Working with WOAR to Educate Teens on Safety in Sexual Health

WHEP ELECTIVE: Women’s Health in the Community

For my Women’s Health in the Community elective, I reached out to the organization Women Organized Against Rape (WOAR). WOAR provides counseling services, advocacy for victims of sexual violence, and educational programs to stop sexual and domestic violence and bullying. As a future gynecologist, I am aware of the dangers of intimate partner violence and sexual assault, and I wanted to better educate myself on the topic.

Once I got in touch with Teresa White-Walston, Director of Educational Services, we discussed WOAR’s educational programs and how I could contribute. Teresa works closely with local schools, teaching teens about bullying, self-esteem and character building. She saw the need for sexual health education for her students, as many of them become involved in sexual activity before they are ready and, often, are misinformed by their peers on the topic.

I developed a lecture geared toward middle school girls where I covered basic female reproductive anatomy, facts about teen sexual activity, sexually transmitted illnesses (STI) risks and the realities of teen pregnancy. Researching, alone, for this presentation was an eye-opening experience! Here are some interesting facts that stood out to me (AND my students):


-43% of teenage girls and 42% of teenage boy have had sexual intercourse, but only 33% are currently sexually active (CDC Youth Risk Behavior Survey)


-15-24 year olds account for only 25% of the sexually active population in US, but are nearly 50% of all new STI’s diagnosed annually (CDC)


-In 2009, more than 400,000 girls aged 15-19 years old gave birth (CDC)


-50% of teen moms have a high school diploma by age 22, compared to 90% of teenage girls who don’t give birth (CDC)


As I gave my lecture to classrooms of curious 6th, 7th, and 8th graders, I could see that many of the things I taught were completely new to them. First of all, most of the girls had no idea what body parts they had or what their proper names are. Secondly, my students were surprised to see that only 33% of teens are sexually active. Based on the media and schoolyard gossip, they thought the number was closer to 80 or 90-percent! I’m glad I could show them otherwise. The information I gave the students about STI’s seemed to hit the kids from left field. Sure, they’ve heard of HIV and how bad it is. But they didn’t know about all of the other STI’s or how many people have them. I shocked many when I informed them that some sexually-transmitted infections are life-long and could have serious consequences like cancer and infertility. As for the pregnancy part of the lecture, it seemed like each of the students knew someone who got pregnant and gave birth before she was ready. I ended each lecture with a discussion on the magnitude of engaging in sexual activity, the importance of waiting until one is ready, and what a responsible teenager should do when she is.

I hope the information I gave these girls empowered them to stand up against peer pressure and wait until they are truly ready and fully educated to be sexually active, as there are many consequences to consider and protect against. I hope I prepared them with a good foundation on reproductive health and safety. In the end, it is each girl’s responsibility to protect herself, and I hope these girls rise to the challenge to take care of her health and future.


Teresa was terrific. In addition to teaching, she took the time to give me some training for crisis counseling. We discussed the issues surrounding sexual and domestic violence and how to empower victims. She even took me to the Philadelphia Sexual Assault Response Center, so that I could see where a rape victim is treated and what she must go through.


Unfortunately, my time with WOAR has come to an end. However, Teresa and the schools I visited would love to have more Drexel students come through and do similar work to what I had been doing. As medical students, we offer more medical information than Teresa and her volunteers can give to their students, and there is a great need for strong role models at these schools. Please consider working with WOAR either through a Women’s Health elective or as a volunteer. You will be able to reach out to many young girls who need your expertise, and you will probably learn a few things along the way as well. If you are interested, email WHEP at mnickens@drexelmed.edu. To learn more about WOAR, check out their website: www.woar.org.

Submitted by Jennifer Lee, Class of 2012

NO HITTING!! February is Teen Dating and Violence Awareness and Prevention Month

A number of our terrific seniors are engaged in teen health activities this month, Sonia on teen attitudes on sources of sexual health information, Jen and Rita on interactive strategies to raise awareness and knowledge about core health education important for youth, Patti Jo on college health issues.

During our group discussion, Rita mentioned the unhealthy trend of Date Fighting and it's association with relationship violence. (e.g. a young man grabbing a girl's wrist and punching her in the arm). Many of you may have seen youth 'horsing around' - punching each other or grabbing someone. This may seem innocuous, but the rates of interpersonal violence tell us another story. The inability to address anger and frustration or have role models who show how to do so in a healthy fashion;  the role of trauma as an layer that confounds health all contribute to interpersonal violence. Clinicians play a pivotal role in talking with youth and highlighting that they have different options. 

Here's the AAP's policy statement about the role of the Pediatrician in Youth Violence

Prevention http://www.clemson.edu/olweus/aap.pdf and here's ACOG's Tool Kit for Teen Care Tool Kit for Teen Care ACOG 2009 

There was another article of interest that I came across - Attitudes Affecting Physical Dating Violence Perpetration and Victimization: Findings From Adolescents in a High-Risk Urban Community   Ali, Bina; Swahn, Monica; Hamburger, Merle. Violence and Victims26. 5 (2011): 669-83.  This article discussed factors in adolescent hitting and dating violence behavior across gender difference lines. Boys and girls hit, maybe for different reasons. The support of their friends associated with behavior, among other items was associated with interpersonal / dating violence. There are number of interesting risk factors they found. One that I found interesting was that they found the lack of self-efficacy and illicit drug use were unique important factors associated with physical dating violence perpetration for girls only.

Violence prevention is a health issue - as clinician's we need to develop our antennaes and help young women and men to heal from trauma and to be able to lead healthier lives.

That’s Not Cool.com, is a national public education campaign that uses digital examples of controlling, pressuring, and threatening behavior to raise awareness about and prevent teen dating abuse. OVW also funds the National Dating Abuse Helpline at 1-866-331-9474. Teens can also text “loveis” to 77054 to reach an advocate or chat on line by clicking on the icon found on loveisrespect.org.

Invisibility and Lesbian Health

One size does not fit all. Even when we evaluate trends within a given group, we need to deduce what are the individual traits of the person in front of us and what are the population trends that we need to be aware of when assessing support structures, risk and treatment options.


Littlest Pride J.Foster 2008

 Lesbian women, similarly do not fit any one socioeconomic class, ethnicity or educational status. They are young and old; majority and minority; affluent and poor. Although media images of Lesbians may portray stereotypic images of androgenous women (and some are), others are not. So, you can't just 'tell by looking at her.' Rather you need to create a safe clinical space to enable her to tell you about herself and who is important to her and her life.
Lesbian's health risks can differ from heterosexual women.
Would you ever ask a heterosexual woman when she 'came out' as heterosexual?
Sexual minorities have barriers to health. These include: discrimination, presumed heterosexism, lack of inclusivity in environment/language/forms. 

ENVIRONMENT
FORMS When a Lesbian woman sits in a waiting room, surrounded by images of happy (heterosexual) couples, the visual impact is not inclusive. When her first visit form gives her the option of "Single"; "Married"; "Divorced" "Widowed."What are her choices? She can leave it blank (and be treated as single, even if this is not accurate.) She can check off married as she has been in a monogamous relationship for 20 years. More likely than not, if she opts for the latter, the health care provider in their perusal of the form will say: "So what does your husband do?" So now - she comes out and risks a distancing response by the clinician or she is forced to create a story that colludes with presumed heterosexuality. Creating a condition that forces lack of authenticate communication is not the best start to a clinical relationship.

MORE THAN YOU So you may be saying that you are hip to inclusive language (who helps you? who all lives at home with you? Who do I need to include in your care and what connection are they to you?) But it is more than you. You may terrific, warm, sensitive and inclusive - but they have to get to you. So part of being a responsible clinician is being responsible for oversight of your environment. Snickers or disrespectful treatment of patients by staff have to be addressed and potentially in-service/staff trainings on quality care delivery need to include LGBT issues.
MISPERCEPTION OF RISKS BY PATIENTS AND CLINICIANS
PATIENT CENTERED Lesbian women may not be accurate in assessing their health risks. For example, despite statistics that most lesbian women (2/3-3/4) have had sexual intercourse with men (and therefore have similar risks to heterosexual women.) Many Lesbians feel that they have minimal risk for STIs and for screening studies. Thus, they don't come into care for regular preventive visits.

INVISIBILITY Clinicians might 'miss' risks if they don't know that the woman is a Lesbian. Unclear many other minorities with whom the visual at least generates a question, Lesbian women look like heterosexual women. Additionally, they may feel that it is none of our business (their sexuality) and not include it in their health information. Assessing a support structure is essential when dealing with health issues (who will take to the test? who else should be in the room to hear this in order to reinforce/ decode/support you?)  Thus understanding the context of a patient's world and who they are and identify as is important if our goal is excellent care for all.
SPECIFIC HEALTH CONDITIONS AT HIGHER RISK Health specific conditions of note include cancer, cardiovascular disease (as a result of suboptimal weight and smoking), delay in health screening, Breast cancer (both from higher risk factors and fewer screenings), depression, anxiety, smoking, heart disease, uterine cancer, obesity (and therefore obesity related cardiovascular disease), alcohol abuse  They may be at higher risk of unabated estrogen related cancers if they are nulliparous (uterine, breast, etc.)
SEXUAL HEALTH PRINCIPLES Remember that there are three important domains to consider when understanding sexual health: orientation, identity and behavior. Orientation: to whom do I gravitate to/ sexual attracted to; Identity: who do I say I identify as; Behavior: what exactly do I do and with whom. We've discussed how these three elements are not concordant (a patient - can have an orientation but not identify as such;can have an identity but not have concordant behavior; can have a behavior but not feel that this relates to identity) There is an arcane term of sexual preference which many people in the non-health arena inaccurately use interchangebly or substitute for orientation. Orientation of sexuality for all people (and creatures) has an neural basis, so it is the preferred medical description. Preference implies that behavior is rather capricious (e.g. I'd like strawberry ice cream, no, vanilla.) We are all socialized in a heterosexual environment. I have yet to meet a person who wants to have discrimination or barriers.

QUICK SAFE SEX TIPS: HPV is a STI (as well as Chlamydia) that is found among women who have sex with women. So first, we need to advise women to wash up (as is true actually with everyone!). Hand washing is important in safe sex. Cleaning sex toys or using condoms and/or dental dams is also important. Lastly, getting regular health maintanence visits to be promote wellness is important. There are a number of resources for Lesbians to identify high quality respectful clinicians. Some cities have Rainbow Health Pages; resources can also be found on the Internet. There are national groups that promote Lesbian Health like our friends at UCSF Lesbian Health & Research Center

Updating our discussion on health issues for women who are lesbians, here's some additional resources.
JAMA September article mentioned - across the U.S. in med schools the coverage is low and variable in nature.

The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding Institute of Medicine 2011 Report available here

and the previous Lesbian Health IOM Report available here 

Is Body Image Protected in Lesbian Relationships?  Romantic Relationships and Body Image - Lesbian women are not 'protected' by body image issues by being in a relationship and are influenced by their self-perception; their perception of their partner and their partner's actual opinion of their body (image) (Markey, Markey, & Birch, 2004; Markey & Markey, 2006) and Markey, P. M. & Markey, C. N. (2011). The complementarity of behavioral styles among lesbian couples. Manuscript under review


Other web resources:
Gay and Lesbian Medical Association: http://www.glma.org/

Gay Mens Health Crisis (GMHC): http://www.gmhc.org/
CDC Gay and Bisexual Mens Health: http://www.cdc.gov/msmhealth/http://www.cdc.gov/msmhealth/


Lesbian Health and Research Center (UCSF): http://www.lesbianhealthinfo.org/http://www.lesbianhealthinfo.org/


LGBT Aging Project http://www.lgbtagingproject.org/


Lesbian and Bisexual Women’s Health Fact sheets (DHHS): http://www.womenshealth.gov/


American Public Health Association LGBT Initiatives (APHA): http://www.apha.org/about/Public+Health+Links/LinksGayandLesbianHealth.htm


Gay and Lesbian Advocates and Defenders  http://www.glad.org/
  New England Legal Advocates (lists laws and topics by state)


Makadon H. Improving health care for the lesbian and gay communities. New England Journal of Medicine 2006, Vol. 354 (No. 9), pp. 895-7.
 Coker TR, Austin SB, Schuster MA. The health and health care of lesbian, gay, and bisexual adolescents. Annual Review of Public Health 2010. Vol. 31. pp 457-77.


Coren JS, Coren CM, Pagliaro N, Weiss LB. Assessing your office for care of lesbian, gay, bisexual, and transgender patients. Health Care Manager 2011. Vol 30 (No. 1), pp 66-70.


Dowshen N, Garafalo R. Optimizing primary care for LGBTQ youth. Contemporary Pediatrics, October 2009, pp. 58-65.


Kann L, Olsen EO, McManus T et al. Sexual Identity, Sex of Sexual Contact, Health-Risk Behaviors Among Students Grades 9-12 – Youth Risk Behavior Surveillance, Selected Sites, United States, 2001-2009. MMWR, June 10, 2011, Vol 60, No. 7.


Katz K. Health Hazards of “Don’t Ask, Don’t Tell”. New England Journal of Medicine 2010. Vol 363 (No. 12), pp 2380-1.

WHERE TO BEGIN? Figuring Out What You Don't Even Know That You Don't Know?

It is pretty easy to feel comfortable with what we know. It is equally comfortable (especially in an insatiably curious person) to be comfortable asking lots of questions about a topic that we are aware we don't know enough or have enough knowledge (aka a 'Wiki dip' to answer a question).

But how do we get an inroad to asking a question when we haven't yet thought about it? When we don't even know that we need to know about it?  It is a huge challenge. The only approach I have come up with thus far, is to intentionally expose yourself to diverse experiences - stream a video on a topic or area you know little about; read a book (or even a blog!) on a topic that you stumble upon; go visit an art exhibit on a style that doesn't grab you; visit countries and work on gaining a different perspective.

So here'a health literacy example, I came upon while delivery a community engagement workshop that highlights 'knowing.' In our Philadelphia Ujima Network, we have the honor of training lay health ambassadors. These women and men are the informal opinion leaders and experts on health in their community based groups(faith based, social service, educational, etc.) Our training sessions happen on Saturday mornings and we have highly interactive sessions to learn things like "Know Your Numbers and Your Health." In one of these sessions, we were discussing heart health risks and hypertension. As I spoke to the group, I became aware that 1) they knew many people with hypertension; 2) they had heard 'a lot' about it; 3) they were aware that it was a very prevalent condition (HTN). But here is where they didn't know what they didn't know.

Because of health outreach successes of others, almost every knew that high blood pressure was associated with the reading of 140/90. But here was the gap. What hadn't been conveyed effectively was that this number represented the 'admissions ticket' to a diagnosis of hypertension,  instead of the audiences' interpretation on this number. Most of the group believed that controlled blood pressure MEANT a bp of 140/90 (or 'near that, 150/100'!). When I clarified that the target BP control range (at least) was 120-134/70-84, many were shocked. "How can you have that blood pressure if you have High Blood Pressure?" one asked.  "By taking medications," I responded. It was new news to the group - something they didn't know (that they needed to know), that good control of BP had readings that were the same as someone who didn't have High Blood Pressure. We didn't even get to the lower numbers needed if you also had Diabetes.

It made me wonder, from a literacy perspective - do we confuse people by accepting the common phrase of High Blood Pressure instead of Hypertension? (e.g. If you have High Pressure (this condition), how can it be low  or normal?)

Every opportunity to teach, we open ourselves up to the gift of learning.

Stimulating questions of the unknown, reminds me of the saying that when you learn a little about a topic, it is not too dissimilar to lighting a match in a huge auditorium - you become aware how little you know and how much more you need to know.

Gaining experiences that engage us in the uncovering of what we don't know and haven't yet thought of asking about, increases the number of matches we hold!

RESOURCES:
Health Literacy •Ask Me Three click here
•Teach Back Technique in Removing barriers to safer care. Health literacy and patient safety. Help patients understand. Manual for clinicians. Weiss, B. AMA Foundation
•Institute of Medicine (2010) Safe Use Initiative and Health Literacy: A Workshop. National Academy Press. Washington, DC.

READ MORE: A very interesting blog to read more on Knowing and Not Knowing:  
Atherton J S (2011) Doceo; Knowing and not knowing [On-line: UK] retrieved 23 February 2012 from http://www.doceo.co.uk/tools/knowing.htm #ixzz1nFFYq2B6  Under Creative Commons License: Attribution Non-Commercial No Derivatives

ASSESSING RISK AND STILL PROMOTING HOPE FOR THE FUTURE

In Medicine, we are taught to assess risk. To identify factors that make a condition more or less likely. It is akin to a detective novel. Uncovering and eliciting information to put together a high, medium or low risk for conditions. It enables us to generate our differential diagnosis - the list of most to lesser likely items associated with a symptom.

Risk assessment is not an emotional charged process for the assessor.

Pulling out the Framingham risk factors for heart disease and assessing becomes a memorized habit. Switch seats and it becomes an entirely different experience.

Patients often say that they'd rather not visit their clinicians office because we will 'find something' (wrong) with them.

In fact, in lifestyle and disease prevention, in history and laboratory screening - we do just that. But it is important for the assessment to not stop there. We have a role in assessing what is right as much as what is not. The twice weekly exercise (in contrast to none) needs to be identified and lauded, for example. Dr Bloom's Trauma model talks about SELF - safety, emotions, loss and future. Without future, there is no healing from trauma. As we 'do our jobs' and identify health risks, patients can feel traumatized. So we need to intentionally include optimism in the process.

During a Ujima Lay Health Ambassador training session, the participants brought this point home to me. We talked about risks associated with heart disease. As I went through the components (DM, HTN, premature heart disease, elevated lipid levels, smoking, etc.), the vibe from the group back to me was of being sad or overwhelmed. This made me mentally pause and reconsider how I was presenting the information. I paused in the laundry listing of 'bad stuff' to then start to highlight the impact of intervening in each factor. Inside of the runaway railroad train of bad stuff down to Heart Attack land, I covered one area at time and then talked about how, for example, quitting smoking, can decrease your risk.

Every time you have the privilege to teach, you can also have the opportunity to learn - another way of thinking, a question not yet considered, the impact of your information.  The group enabled me to truly appreciate how the automatic nature and the speed of risk assessment can adversely affect hope for the future. And if hope for the future is annihilated, the likelihood of intentional action for behavior change is too.
 

So my take home with this is that despite time constraints to quickly deduce and figure out risks, it is even more important in imparting hope for positive change when relaying this information to a patient. From risks to findings it important to put the data in a context that promotes understanding and change. For example - What lab value is abnormal? What does it / can it mean? What can I do about it?

Perhaps risk and hope are a yin/yang type of thing - highlight the change I need and support me to be optimistically ready to take action (and coach me to make the hard changes.) Either way, we need to have one script inside our heads and a different language of delivery to patients if we hope to have them a) come back and see us again :> and,  b) take action to promote healthier lives.