Learning Objectives:
Required Assignments:
Articles:
Video Presentations:
Supplemental Resources:
Videos:
Reproductive Justice in Clinical Practice:
Topic focus: Incarceration and Immigration Detention
Topic focus: Discrimination, mistreatment, and inequity
Topic focus: Environmental justice
Trending Topics:
Learning Objectives:
Visit this link to open the course glossary!
Required Assignments:
VIDEO PRESENTATIONS (available in RheCourse)
Please take a moment to review the supplemental resources at the end of each video presentation.
Visit this link to open the course glossary!
Required Assignments:
VIDEO PRESENTATIONS AND LEARNING OBJECTIVES:
• Sex and Gender
o Define gender and sex and describe their differences
o Understand that human sex diversity goes far beyond the binary of male and female
o Identify ways in which the socially constructed binaries of sex and gender are damaging
• Gender Beyond the Binary
o Understand that gender is experienced in a spectrum of ways and not simply as one of two check boxes
o Become familiar with the historical context and implications of colonization on the idea of a strict gender binary in the US
o Name other cultures from around the world that acknowledge more than 2 genders
• Understanding Identity: The Gender Opossum
o Understand the importance of using the pronouns people ask you to use for them
o Describe the difference between gender identity and gender expression
o Understand that it is not our place to hold trans people to standards of being “man” or “woman” or “nonbinary” enough
o Avoid making assumptions about someone’s sex or gender
o Avoid putting gender assumptions, expectations, or beliefs on other people
• Spectrums of Identity
o Understand that identity labels are personal and can mean different things to different people
o Remember that almost all elements of identity, including gender, exist on a spectrum, and there’s no one right way to do it
o Understand it is not our place to police how other people exist in their gender and that we should appreciate all the human diversity that exists
• Language and Impact
o Accept that changing our language is something that is essential and necessary to provide competent care to trans people
o Have the tools they need to change language in clinical encounters that excludes trans people
o Remember that language changes all the time and we need to remain flexible and willing to change
• Do’s and Don’ts
o Ask people for their pronouns when it’s safe and appropriate to do so
o Use neutral language when talking about someone if they do not know how the person identifies
o Apologize in a healthy way if they misgender someone or mess up in another way
o Thank people who correct them on pronouns, and work to do better
o Understand that if they misgender someone and the person corrects them, that correction is an opportunity to change language and behavior to be more inclusive
Please take a moment to review the reflection questions below each video presentation.
CASE STUDIES
1. You have a new patient named Alex who is in for a prenatal checkup, and the front desk staff lets you know that Alex has a support person named Beth, and both are in the exam room waiting. You walk into the exam room to see Alex (short brown hair) wearing the exam gown and sitting on the exam table, and Beth (long blonde hair) wearing a dress and sitting in the extra chair. You greet the two and say, “Hello! You must be Alex, it’s great to meet you. You must be Beth. It is always so nice to see sisters supporting each other, especially for something as exciting as pregnancy. Before we get started, are there any burning questions you have for me?”
Beth, the support person at the appointment, says, “We’re not sisters. He is my husband. I’m a little confused–when Alex called to set up the appointment, he was told that this office had experience with trans people.” You apologize profusely for the mistake and continue with the appointment. A few times, you stumble over your language, as you are used to saying things like, “When a woman is in the first trimester,” and, “many women have these symptoms,” though you do try to correct yourself. Even with your apology, correcting yourself, and using the correct language to refer to the patient and his wife throughout the rest of the visit, it is tense. Later that day, the front desk staff asks if anything odd happened in the visit, as Alex asked if he could see a different provider going forward, or to have his records so that he could go to a different office.
o How could you have greeted the patient/support person differently? [“Hi, my name is _____, you must be Alex and you must be Beth, unless you decided to sit in the wrong spots haha. I’m excited to get started, but how about you tell me a little more about you.”]
o If the patient had been a woman, why might the greeting that was used still be offensive and alienating? [Bisexual and lesbian women have babies.]
o Even though you apologized and made corrections, it was still a tense appointment that the patient did not feel good about. Why might an apology not be enough? [Apologizing is important, but it does not undo the harm that was done.]
o Aside from being alienated by the language that you used, why might the patient seek out a different provider for their pregnancy care after this experience? [Beth specifically mentioned that the couple was looking for a trans competent provider. Alex may have pregnancy-related questions that are specific to being trans.]
2. You have a new patient come in for abortion care named Scout. The patient’s pregnancy has been confirmed at 6 weeks, and the patient has opted for medication abortion. You go in to the room to meet with the client, give them information about how medication abortion works, answer any questions, and give them the medication. When you enter, you introduce yourself and say, “Sometimes women can have complicated feelings about accessing abortion. I just want to let you know that you know best what you need, and we support you no matter what.” Scout says, “I’m not a woman, I’m agender. I thought I put that on the intake form with my pronouns?” You look at the chart to see a sticky note that says, “agender, they/them pronouns.” Confused, you say, “I’m sorry, I didn’t see that. What’s agender? And I guess I’m a little confused why you’re here for abortion care if you’re not a woman?” Scout sighs and says, “I don’t really want to get into it. I’d really like to just get this over with. The chart confirms I’m pregnant. I have the required parts.”
You want to ask more questions about this “agender” thing, but as the schedule is tight today and the chart does confirm that Scout is pregnant, you go into your regular spiel of explaining how the medication abortion works and the instructions for the patient to follow. You notice that as the appointment goes on and you explain what symptoms most women have and concerning symptoms to look out for, that Scout looks increasingly upset. You ask, “Sweetie, are you okay? If you’re having second thoughts or you’re feeling scared, I’m here to help.” Scout replies, “I’m just not having a good day. I’d like to get this over with. I know that I don’t want to be pregnant anymore.”
You finish the appointment. Later that day, the front desk staff who checked out the patient approaches you and says, “What happened in that appointment? When I asked Scout if they wanted to schedule an appointment for birth control, they said ‘only if it wasn’t with you,’ but I didn’t see anything in the chart from you about them being difficult, and otherwise they were nice as could be.” You reply, “That’s weird. She said some confusing stuff during the appointment, but I thought maybe it was just stress? She mentioned that she wasn’t having a good day.” The front desk staff member replies, “Ahh, that would be why Scout was upset. They’re trans, they use they/them pronouns.”
o What could you have done differently to not alienate the client? [Used inclusive language, not continuously misgender them.]
o What are some negative outcomes that Scout may experience because of how they were alienated in this appointment? [Lack of continued access to all healthcare, lack of access to contraceptives, lack of access to safe abortion care if it is needed in the future.]
o Why would it be inappropriate to ask Scout about “that agender thing” in an abortion appointment? [While it is good to verify with patients what language is affirming for them, it is not appropriate to ask invasive questions that do not relate to the appointment. Ex: it is appropriate to ask what pronouns a patient uses and what medications they take, including gender-affirming hormones, to check for negative medication interactions. It is not appropriate to ask the patient what their gender “means” and if they have plans to have gender-affirming surgeries if it is not pertinent to know for the care you are providing.]
The following case scenarios come from “Learning to Address Implicit Bias Towards LGBTQ Patients: Case Scenarios” from the National LGBT Health Education Center, The Fenway Institute. Additional cases can be found here.
1. Celina is a transgender woman being examined for an infection in her hand. The nurse has never taken care of a transgender person before and finds himself very curious about Celina. He repeatedly catches himself staring at her. While taking Celina’s vitals, the nurse asks, “You know, at first I thought you were a real woman. Do you take hormones? Have you had the surgery yet?” Celina angrily responds, “I don’t think that has anything to do with my hand.”
o Why did the nurse upset Celina?
o What could the nurse have done differently?
o How could the nurse practitioner apologize?
2. Carmen is having her annual physical exam with Dr. Jones, an openly gay physician. Dr. Jones recently skipped his health center’s training on LGBTQ care because he believed he already knew everything about LGBTQ health. Dr. Jones asks Carmen, “Are you sexually active with men, women, or both?” Carmen says, “I am sexually active with one woman.” Hearing this, Dr. Jones skips the questions about condom use. Unbeknown to Dr. Jones, Carmen’s partner is a transgender woman.
o How does this case demonstrate the importance for every team member to receive training in LGBTQ health care delivery?
o How could the doctor rephrase his question to ensure effective communication?
3. Dawud is meeting his pregnant wife, Imran, at the health center for a prenatal appointment with the midwife. Dawud is transgender and is in the process of transitioning from female to male. The midwife, along with a midwife in training, enters the room and sees Dawud. The midwife says to Dawud: “Hi, you must be Imran’s sister, it’s nice to meet you!” Dawud, upset, responds, “No, I am her husband.” The midwife looks startled and mumbles “Oh, sorry.” The trainee notices that Dawud and Imran are visibly uncomfortable, but does not say anything.
o Why are Dawud and Imran upset?
o What could the midwife have said instead?
o How can the midwife in training talk to the midwife preceptor about the interaction?
Learning Objectives:
• Describe the epidemiology of abortion in the U.S. and throughout the world.
• Identify steps to enhance and teach professionalism in abortion care.
• Provide objective and compassionate pregnancy options counseling.
Required Assignments:
• Module Pre-Quiz
• Module Post-Quiz
Articles:
• Induced Abortion in the United States. Guttmacher Institute. Published May 3, 2016. Accessed April 24, 2023. https://www.guttmacher.org/fact-sheet/induced-abortion-united-states
• Unintended Pregnancy and Abortion Worldwide. Guttmacher Institute. Published June 10, 2020. Accessed April 24, 2023. https://www.guttmacher.org/fact-sheet/induced-abortion-worldwide
• Interactive Map: US Abortion Policies and Access After Roe. Guttmacher Institute. Accessed April 24, 2023. https://states.guttmacher.org/policies/
• Steinauer J, Patil R. Overview of Pregnancy Termination. Accessed April 24, 2023. https://www.uptodate.com/contents/overview-of-pregnancy-termination?search=abortion&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
• American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 385 November 2007: The Limits of Conscientious Refusal in Reproductive Medicine. Obstet Gynecol. 2007;110(5):1203-1208. doi:10.1097/01.AOG.0000291561.48203.27
Video Presentations in RheCourse:
• Abortion in the International Context
• Abortion Disparities, A Public Health Approach
• Decision Counseling for Positive Pregnancy Results
• Counseling for Pregnancy Ambivalence
• Informed Consent, Decision Assessment, and Counseling in Abortion Care
• The Framework
o The Patient Has the Answer
o Liberation
o Not a Failure
o The Approach
• Explained: Turnaway Study Lecture
• When Abortion is Not Available
o Healthcare Provider Responsibilities
o Abortion is Essential Healthcare
Trending Topics:
• Traub AM, Mermin-Bunnell K, Pareek P, et al. The Implications of Overturning Roe v. Wade on Medical Education and Future Physicians. Lancet Reg Health Am. 2022;14:100334. doi:10.1016/j.lana.2022.100334
Supplemental Resource:
• The Turnaway Study. ANSIRH. Accessed April 24, 2023. https://www.ansirh.org/research/ongoing/turnaway-study
Learning Objectives:
• Understand the principles of uterine aspiration abortion and dilation and evacuation.
• Describe cervical preparation techniques for uterine aspiration abortion and D&E.
• Safely and effectively manage patients’ pain during first-trimester uterine aspiration abortion and second-trimester D&E.
• Understand techniques to prevent and manage post-abortion complications.
Required Assignments:
• Module Pre-Quiz
• Module Post-Quiz
Articles:
• Shih G, Wallace R. First-trimester Pregnancy Termination: Uterine Aspiration. https://www.uptodate.com/contents/first-trimester-pregnancy-termination-uterine-aspiration#topicContent
• Hammond C. Overview of Second-trimester Pregnancy Termination. https://www.uptodate.com/contents/overview-of-second-trimester-pregnancy-termination#topicContent
• Diedrich JT, Drey EA, Newmann SJ. Society of Family Planning Clinical Recommendations: Cervical Preparation for Dilation and Evacuation at 20-24 Weeks’ Gestation. Contraception. 2020;101(5):286-292. doi:10.1016/j.contraception.2020.01.002
• Cansino C, Denny C, Carlisle AS, Stubblefield P. Society of Family Planning Clinical Recommendations: Pain Control in Surgical Abortion Part 2 – Moderate Sedation, Deep Sedation, and General Anesthesia. Contraception. 2021;104(6):583-592. doi:10.1016/j.contraception.2021.08.007
• Henkel A, Blumenthal PD. Second-trimester Abortion Care for those with Complex Medical Conditions. Curr Opin Obstet Gynecol. 2022;34(6):359-366. doi:10.1097/GCO.0000000000000817
Video Presentations in RheCourse:
• Uterine Aspiration Abortion
• Pain with Uterine Aspiration Abortion
• Uterine Aspiration Video
o Innovating Education in Reproductive Health. Uterine Aspiration Videos. Vimeo. https://vimeo.com/album/3395660. Accessed April 2023.
o Includes animations of paracervical block, MVA use. Password: outpatientEPL2015
• Overview of Abortion Care After the First Trimester
• Medication Abortion Care After the First Trimester
• Procedural Abortion Care After the First Trimester
• Cervical Preparation with Osmotic Dilators
• Dilation and Evacuation Animation
• Complications of Procedural Abortion and Prevention Strategies
• Managing Complications of Procedural Abortion
• Cannula Animation
• Cervical Laceration Animation
• Foley Balloon Animation
Trending Topics:
• Latta K, Barker E, Kendall P, et al. Complications of Second-trimester Induction for Abortion or Fetal Demise for Patients with and Without Prior Cesarean Delivery. Contraception. 2023;117:55-60. doi:10.1016/j.contraception.2022.06.011
• White K, Baum SE, Hopkins K, Potter JE, Grossman D. Change in Second-trimester Abortion After Implementation of a Restrictive State Law. Obstet Gynecol. 2019;133(4):771-779. doi:10.1097/AOG.0000000000003183
Supplemental Resource:
• Lee SJ, Ralston HJP, Drey EA, Partridge JC, Rosen MA. Fetal Pain: A Systematic Multidisciplinary Review of the Evidence. JAMA. 2005;294(8):947-954. doi:10.1001/jama.294.8.947
• O’Shea LE, Lord J, Fletcher J, Hasler E, Cameron S. Cervical priming Before Surgical Abortion up to 13+6 Weeks’ Gestation: A Systematic Review and Meta-analyses for the National Institute for Health and Care Excellence-New Clinical Guidelines for England. Am J Obstet Gynecol MFM. 2020;2(4):100220. doi:10.1016/j.ajogmf.2020.100220
• O’Shea LE, Lohr PA, Lord J, Hasler E, Cameron S. Cervical Priming Before Surgical Abortion Between 14 and 24 Weeks: A Systematic Review and Meta-analyses for the National Institute for Health and Care Excellence-New Clinical Guidelines for England. Am J Obstet Gynecol MFM. 2021;3(1):100283. doi:10.1016/j.ajogmf.2020.100283
Learning Objectives:
• Understand the mechanism, pharmacokinetics, and efficacy of medication abortion/labor induction termination agents (mifepristone, misoprostol).
• Describe the evidence-based dosing regimens of medication abortion and labor induction termination.
• Counsel patients about eligibility, pain management, side effects, and risks of medication abortion.
• Provide post-procedure care for patients who undergo medication abortion and labor induction termination.
Required Assignments:
• Module Pre-Quiz
• Module Post-Quiz
Articles:
• American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology, Society of Family Planning. Medication Abortion Up to 70 Days of Gestation: ACOG Practice Bulletin, Number 225. Obstet Gynecol. 2020;136(4):e31-e47. doi:10.1097/AOG.0000000000004082
• Information about Mifepristone for Medical Termination of Pregnancy Through Ten Weeks Gestation. FDA. Published online March 24, 2023. Accessed April 5, 2023. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation
• Dzuba IG, Chong E, Hannum C, et al. A Non-Inferiority Study of Outpatient Mifepristone-Misoprostol Medical Abortion at 64-70 Days and 71-77 Days of Gestation. Contraception. 2020;101(5):302-308. doi:10.1016/j.contraception.2020.01.009
• Grossman D, Verma N. Self-managed Abortion in the US. JAMA. 2022;328(17):1693-1694. doi:10.1001/jama.2022.19057
• Hammond C. Second-trimester Pregnancy Termination: Induction (Medication) Termination. Accessed April 5, 2023. https://www.uptodate.com/contents/second-trimester-pregnancy-termination-induction-medication-termination
Video Presentations in RheCourse:
• Medication abortion
• When abortion is not available: self-management of abortion
• When abortion is not available: caring for patients after self-management of abortion
• Patient decision making about abortion after the first trimester
Trending Topics:
• Aiken ARA, Romanova EP, Morber JR, Gomperts R. Safety and Effectiveness of Self-managed Medication Abortion Provided Using Online Telemedicine in the United States: A Population Based Study. Lancet Reg Health Am. 2022; 10:100200. doi:10.1016/j.lana.2022.100200
• Upadhyay UD, Raymond EG, Koenig LR, et al. Outcomes and Safety of History-Based Screening for Medication Abortion: A Retrospective Multicenter Cohort Study. JAMA Intern Med. 2022;182(5):482-491. doi:10.1001/jamainternmed.2022.0217
• Raymond EG, Mark A, Grossman D, et al. Medication Abortion with Misoprostol-only: A Sample Protocol. Contraception. Published online February 2023:109998. doi:10.1016/j.contraception.2023.109998
Supplemental Resource:
• Meckstroth KR, Whitaker AK, Bertisch S, Goldberg AB, Darney PD. Misoprostol Administered by Epithelial Routes: Drug Absorption and Uterine Response. Obstet Gynecol. 2006;108(3 Pt 1):582-590. doi:10.1097/01.AOG.0000230398.32794.9d
Learning Objectives:
• Describe the mechanisms of action and efficacy and effectiveness of contraceptive methods.
• Use the US Medical Eligibility Criteria to evaluate eligibility for the use of contraceptives among people with specific medical conditions or characteristics.
• Apply the US Selected Practice Recommendations for initiation of contraception and management of common problems.
• Provide person-centered and evidence-based contraceptive counseling, including postpartum and post-abortion contraception.
Required Assignments:
• Module Pre-Quiz
• Module Post-Quiz
• Module Supplemental Quiz
Articles:
• All Birth Control Options | Types of Birth Control | Learn More. Bedsider. Accessed April 25, 2023. https://www.bedsider.org/birth-control
• Contraceptive Technology. Accessed April 25, 2023. https://contraceptivetechnology.org/the-book/
• Note: The next edition of Contraceptive Technology will be published in October 2023 and will have an updated table and chart.
• US Medical Eligibility Criteria for Contraceptive Use, 2016 (US MEC) | CDC. Published March 27, 2023. Accessed April 25, 2023. https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html
• US Selected Practice Recommendations for Contraceptive Use, 2016 (US SPR) | CDC. Published March 28, 2023. Accessed April 25, 2023. https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html
• Whitaker AK, Chen BA. Society of Family Planning Guidelines: Post placental Insertion of Intrauterine Devices. Contraception. 2018;97(1):2-13. doi:10.1016/j.contraception.2017.09.014
• American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 208: Benefits and Risks of Sterilization. Obstet Gynecol. 2019;133(3):e194-e207. doi:10.1097/AOG.0000000000003111
Video Presentations in RheCourse:
• Contraception 101
• getLARC training
• Initiation of Shared Decision-Making Process
• Shared Decision Making Using a Decision Aid
• Prescribing Emergency Contraception
• LARC Insertion: Immediate Postpartum Period
• Immediate Post – Placental IUD Insertion Video
Trending Topics:
• Guillard H, Laurora I, Sober S, Karapet A, Brass EP, Glasier A. Modeling the Potential Benefit of an Over-the-counter Progestin-only Pill in Preventing Unintended Pregnancies in the U.S. Contraception. 2023;117:7-12. doi:10.1016/j.contraception.2022.10.006
• Turok DK, Gero A, Simmons RG, et al. Levonorgestrel vs. Copper Intrauterine Devices for Emergency Contraception. N Engl J Med. 2021;384(4):335-344. doi:10.1056/NEJMoa2022141