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. One of your patients presents with an unexpected positive pregnancy test during clinic or in the ED. How would you approach this?
    • If a pregnancy test is being discussed or requested in advance, some providers will ask patients what result they hope for. Once you have given the result, wait for the patient to respond. If it’s not clear how they’re feeling, or what they want to do, you can 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?” 
    • If the test itself was a surprise to the patient, explain that a pregnancy test is often done as a routine part of the visit, and that the result suggests that they are pregnant. Ask if they had at all suspected that they might be pregnant.
    • Your role is to listen, support, and ask questions that will help a patient come to a decision about this pregnancy, although not necessarily at this visit.   
    • A patient may have feelings and intentions one way or the other, and may not need (or appreciate) full options counseling.  
    • If they need more time, consider giving them space to imagine their life now and a few years from now, and to reflect on how each of the available options might change those circumstances. For a more comprehensive exploration of thoughts, feelings, dreams and goals, offer them the Pregnancy Options Workbook (online, Johnson 2013). 
    • A helpful video: Decision Counseling for the Positive Pregnancy Test (IERH).
  2. When you ask a patient what questions they have, they want to know if an abortion will affect their ability to have children in the future. How would you respond?
    • Uncomplicated uterine aspiration and medication abortion has been shown to have no effect on a patient’s future reproductive health. 
    • There is no increased risk of infertility, spontaneous abortion, or pre-term 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, but abortion is extremely safe and will not affect your ability to get pregnant in the future if and when you want to.”
  3. A patient 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. You might be ready for one but not for the other.
    • A birth parent can think of adoption as a way to select parents for the baby, as opposed to giving the baby to adoptive parents.
    • Birth parents commonly feel sadness about relinquishing a child, even if they feel it is the best decision for them.
    • Introduce differences between open and closed adoptions, and give resources and local/national referrals as appropriate. Please see the Chapter 1: Adoption Facts Section.
  4. While you are explaining the protocol for a medication abortion to a patient, they mention that their boyfriend “absolutely cannot find out about this.”  What concerns does this raise and how can you explore this further?
    • Use open-ended questions to explore the relationship dynamics, as there may be reproductive coercion occurring.
    • “Tell me a little more about your relationship, and how your partner might feel about the pregnancy.”
    • “Is your partner pressuring you to make a decision about this pregnancy, or about the birth control you used?”
    • Validate and normalize the patient’s feelings about the situation and remind the patient that you will support their decision no matter what.
    • You can explore options for birth control that their partner would not know about or be able to control.
    • If not done already, screen for intimate partner violence and make a safety plan. 
    • Offer to refer the patient for further counseling around these issues if needed. 
  5. You receive a phone call from a man who would like to schedule a medical abortion for himself. What questions should you ask during counseling and intake?
    • TGD patients 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 client decides to continue their pregnancy, they should connect with their provider about potentially altering hormone therapy. 
    • Work to create a safe gender-affirming environment by asking about pronouns and any preferred terms for specific parts of their body or their menstrual cycle. Make sure all staff and providers are aware of preferences.
    • Ask standard questions to accurately date the pregnancy and ensure that their decision is free of coercion.
    • Ask about plans for contraception. TGD patients are free to use any form of birth control they might like, however some may want to avoid estrogens, due to the potential for undesired feminizing side effects.
  6. You have a 19-year old patient who has been to the clinic for several abortions in the past her first abortion was when she was 14.  She is always accompanied by an older male relative. You are concerned she may be the victim of sex trafficking. What questions might you ask? What should you do if you find out she is the victim of trafficking?
    • Make sure to see all your patients privately for a few minutes at the beginning of each visit to assess for intimate partner violence and reproductive coercion.
    • Ask about her relationship to the older man; look for cues that she might be deferring decision making to him.
    • If she indicates (either through verbal or non-verbal cues) that she feels trapped in the relationship, ask about what might be keeping her—assess for fear of violence or other negative consequences of leaving.
    • Ask about work: is she being forced to work, is payment ever withheld based on performance? Is she being coerced into sleeping with other men (either to make her partner happy or because she is afraid)?
    • If the answers to any of the above questions lead you to think she is a victim of human trafficking, explain what human trafficking is and tell her that you think she may be in a situation where she is being trafficked. Offer support and access to confidential resources. If the victim is a minor, immediately call child protective services. 

EXERCISE 2.2: Counseling around clinical care

Purpose:  Discuss what you might do or what you might say to the patient in each of the following situations when you come into the procedure room.

  1. As you enter the exam room you hear the patient’s partner criticizing them 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 patient without the partner present. 
    • Explain that you routinely do an exam with the patient alone and have the partner go out to the waiting room. 
    • Ask the patient about the tension you observed and how they are feeling about the decision. 
    • A domestic violence screen is appropriate, and you should know the reporting laws for your state or country.
  2. When you come into the exam room and ask the patient how they are feeling, they start crying uncontrollably. The patient has their head turned away from you and does not make eye contact.
    • Crying is normal, but check in with the patient about how they are feeling. “Many patients cry at the time of abortion. Is there any way I can help you now?” Consider asking, “Can you tell me a bit about what you’re experiencing?”
    • The patient may be afraid, or experiencing sadness or loneliness, but still sure of their decision. Alternatively, they may be unsure, or feeling pressured and trapped. You may add something like, “In order to take care of you, I need to understand how you are feeling about this decision today. Do you need some more time?”
  3. The patient is a 14-year-old rape survivor who is 7 weeks pregnant. Every time you attempt to insert the speculum, they raise their hips off the table.
    • Consider using a pediatric speculum (which can be used for up to at least 13-weeks gestation).
    • Offer, “I’m sorry this is uncomfortable. Would any of these options help? Would it help to insert the speculum yourself or to raise the head of the bed?
    • Offer to practice a Kegel during the exam to relax perineal muscles or push their hips downward into the table.
    • Reinforce that they are in control of their own body, and give suggestions about what they can focus on to help keep the procedure safe.   
    • If still unable to tolerate the speculum and keep their hips low, consider more pain medication or conscious sedation.
    • Consider the possibility that they may want or need a referral for deep sedation.
    • Familiarize yourself with the mandated reporting laws in your state. Most states require reporting for any minor (<18 years old) who reports sexual abuse or if the partner is significantly older than the minor. For state laws: http://aspe.hhs.gov/hsp/08/sr/statelaws/statelaws.shtml.
  4. You are about to see a 22-year-old G0 patient with a mild motor and cognitive disability. She arrives in clinic in a wheelchair with her mother. During the intake, the mother states that she would like to discuss birth control that will assist her daughter with periods.
    • Counseling on reproductive topics for adolescents and young adults with disabilities can be complex given possible medical comorbidities in these patients, intellectual disabilities that may raise concerns regarding consent, and the involvement of families or caregivers who may seek to support such decision-making (Ernst 2020).
    • Assume but assess intellectual competence. Do not mistake speech impairment for intellectual incapacity; this patient’s motor disorder may hinder articulation.
    • If possible, conduct part of the interview alone to discuss sexual health screening questions, the patient’s own priorities, and comfort with a supportive decision-making role of the parent.
    • Allocate extra time and consider special issues for the visit so that the patient’s needs can be appropriately addressed.
    • If an exam in needed, consider using a mechanical exam table with leg rests, and always ask the patient how they would like to be assisted in transferring, and discuss alternative positions for doing a gynecologic exam or procedure.
    • For more in depth information on contraceptive counseling in patients’ with disabilities, see Ernst 2020, ACOG 2016, this helpful video (University of Michigan 2017), and Chapter 7: Contraceptive Counseling.
  5. You have just completed an aspiration (for abortion or early pregnancy loss) for a patient at 8-weeks gestation. The patient asks, “Can I see what it looks like?” How would your response differ at 12 weeks gestation?
    • Normalize the request and ask for clarification. “That’s a common question. Tell me more about what you’re thinking.” Sometimes a patient is really asking just if it’s possible to see it, or what you do with the tissue.
    • Before 9 weeks it is difficult to visualize fetal parts, and it can be therapeutic for a patient to see the pregnancy tissue, particularly if they perceive the pregnancy as “a formed baby” (often the impression from the protestors’ signs outside the clinic). You can say, “The pregnancy may look like a blood clot or a cotton ball.”
    • For later gestations, consider asking tactfully what the patient expects to see. Alert the patient that the fetus may not be intact and that some recognizable parts will be visible, and confirm they still want to see.
    • If you are asked about fetal tissue donation, you can let them know in the rare case that a tissue donation program exists at your facility, that it is entirely voluntary and in accordance with the highest 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 in order to obtain the tissue.

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