Smiles, Apologies, and Drawing Trauma-Informed Care in the PurpLE Clinic.

This medical narrative highlights ways in which comics reflect the author's experience as a primary care physician striving to offer sensitive care to people who have experienced sexual violence.

Trafficking and Trauma: Insight and Advice for the Healthcare System From Sex-trafficked Women Incarcerated on Rikers Island.

BACKGROUND: Sex-trafficked persons experience significant trauma while exploited, resulting in complex health issues and barriers to health care. Incorporating survivor perspectives is critical in optimizing health care delivery for this population. OBJECTIVES: We interviewed sex-trafficking survivors regarding their experiences with trauma while being trafficked and elicited advice about health care delivery. RESEARCH DESIGN: Qualitative interviews were conducted in New York City's Rikers Island jail from July to September 2015. SUBJECTS: In total, 21 English-speaking women who had experienced sex trafficking were the subjects of the study. MEASURES: Interview domains included: interpersonal violence, behavioral health, and health care delivery advice. RESULTS: Interviewees described experiencing severe and chronic trauma perpetrated by traffickers and sex buyers. Substance use was the primary method of coping with trauma. With regard to mental health, interviewees noted diagnoses of depression, anxiety and posttraumatic stress disorder, low self-esteem, and challenges in intimate relationships. Health care delivery themes included approaches to discussing trafficking in health care settings, concerns regarding sexual assault examinations, and suggestions for improving direct-services and prevention programming. CONCLUSIONS: With this perspective into the complex intersection of trauma and behavioral health that sex-trafficked women can experience, health care providers can better understand the context and recommendations regarding trauma-informed care practices for this population. Our results also offer several avenues for future studies with regard to discussing trafficking in clinical settings and an opportunity for stakeholders to incorporate survivor-based input to improve health care for this population.

Identifying Health Experiences of Domestically Sex-Trafficked Women in the USA: A Qualitative Study in Rikers Island Jail.

While sex trafficking in the USA is a significant medical and public health issue, there is sparse data on the healthcare needs of and access for this population. This study was designed to identify experiences of domestically sex-trafficked women regarding healthcare access, reproductive health, and infectious diseases while trafficked. Trafficking survivors incarcerated in New York City's Rikers Island women's jail participated in audio-recorded interviews between July and September 2015. Recordings were transcribed, and a content analysis was completed to identify health-related themes. Twenty-one women ranging from 19 to 60 years old were included in this study. Reasons for accessing care included sexually transmitted infections (STIs) and HIV testing, unintended pregnancies, traumas, and chronic diseases. Emergency departments, Planned Parenthoods, and jails were common care sites. Traffickers and substance use impeded care and access to follow-up. Unintended pregnancy and STIs resulted in trafficker-perpetrated violence. Condoms, the most common form of contraception and HIV prevention, were inconsistently negotiated due to financial and violent consequences. These findings demonstrate that domestic sex trafficking survivors experienced chronic and acute health issues while trafficked and multiple barriers to care. Substance use and financial vulnerabilities furthered unintended pregnancy and infection risk. These findings can inform future research regarding healthcare access and practices for domestically trafficked women.

Beyond the Surface: Care Seeking Among Patients Initiating Contraceptive Implant in an Urban Federally Qualified Health Center Network.

PURPOSE: To describe rates of and reasons for follow-up among adolescents and adults receiving contraceptive implants in a Federally Qualified Health Center (FQHC). METHODS: Retrospective comparison of patient-initiated implant-related contacts during the 6 months postinsertion among adolescents (110) and adults (154) who had implants placed at a FQHC network. RESULTS: Forty percent of adolescents and 26% of adults initiated follow-up ( P = .016). Bleeding changes and discussing removal were the most common reasons for follow-up for both groups. Adolescents (5.5%) and adults (9.0%) had similar removal rates ( P = .348). However, among patients who discussed implant removal, adults were more likely to have removals compared with adolescents ( P = .002). CONCLUSIONS: Other FQHCs may anticipate a similar experience to ours, where adolescents may be more likely than adults to initiate implant-related follow up, with removal rates of less than 10% at 6 months. Further study of physician decision making and patient autonomy regarding implantable contraception removal requests is warranted.

Intrauterine devices at six months: does patient age matter? Results from an urban family medicine federally qualified health center (FQHC) network.

BACKGROUND: Federally qualified health centers (FQHCs) can address high rates of unintended pregnancy among adolescents in the United States by increasing access to intrauterine devices (IUDs) in underserved settings. Despite national guidelines endorsing adolescent use of IUDs, some physicians remain concerned about IUD tolerance and safety in adolescents. Therefore we compared adolescents and adults in a family physician staffed FQHC network with regard to (1) IUD postinsertion experience, (2) device discontinuation, and (3) sexually transmitted infection (STI) rates. METHODS: We conducted a retrospective cohort study among women <36 years old who had an IUD inserted in 2011 at a New York City FQHC staffed by family physicians. RESULTS: We included 684 women (27% adolescents, 73% adults). During the 6-month postinsertion period, 59% of adolescents and 43% of adults initiated IUD-related clinical contact after insertion, most commonly for bleeding changes and pelvic or abdominal pain. There were no significant differences between groups in IUD expulsion or removal or STI rates. CONCLUSIONS: Urban FQHC providers may anticipate that, compared with their adult IUD users, adolescents will initiate more clinical follow-up visits after insertion. Both groups will, however, have similar clinical concerns about, reasons for, and rate of device discontinuation and low STI rates.

Progestogen-only contraceptive use in obese women.

BACKGROUND: The objective of this systematic review is to determine whether obese women who use progestogen-only contraceptives are more likely to experience weight gain or serious adverse events as compared to nonobese users. STUDY DESIGN: We searched PubMed for all articles (in all languages) published in peer-reviewed journals from database inception through October 2008, for evidence relevant to obesity and progestogen-only contraceptives. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. RESULTS: From 579 articles, we identified nine studies fitting our selection criteria. Evidence from five studies suggests that among adult women, baseline weight or body mass index is not associated with weight gain among depot medroxyprogesterone acetate (DMPA) users (Level II-2, Fair). Evidence from three studies suggests that among adolescent women, overweight or obese DMPA users may gain more weight than normal weight DMPA users or overweight/obese nonusers (Level II-2, Fair). Evidence from one small study of Norplant users showed no differences in weight gain by baseline weight (Level II-3, Poor). We did not identify studies of other progestogen-only contraceptive methods that examined weight change by baseline weight, nor did we identify studies that reported on any serious adverse events by baseline weight. CONCLUSIONS: Adolescent DMPA users who are obese may gain more weight than normal weight users. This observation was not seen in adult DMPA users or adolescent Norplant users.

Use of combined oral contraceptives post abortion.

BACKGROUND: Providing combined oral contraceptives (COCs) following surgical or medical induced abortion offers women an opportune moment to initiate a reliable contraceptive method. STUDY DESIGN: We conducted a systematic review, searching MEDLINE and The Cochrane Library for articles in any language concerning COC use following spontaneous, induced (medical or surgical) or septic abortion, from 1966 through June 2008. Seven articles were identified and evaluated using the United States Preventive Services Task Force system. RESULTS: Immediate COC initiation after first-trimester medical or surgical induced abortion did not increase side effects or prolong vaginal bleeding compared with use of a placebo, copper-bearing intrauterine device (IUD), nonhormonal contraceptive method or COC initiation at a later time. Initiating COCs after first-trimester surgical abortion produced small increases in coagulation parameters compared with IUD use; although they are statistically significant, their clinical relevance is unlikely. No study examined second-trimester induced or spontaneous abortion, or septic abortion. CONCLUSIONS: Evidence shows that COCs can be safely initiated immediately following surgical and medical abortion in the first-trimester of pregnancy.

Oral contraceptives and family history of breast cancer.

BACKGROUND: Questions remain regarding whether oral contraceptive (OC) use among women with a family history of breast cancer increases disease risk. STUDY DESIGN: We conducted a systematic review by searching MEDLINE and CENTRAL databases for evidence (in all languages) published in peer-reviewed journals from 1966 to July 2008 that provided estimates of breast cancer risk according to family history. Twelve articles were identified and the quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS: Results from 10 studies and one pooled analysis of 54 studies suggest that the use of OCs does not significantly modify the risk of breast cancer among women with a familial history of breast cancer; however, evidence from four studies shows that some women may be at a greater risk, particularly women who took OCs prior to 1975. CONCLUSIONS: Current evidence shows that women with a family history of breast cancer do not increase their disease risk by using OCs.

The association between history of violence and HIV risk: a cross-sectional study of HIV-negative incarcerated women in Connecticut.

PURPOSE: We examine the association between history of violence and risk for HIV infection among incarcerated women. Specifically, we consider physical violence and rape as they relate to unprotected sex with male primary and nonprimary (male or female) sexual partners among a sample of HIV negative female inmates (n = 1,588) housed in Connecticut's sole correctional facility for women between November 1994 and October 1996. METHODS: A supplement to the mandatory Connecticut Department of Correction Inmate Medical Screening/Health History was used to collect information on each woman's background, history of violence, and unprotected sex practices. Multivariate logistic regression was used to determine the associations between violence and unprotected sex by partner type. RESULTS: Experiencing any violence was significantly associated with increased odds of unprotected sex with one's primary partner, even after controlling for race, history of sex work, drug use, employment status, and having other nonprimary partners. Of particular importance was having a history of physical violence. History of violence was not significantly associated with unprotected sex with nonprimary partners. CONCLUSIONS: These findings demonstrate the considerable vulnerability of incarcerated women to violence and suggest that this history is associated with increased unprotected sex practices, especially with male primary partners. HIV prevention interventions among women should take experiences of violence into account. Conversely, violence prevention and interventions aimed at coping with violence can be a part of the HIV prevention agenda for incarcerated women. Future longitudinal research can confirm the relationships of violence to HIV risk in women.