Polyvictimization and Psychiatric Sequelae Associated with Female Genital Mutilation/Cutting (FGM/C)
Female Genital mutilation/cutting (FGM/C) is associated with enduring psychiatric complications. In this study, we investigate the rates of co-morbid abuses and polyvictimization experienced by survivors of FGM/C. This is a sub-analysis of a cohort study examining the patient population at the EMPOWER Center for Survivors of Sex Trafficking and Sexual Violence in New York City. A retrospective chart-review of electronic medical records was conducted for all consenting adult patients who had FGM/C and had an intake visit between January 16, 2014 and March 6, 2020. Of the 80 participants, ages ranged from 20 to 62Â years with a mean of 37.4 (SDâ€‰=â€‰9.1) years. In addition to FGM/C, participants were victims of physical abuse (43; 53.8%), emotional abuse (35; 43.8%), sexual abuse (35; 43.8%), forced marriage (20; 25%), child marriage (13; 16.3%), and sex trafficking (1; 1.4%). There was a high degree of polyvictimization, with 41 (51.2%) experiencing 3 or more of the aforementioned abuses. Having FGM/C on or after age 13 or having a higher total abuse score was also found to be strong predictors of depression and PTSD. The high rates of polyvictimization among survivors of FGM/C are associated with development of depression and PTSD. Despite co-morbid abuses, patients still attribute substantial psychiatric symptoms to their FGM/C. Health care providers should understand the high risk of polyvictimization when caring for this patient population.
Perceptions of Female Genital Mutilation/Cutting (FGM/C) among Asylum Seekers in New York City
Female Genital Mutilation/Cutting (FGM/C) affects millions of girls and women globally each year despite widespread criminalization of the practice. Eradication efforts have focused on the health risks associated with FGM/C however, it is important to understand the sociocultural context in which this practice exists. We conducted a cross-sectional study using retrospective chart review and structured interviews with women recruited through the Bellevue/New York University Program for Survivors of Torture. Of the 43 participants enrolled in the study, 88.4% initially indicated there is no benefit of undergoing FGM/C but when prompted, agreed that social acceptance (16.3%), religious approval (11.6%), and better marriage prospects (9.3%) are possible benefits. More sexual pleasure for the women (46.5%), avoiding pain (30.2%), and fewer medical problems (16.3%) were stated as benefits of not undergoing FGM/C. Overall, 40 (93%) participants believed the practice should be discontinued. This study highlights that there may be a perception of social benefit of undergoing FGM/C. Although most participants believed the practice should be discontinued, the complex social milieu within which this practice exists must be addressed.
Caring for long term health needs in women with a history of sexual trauma
A prospective cohort study comparing expulsion after post-placental insertion: the levonorgestrel versus the copper intrauterine device
OBJECTIVES/OBJECTIVE:To compare the expulsion rate at 6months after post-placental insertion by intrauterine device type. STUDY DESIGN/METHODS:This prospective cohort included participants with a post-placental intrauterine device inserted after vaginal or cesarean delivery, aged 18-45 andâ‰¥24weeks gestation. Study enrollment took place after IUD selection and insertion. Participants returned for a postpartum visit and received a short message service survey regarding intrauterine device expulsion, removal, vaginal bleeding and breastfeeding weekly from weeks 0 to 5 and on weeks 12 and 24 postpartum. Multivariable logistic regression examined 6-month expulsion rate by intrauterine device type. adjusting for variables that differed between the groups at baseline and in the bivariate analyses. RESULTS:Of 114 participants, 75 (65.8%) chose a levonorgestrel 52 mg intrauterine device and 39 (34.2%) chose a copper intrauterine device; 58 (50.9%) had a vaginal delivery and 56 (49.1%) had a cesarean delivery. Groups were similar except that copper intrauterine device users had a higher median parity (3 vs. 2, p=.03) and a higher proportion of senior residents compared to junior residents had performed insertion (46.2% vs. 22.7%, p=.02). The expulsion rate at 6-months was similar between the levonorgestrel and copper groups (26.7% and 20.5%, respectively; p=.38). Multivariable logistic regression also demonstrated that the odds of expulsion did not differ by intrauterine device type (aOR 0.98, 95% CI 0.22-4.48). CONCLUSION/CONCLUSIONS:The expulsion rate at 6-months after post-placental insertion did not differ between the levonorgestrel and copper intrauterine device type. IMPLICATIONS/CONCLUSIONS:Prior studies demonstrate a wide range of expulsion after post-placental insertion and recent data suggest a higher expulsion rate for the levonorgestrel compared to the copper intrauterine device. However, many studies did not control for patient level factors or delivery route. We found that when controlling for these confounding variables, the expulsion rate at 6-months postpartum did not differ by intrauterine device type.
Gynecological and Contraceptive Needs of Female Survivors of Sex Trafficking and Sexual Violence [Meeting Abstract]
INTRODUCTION: Survivors of sexual trauma need trauma-informed care, but their specific gynecologic needs have not been explored. This study aims to examine the gynecological and contraceptive needs among survivors who did present to a specialized gynecology clinic for trauma survivors. This data may help gynecologists who encounter patients with sexual trauma to better understand their medical needs.
METHOD(S): This is a retrospective cohort study of patients at the EMPOWER Clinic for Survivors of Sex Trafficking and Sexual Violence. IRB approval and patient informed consent were obtained. Data were abstracted from electronic medical records, and stored and analyzed using REDCap.
RESULT(S): Data were available for 232 patients. Most patients presented to the clinic for a routine gynecological exam or due to gynecological symptoms. The most common chief complaints were dysmenorrhea, menorrhagia, and abdominal pain. Seventy percent of childbearing age patients were not on any form of effective contraception at the time of their intake visit. However, more than half of these patients with whom family planning was discussed accepted a new form of contraception, with 50% of these patients choosing oral contraceptive pills.
CONCLUSION(S): Trauma survivors often present with routine gynecological complaints, and providers should be prepared to address these in addition to the trauma. Many patients were not using an effective form of contraception at intake, but a majority of patients who discussed family planning with the Ob/Gyn accepted a new form of contraception, suggesting that there may be a high unmet need for contraception in this population
Knowledge and Use of Contraception among a Population of Female Survivors of Torture [Meeting Abstract]
INTRODUCTION: Bellevue Hospital's Program For Survivors of Torture (PSOT) sees patients applying for asylum from developing countries with limited access to contraception. The objective of this study is to examine contraceptive knowledge and use among a population of asylum candidates, in order to better understand their contraceptive educational needs.
METHOD(S): An observational study was conducted using a cross-sectional structured interview questionnaire. IRB approval and patient informed consent were obtained. Data were collected from 55 participants as part of a larger research study to assess histories, perceptions, and gynecological needs of immigrant female survivors of torture. Data analysis was conducted via REDCap.
RESULT(S): Sixty-three percent of participants did not want to get pregnant within the next year, but only 32% of them were using any form of effective contraception. The only effective method of contraception that a majority (53%) of participants had been taught to use were oral contraceptive pills (OCPs) and only 36% had knowledge about long-acting reversible contraceptives (LARCs). Comparatively, 75% knew how to use the rhythm method. Prior use of LARCs, OCPs, and noneffective methods were 9%, 31%, and 63%, respectively.
CONCLUSION(S): A majority of the immigrant women in this study did not want to get pregnant in the next year, but a minority had knowledge about effective contraceptive options outside of OCPs, and an even fewer had knowledge about LARCs. The discrepancy of usage between non-effective methods of contraception and effective methods suggests providers who see patients entering the American healthcare system should provide education on effective contraceptive options
An Integrated, Trauma-Informed Care Model for Female Survivors of Sexual Violence: The Engage, Motivate, Protect, Organize, Self-Worth, Educate, Respect (EMPOWER) Clinic
This article describes the Engage, Motivate, Protect, Organize, self-Worth, Educate, Respect (EMPOWER) Clinic for Survivors of Sex Trafficking and Sexual Violence located at Gouverneur Health in New York, New York, as a model for integrated gynecologic and psychiatric care of survivors of sexual and gender-based violence. Although patients with a history of sexual trauma often have critical health needs that persist long after the traumatic event, most existing services for survivors of sexual violence focus solely on the provision of acute care immediately after the violence has occurred. There are very few clinics in the United States dedicated to managing the significant long-term medical consequences and sequelae of sexual violence in a trauma-informed setting. We report on best practices for the provision of trauma-sensitive medical care to this patient population based on those employed at the EMPOWER Clinic. In particular, we outline some of the unique considerations for treating survivors relating to taking a patient history, conducting the physical and gynecologic examinations, ensuring confidentiality, and managing legal issues. Finally, we reflect on the challenges faced in sustaining the EMPOWER Clinic and the importance of the existence of a clinic dedicated to this specific population.
Who's at the podium?: Gender & Authorship of Oral Presentations at SMFM & SGO (1998-2018) [Meeting Abstract]
On Female Genital Cutting: Factors to be Considered When Confronted With a Request to Re-infibulate
According to the World Health Organization, female genital cutting affects millions of girls and women worldwide, particularly on the African continent and in the Middle East. This paper presents a plausible, albeit hypothetical, clinical vignette and then explores the legal landscape as well as the ethical landscape physicians should use to evaluate the adult patient who requests re-infibulation. The principles of non-maleficence, beneficence, justice, and autonomy are considered for guidance, and physician conscientious objection to this procedure is discussed as well. Analyses of law and predominant principles of bioethics fail to yield a clear answer regarding performing female genital cutting or re-infibulation on an adult in the United States. Physicians should consider the patient's physical, mental, and social health when thinking about female genital cutting and should understand the deep-rooted cultural significance of the practice.
Medical needs of patients in the empower clinic for survivors of sex trafficking and sexual violence [Meeting Abstract]
Objectives: To describe demographic, gynecological, and psychiatric characteristics of survivors of gender-based violence seeking routine gynecological care in New York City. Method: Data was available for for 200 patients of the EMPOWER Clinic for Survivors of Sex Trafficking and Sexual Violence, a New York City gynecology clinic with co-located psychiatric services. Patients may have seen the gynecologist, psychiatrist, or both. Data were abstracted from the medical records of patients' gynecology and psychiatry intake visits. Results: The EMPOWER Clinic patients are mostly from Latin America (33%), Africa (32%) and Asia (10%). Of the 200 enrolled patients, A quarter (25%) have a history of female genital cutting (FGC), and over a third (39%) have a history of sex trafficking. Over a quarter (28%) had a previous induced abortion, and 9% had a forced abortion. Nearly a quarter of patients (23%) report a history of sexually transmitted disease and 12% have had an abnormal Papanicolaou smear. Of patients who were connected to a psychiatrist, a majority were diagnosed with major depressive disorder (79%) and/or post-traumatic stress disorder (90%). Conclusions: EMPOWER patients hail from all over the world, and have experienced forms of SGBV such as sex trafficking and FGC. They have important gynecologic and mental health history and needs