Trauma-Informed
Reproductive Health
Care for Underserved
Populations
LEARNING TO CARE FOR UNDERSERVED
POPULATIONS

APRIL 25TH, 2024

My Career Path

Undergrad – Anthropology & Biology
• Health Leads, global health experiences, Health4Chicago

Med School – Patient Centered Medicine
• Domestic Violence Shelter, Homeless Shelter, global health

experiences

Residency – Internal Medicine/Primary Care/Women’s Health
• Immigrant/refugee health, HPV vaccination in East African

communities in Seattle, global health experiences

Fellowship – Women’s Health Services Research
• Anti-racism, trauma-informed care, postpartum care

Faculty – Patient Care, Teaching, Research
• Trauma informed care, UCSD Asylum Seekers Medical Screening

and Stabilization Program, Survivors of Torture, MED 236:
Refugee, Immigrant, and Migrant Health

Learning
Objectives

Identify evidence-based principles of trauma-
informed care.Identify

Explain the importance of cultural humility in
cases where underserved populations have
suffered gender-based violence.

Explain

Apply principles of trauma informed care and
cultural humility to reproductive health care. Apply

*Note on language

Trauma-Informed Care
•An approach to care that recognizes, understands, and
empathizes with the impact of trauma on an individual and
their health.

•”What’s wrong with you?” –> “What happened to you?” –>
“What are your strengths?”

Cultural Humility
Active engagement in an ongoing process of self-
reflection
• Examine how personal history and

background impacts patient care.
• Reflect on how patient interactions are

impacted by bias.
• Gain understanding of patients’ lived

experience through active inquiry.
• Recognize patients are their own expert.

Gender Based Violence

Sexual Violence

Military Sexual
Trauma

Reproductive
Coercion

Displacement Trauma Adverse Childhood
Experiences (ACEs)

Sexism & Racism

Female Genital
Cutting (FGC)

Intimate Partner
Violence (IPV)

Cases:
Cervical Cancer Screening &
Reproductive Counseling

– Clinical Guidelines
– Cultural Considerations
– Trauma-Informed Approaches

Cervical
Cancer
Screening
Case

Asha is a 23-year-old woman who presents to
establish care. She moved to the US from
Somalia after she got married a year ago. She
has no medical issues, and she is due for
screening tests. She has never had a pap
smear. Her husband is her only lifetime sexual
partner. She comes from a community that
practices female genital cutting (FGC).

Cervical
Cancer
Screening:
Clinical
Guidelines

Start pap smears at age 21 every 3 years with
cytology alone
Age 30 – 65 every 5 years with co-testing or
primary HPV testing
If above age 65, 10 years of negative tests
before stopping screening

Cervical Cancer Screening:
Cultural Considerations
Pap smear myth – breaks hymen,
no longer considered virgin
Cultural expectations around
virginity and marriage
Stigma around reproductive health
Gender based violence
◦ Pap smears not possible with certain

types of female genital cutting

Female Genital Cutting
• Any ceremonial or nonmedical

alteration of the female genitals
◦ Type 1: Clitoridectomy
◦ Type 2: Excision
◦ Type 3: Infibulation

Singer and Wilson 2007UNICEF, 2013

McCarthy, 2016

AHA Foundation, 2017

• Celebrated rite of passage into
womanhood

• Virginity
• Femininity
• Hygiene
• Fertility
• Marriage

Goodwin, 2017

Female Genital Cutting

• Medical advocacy through asylum
forensic evaluations

• Legal advocacy through immigration
services

• Organizations in San Diego:
• Survivors of Torture
• UCSD Asylum Seekers Medical

Screening and Stabilization
Program

Advocacy in San Diego

Cervical Cancer Screening:
Trauma Informed
Approaches
Explain that the reason for pap smears is to
check for cancer and that we recommend it
for anyone 21 and older, regardless of
sexual activity
Clarify that pap smears do not cause the
hymen to break
Gender concordant provider, chaperone,
and interpreter
Ask for permission, prepare the patient and
the clinical space, empower the patient
throughout the exam, and support the
patient after the exam.

Tips for Sensitive Exams
» Avoid terms like “bed”, “open”, “touch”,

“spread, ”and “relax,” which could have
been words that were spoken to the
patient during a previously traumatizing
encounter.

» For patients with significant vaginismus,
to the point where placement of anything
can be difficult, offer medication to help
with pain during the exam.

Reproductive Counseling
Case
Linh is a 35-year-old woman who presents to
establish care. She presents with her
husband. They recently moved from
Vietnam to the US with their four children.
She is not taking any medications, and all
her pregnancies were normal. During the
visit, her husband is doing all the talking and
she is very quiet. Her husband asks if she
can get a pregnancy test as he is eager to
have more children.

Reproductive Counseling:
Clinical Guidelines
STI screening
◦ Gonorrhea/chlamydia 24 years and younger or

25+ if at increased risk
◦ HIV screening

Family planning
◦ One Key Question
◦ PATH Questions

IPV Screening
◦ Validated tools

Reproductive Counseling:
Cultural Considerations
Social, cultural, religious pressures on
fertility and reproduction
Intimate partner violence and reproductive
coercion

◦ Birth control sabotage
◦ Menstrual cycle tracking
◦ Violence increases during pregnancy

Birth spacing
Stigma around sexual health

Menstrual practices

Reproductive Counseling:
Trauma-Informed Approaches
Discuss in private with the patient with a medical
interpreter – never use family members to interpret

Ask about the patient’s pregnancy intentions
Screen for intimate partner violence and reproductive
coercion

◦ Normalize screening
◦ Discuss mandated reporting
◦ Provide universal education
◦ VAWA – Violence Against Women’s Act

Offer anonymous partner notification:
tellyourpartner.org

Cultural
Humility in
Reproductive
Health
Shankar et al 2020; JGIM

Resources
Besider.org

Tellyourpartner.org

Ethnomed.org

CareRef

One Key Question®

PATH Questions

National Domestic Violence Hotline

National Human Trafficking Hotline

Thank
you!

Feel free to reach out to
me with any quest ions at
meshankar@health .ucsd.edu