DEIA Curriculum: OB-GYN/Sexuality

Suggested Rotations: Obstetrics PGY-1, PGY-2, PGY-3

Objective: Residents will describe historical perspectives regarding racism in medicine, especially in OB/GYN specialties.

Resources:

• Medical Apartheid by Harriet A. Washington: Chapter 8 The Black Stork. We suggest programs buy copies of the book. (30-minute read)
• Law Blog about Forced Sterilization in the United States. (8-minute read)
• Anarcha Speaks: A History in Poems In the poem “Anarcha” by TJ Jarrett, one of those slave women is given a voice. (5-minute read)
• Remembering Anarcha, Lucy, and Betsey: The Mothers of Modern Gynecology Podcast (27-minute listen)

Applications and Questions:

Reflect:

• How might the racist legacy of Dr. Sims still be impacting the health of Black women today?

Explore: 

• Look up the concept of the “Mississippi Appendectomy.” How might that compare to forced sterilizations in ICE facilities in 2021? What other populations have historically experienced forced sterilization in the USA?
• Want to get deeper on this topic? Consider reading the book Reproducing Race by Khiara Bridges.

Suggested Rotation: Obstetrics/GYN PGY1, PGY2, PGY3

Objective 1A: Demonstrate cultural humility in the care of Muslim patients.

Objective 1B: Explain how to counsel patients about how to safely participate in fasts, particularly those with diabetes. 

Resources:

• Cultural Competence in the Care of Muslim Patients and Their Families (20-minute read)

Applications and Questions:

Reflect:

• Fasting is a meaningful experience in many cultures. How can we help patients who fast to do so safely and healthily? Who might be exempt from fasting during Ramadan? Can pregnant women safely participate in fasting?
  
  

Objective 2: Describe an ethical approach to obtaining consent for a pelvic exam in medical care and in medical education.

Resources:

• Consent in Pelvic Care (25-minute read)

Applications and Questions:

• Many women might prefer/demand female clinicians due to religious preferences or experiences of trauma. How does your clinic/OB floor handle this in a way that respects patient autonomy?
• Historically some learners have done pelvic exams to women under anesthesia without explicit consent. Have you observed this practice? How do you feel as a learner about being included in pelvic exams?

Suggested Rotations: Obstetrics/GYN PGY1, PGY2, PGY3

Objective 1A: Identify barriers and ways to overcome them for obstetric care in LGBTQIA2S+ population.

Objective 1B: Describe options for transgender and gender-diverse people to preserve their fertility.

Objective 1C: Describe best practices for contraceptive counseling in LGBTQIA2S+ populations.

Resources:

• This is a comprehensive PowerPoint on trans-reproductive health (15-minute read)
• Gender-Affirming Approach to Contraceptive Care for Transgender and Gender-Diverse Patients (20-minute read)
• ACOG committee statement on patient-centered contraceptive counseling (15-minute read)
• Reproductive Health Access Project ‘Contraceptive Pearl’ for care of LGBT patients (3-minute read)

Applications and Questions:

Reflect:

• What is one thing you learned from the Queering Reproductive Justice mini-toolkit? 

Explore:

• How does your organization display gender in the medical record? Are preferred pronouns and lived names clear? If not, how can you make them clear in your chart?

Apply:

• Patients can read the notes in many health systems. Consider how you document gender in your notes. Is it important to write gender identifiers in every note for gender-diverse patients? 

Suggested Rotations: Obstetrics/GYN PGY1, PGY2, PGY3

Objective 1: Contemplate a social justice approach to mandated reporting to police or welfare agencies.

Applications and Questions:

• Consider a time you reported to child or adult protective services. How might you apply this statement (or others) from the reading? “If required to make a report to child welfare authorities, healthcare providers should understand the consequences of such reporting, be familiar with community resources that may be able to assist the family, and be cognizant of implicit and explicit biases.” (From Confronting Pregnancy Criminalization)

Objective 2: List at least three examples of obstetric violence.

Resources:

• Obstetric Violence - Birth Monopoly explore the website explaining the concept of obstetric violence. Read at least one patient story. (20-minute read)

Applications and Questions:

• During your rotation note if you observe obstetric violence. How could what you observed been prevented or addressed?

Objective 3: Describe the possible repercussions of conscientious refusal on patients.

Resources:

• The Limits of Conscientious Refusal in Reproductive Medicine | ACOG (15-minute read)

Applications and Questions:

• Reflect: Conscientious refusal in medicine is the refusal to provide particular aspects of medical care due to the personal beliefs of the health care clinician. Have you experienced or witnessed conscientious refusal on the part of a clinician in patient care? If you have a conscientious objection to an aspect of the practice of medicine, how can you assure that your patients receive the care they require while staying true to your morals? Consider a plan to prepare in advance of potentially triggering situations in the future. 
• How will you navigate working with a colleague or staff member who exercises a conscientious objection or refusal?

Suggested Rotations: Obstetrics PGY-1, PGY-2, PGY-3

Objective 1A: Residents will be able to describe the impact of implicit bias in the area of perinatal care and reproductive justice.

Objective 1B: Residents will demonstrate at least two strategies to protect providers and patients from bias.

Resources:

• Dignity in Pregnancy & Childbirth Training: 1-hour training module provides CME credit.

• Community-informed models of perinatal and reproductive health services provision: A justice-centered paradigm toward equity among Black birthing communities (15-minute read)
• Setting the Standard for Holistic Care of and for Black Women
  (18-minute read)

Applications and Questions:

Reflect upon the module and readings above in the context of your current clinical practice of obstetric care. 

• How do you currently explore pregnant patients’ cultures, experiences, and beliefs to prioritize the reproductive justice imperative of ‘consent over bias’?
• How might you change your approach to obstetric care visits to support care that is centered on mutual trust and development of understanding? 
• In what ways does your clinical practice environment support and sustain interprofessional collaboration in the care of pregnant peoples? 
• How can your practice make change towards a community informed perinatal and reproductive healthcare model (PRH), in order to move away from a physician-centered PRH care model? 
• What next steps might your residency program or clinic take?

Suggested Rotations: Obstetrics PGY-1, PGY-2, PGY-3, Outpatient Family Medicine Clinic PGY-1, PGY-2, PGY-3, Adolescent

Objective 1: Residents will apply the concepts of equity and reproductive justice in reproductive health care to their own clinics.

Objective 2: List strategies to identify and address unconscious bias and promote reproductive autonomy at the individual level.

Resources:

• Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020 (7-minute read)
• Creating equitable access to high-quality family planning information and services: A Strategic Planning Guide
  “Equity in family planning does not mean that all groups use contraception—or specific methods of contraception—at the same rates. Rather, equity is realized when all individuals have access to high-quality reproductive health information and contraceptive services, including choice of methods and availability of those methods, that reflect their values and preferences and the context in which they live—regardless of age, sex, disability, race, ethnicity, origin, religion, economic status, or other factors.”
• Reproductive Health Access Project | Contraceptive Pearl: Contraceptive Counseling Through the Lens of Reproductive Justice - Reproductive Health Access Project
• Reproductive Justice — Sister Song
• Oregon Guidance for the Provision of High-Quality Contraception Services: - A Clinic Self-Assessment Tool: This toolkit has many measures that increase the access to contraception in a primary care clinic. (5-10 minutes to skim through)

Applications and Questions:

• Does your clinic provide equitable access to contraception? Evaluate your clinic using either a section of or the entire Clinic Self-Assessment toolkit above.
• How do you currently begin a conversation about contraception? Would you change how you approach these conversations with a reproductive justice lens in mind? 

Suggested Rotations: Obstetrics/GYN PGY1, PGY2, PGY3

Objective: Residents will be able to name the tenets of reproductive justice and apply a reproductive justice approach to reproductive planning.

Resources:

• The Effects of Not Being Able to Access Abortion Care—a Patient's Story (15-minute read)
• The Dangerous Rise of the IUD as Poverty Cure: Reproductive coercion (5-minute read)

Applications and Questions:

• If you will not be providing abortion care to your patients (due to personal belief, laws, Catholic health systems, etc), how can you assure your patients access to the care that they need?
• Consider a patient who had an undesired pregnancy: what non-legal obstacles might impact access to abortion for your patient?  For example, financial, child care, transportation, domestic violence, cultural context, community support and acceptance, etc.
• Do you know what resources exist in and out of your state for patients in need of abortions? For example, the National Abortion Federation helps women in the United States navigate abortion access, including travel funding.
• Exercise: If you had a patient in a state with abortion bans with a non-viable fetal anomaly at 20 weeks, what resources can you offer her?
• Look up your state’s laws about abortion access. Are there restrictions about dating? Are there exceptions for specific groups such as victims of rape? Is Mifepristone accessible by for your patient?

Suggested Rotations: OB GYN, Outpatient PGY3

Objective 1A: Residents will be able to perform non-directive counseling options.

Objective 1B: Residents will be able to explain medication abortion contraindications, consent, and processes.

Applications and Questions:

• Consider how you approach a patient with a positive pregnancy test. Practice a few scripts on how you might sensitively assess if this is a desired pregnancy or not.
• Consider what resources you will use to counsel patients about their pregnancy termination options.

Suggested Rotations: Obstetrics/GYN PGY1, PGY2, PGY3

Objective 1: Residents will be able to identify at least 3 ways to build on CDC recommended 5 Ps to take an inclusive and comprehensive sex history.

Resources:

• CDC Five Ps (6-minute read)
• WHO definition of sexual health (less than 1-minute read)

Applications and Questions:

• Does your clinic have a sexual history intake form? Is it gender inclusive and comprehensive? If not, how might it be improved?

Objective 2: Residents will demonstrate an ability to support patients’ sexual health with an open-minded, sex-positive approach.

Resources:

• Fifty Shades of Stigma: Exploring the Health Care Experiences of Kink-Oriented Patients (look at abstract 1-minute, Ask your library for full article 20-minute read)
• Sexual Health History: Techniques and Tips (5-minute read)
• National LGBTQIA+ Health Education Center: This is a free resource, but you do need to register, lots of resources about Queer health: (30-minutes or more)
• Savage Lovecast: This podcast has weekly sex and body positive shows about sexuality covering a wide range of topics, and can help you understand some of the diversity of sexual expression

Applications and Questions:

• Harvard Implicit Association Test: Take one of the implicit bias tests about sexuality, gender, or transgender people. What struck you about the results? 
• What do you find challenging about taking a sexual history? What can you do to ensure that your approach is open-minded?

Suggested Rotations: Obstetrics/GYN PGY1, PGY2, PGY3

Objective 1A: Describe health disparities for women with intellectual and/or developmental disabilities. 

Objective 1B: Describe possible barriers to contraceptive care for women with physical and/or sensory disabilities. 

Objective 1C: List possible accommodations for pelvic exams for people with vaginas who have physical and/or sensory disabilities or intellectual and/or developmental disabilities. 

Resources:

• Primary Care for Women With Intellectual Disabilities (14-minute read)
• Experiences of Women With Disabilities in Accessing and Receiving Contraceptive Care (22-minute read)

Applications and Questions:

• Review the chart of one of your assigned female at birth patients with intellectual and developmental disability. Are they up-to-date on screenings?
• What are the ethical and legal issues in medical decision making for routine GYN care for women with intellectual disability and how might they apply to your patient?
• Consider how your clinic meets the needs of patients with  disabilities. Is there room for improvement? If so, consider bringing it up at your next clinic team meeting.