculty – Patient Care, Teaching, Research • Trauma informed care, UCSD Asylum Seekers Medical Screening

and Stabilization Program, Survivors of Torture, MED 236: Refugee, Immigrant, and Migrant Health



Learning Objectives

Identify evidence-based principles of trauma- informed care.Identify

Explain the importance of cultural humility in cases where underserved populations have suffered gender-based violence.


Apply principles of trauma informed care and cultural humility to reproductive health care. Apply

*Note on language




Trauma-Informed Care •An approach to care that recognizes, understands, and empathizes with the impact of trauma on an individual and their health.

•”What’s wrong with you?” –> “What happened to you?” –> “What are your strengths?”



Cultural Humility Active engagement in an ongoing process of self- reflection • Examine how personal history and

background impacts patient care. • Reflect on how patient interactions are

impacted by bias. • Gain understanding of patients’ lived

experience through active inquiry. • Recognize patients are their own expert.



Gender Based Violence

Sexual Violence

Military Sexual Trauma

Reproductive Coercion

Displacement Trauma Adverse Childhood Experiences (ACEs)

Sexism & Racism

Female Genital Cutting (FGC)

Intimate Partner Violence (IPV)



Cases: Cervical Cancer Screening & Reproductive Counseling

– Clinical Guidelines – Cultural Considerations – Trauma-Informed Approaches



Cervical Cancer Screening Case

Asha is a 23-year-old woman who presents to establish care. She moved to the US from Somalia after she got married a year ago. She has no medical issues, and she is due for screening tests. She has never had a pap smear. Her husband is her only lifetime sexual partner. She comes from a community that practices female genital cutting (FGC).



Cervical Cancer Screening: Clinical Guidelines

Start pap smears at age 21 every 3 years with cytology alone Age 30 – 65 every 5 years with co-testing or primary HPV testing If above age 65, 10 years of negative tests before stopping screening



Cervical Cancer Screening: Cultural Considerations Pap smear myth – breaks hymen, no longer considered virgin Cultural expectations around virginity and marriage Stigma around reproductive health Gender based violence ◦ Pap smears not possible with certain

types of female genital cutting



Female Genital Cutting • Any ceremonial or nonmedical

alteration of the female genitals ◦ Type 1: Clitoridectomy ◦ Type 2: Excision ◦ Type 3: Infibulation



Singer and Wilson 2007UNICEF, 2013



McCarthy, 2016

AHA Foundation, 2017



• Celebrated rite of passage into womanhood

• Virginity • Femininity • Hygiene • Fertility • Marriage

Goodwin, 2017

Female Genital Cutting



• Medical advocacy through asylum forensic evaluations

• Legal advocacy through immigration services

• Organizations in San Diego: • Survivors of Torture • UCSD Asylum Seekers Medical

Screening and Stabilization Program

Advocacy in San Diego



Haider, 2017



Cervical Cancer Screening: Trauma Informed Approaches Explain that the reason for pap smears is to check for cancer and that we recommend it for anyone 21 and older, regardless of sexual activity Clarify that pap smears do not cause the hymen to break Gender concordant provider, chaperone, and interpreter Ask for permission, prepare the patient and the clinical space, empower the patient throughout the exam, and support the patient after the exam.



Tips for Sensitive Exams » Avoid terms like “bed”, “open”, “touch”,

“spread, ”and “relax,” which could have been words that were spoken to the patient during a previously traumatizing encounter.

» For patients with significant vaginismus, to the point where placement of anything can be difficult, offer medication to help with pain during the exam.



Reproductive Counseling Case Linh is a 35-year-old woman who presents to establish care. She presents with her husband. They recently moved from Vietnam to the US with their four children. She is not taking any medications, and all her pregnancies were normal. During the visit, her husband is doing all the talking and she is very quiet. Her husband asks if she can get a pregnancy test as he is eager to have more children.



Reproductive Counseling: Clinical Guidelines STI screening ◦ Gonorrhea/chlamydia 24 years and younger or

25+ if at increased risk ◦ HIV screening

Family planning ◦ One Key Question ◦ PATH Questions

IPV Screening ◦ Validated tools



Reproductive Counseling: Cultural Considerations Social, cultural, religious pressures on fertility and reproduction Intimate partner violence and reproductive coercion

◦ Birth control sabotage ◦ Menstrual cycle tracking ◦ Violence increases during pregnancy

Birth spacing Stigma around sexual health

Menstrual practices



Reproductive Counseling: Trauma-Informed Approaches Discuss in private with the patient with a medical interpreter – never use family members to interpret

Ask about the patient’s pregnancy intentions Screen for intimate partner violence and reproductive coercion

◦ Normalize screening ◦ Discuss mandated reporting ◦ Provide universal education ◦ VAWA – Violence Against Women’s Act

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