Ob-Gyn Awareness of Sex Workers’ Health Risks During Routine Visits is Essential

Washington, DC—New guidance from The American College of Obstetricians and Gynecologists was released today recommending ob-gyns screen all patients for sex work in a nonjudgmental manner during sexual history-taking. The goal of increasing recognition of this population is to increase their access to preventive care.

Sex work is the exchange of sex or other intimate services for money, drugs or other resources. While sex work is illegal in all but one state, it occurs nationwide and is estimated to generate as much as $290 million per year in major U.S. cities. While circumstances surrounding sex work limit available research on the topic, existing literature establishes that sex work is associated with specific health risks.

“Though sex work is often pushed to the fringes of society, ob-gyns have a responsibility to offer women engaging in sex work the best comprehensive care for their needs,” said Jennefer Russo, M.D., M.P.H., author of the new Committee Opinion “Improving Awareness of and Screening for Health Risks Among Sex Workers.” “This begins by understanding that any patient, regardless of socioeconomic status, may have at one time or another engaged in sex work, and creating a space for that information to be exchanged confidentially and safely.”

Physicians must be aware of the wide variance in how sex work is conducted and should not look to the stereotype of sex work as the solicitation of sex on a street corner. Today, sex work has shifted to solicitation through the internet, and in many instances a woman may be engaging in this work while simultaneously attending school or working a more traditional part-time job. Likewise, reasons for engaging in sex work vary. Some sex work is voluntary and consensual, while in other instances women are forced or coerced.

Due to its illegal nature and stigma, many sex workers do not immediately disclose their work, especially to physicians. In one study, 70 percent of sex workers had not shared their work with providers, citing past negative responses from health care workers as a primary reason. They also had the belief that engaging in sex work wasn’t relevant to their health. To reduce barriers to disclosing sex work, ob-gyn offices should consider incorporating questions about sex in exchange for money, goods or services on self-administered history or intake forms completed by all patients.

Following screening for sex work, ob-gyns must be prepared to treat, counsel and educate patients about the attendant health risks. High risk sexual behaviors, such as lack of condom use or sex under the influence of drugs or alcohol, among others, result in greater health risks for sex workers than the average population. Sex workers also experience higher rates of sexually transmitted infections (STIs), sexual or physical violence, incarceration and reproductive coercion.

Contraception use, including the use of condoms, is low among sex workers. This may be due to a variety of reasons, including lack of access, financial coercion to not use condoms, or violence and force. This leaves sex workers vulnerable to STIs and unintended pregnancy. STI rates for sex workers, in some instances, are twice as high as compared to women who do not engage in sex work. This includes high rates of HIV, among other diseases.

During visits, ob-gyns should screen for STIs, and educate patients about STI prevention, including the availability of preexposure and postexposure prophylaxis for HIV, a therapeutic option for patients with higher risk for HIV, that helps prevent transmission. Patients should also receive counseling about contraception, and be offered all contraceptive methods appropriate to their needs.

In addition to addressing the health care needs unique to sex workers, Russo said, “Ob-gyns must ensure these women also receive standard routine care, like any other patient, including cancer screenings and vaccinations.” Ob-gyns may also suggest more frequent health care visits for sex workers to maintain their health.

Committee Opinion #708, “Improving Awareness of and Screening for Health Risks Among Sex Workers,” will be published in the July issue of Obstetrics & Gynecology.

Other recommendations issued in the July Obstetrics & Gynecology

Committee Opinion #705, “Mental Health Disorders in Adolescents”

Mental health disorders in adolescence are a significant problem, relatively common, and amenable to treatment or intervention. Obstetrician–gynecologists who see adolescent patients are highly likely to see adolescents and young women who have one or more mental health disorders. Some of these disorders may interfere with a patient’s ability to understand or articulate her health concerns and appropriately adhere to recommended treatment. Some disorders or their treatments will affect the hypothalamic–pituitary–gonadal axis, causing anovulatory cycles and various menstrual disturbances. Adolescents with psychiatric disorders may be taking psychopharmacologic agents that can cause menstrual dysfunction and galactorrhea. Adolescents with mental illness often engage in acting-out behavior or substance use, which increases their risk of unsafe sexual behavior that may result in pregnancy or sexually transmitted infections. Pregnant adolescents who take psychopharmacologic agents present a special challenge in balancing the potential risks of fetal harm with the risks of inadequate treatment. Whether providing preventive women’s health care or specific obstetric or gynecologic treatment, the obstetrician–gynecologist has the opportunity to reduce morbidity and mortality from mental health disorders in adolescents by early identification, appropriate and timely referral, and care coordination. Although mental health disorders should be managed by mental health care professionals or appropriately trained primary care providers, the obstetrician–gynecologist can assist by managing the gynecologic adverse effects of psychiatric medications and providing effective contraception and regular screening for sexually transmitted infections. This Committee Opinion will provide basic information about common adolescent mental health disorders, focusing on specific implications for gynecologic and obstetric practice.

Committee Opinion #706, “Sexual Health”

Sexuality involves a broad range of expressions of intimacy and is fundamental to self- identification, with strong cultural, biologic, and psychologic components. Obstetrician–gynecologists often are consulted by patients about sexual health and are in a unique position to open a dialogue on sexual health issues. Several obstacles to frank conversations with patients about sexual health exist, including a lack of adequate training and confidence in the topic, a perception that there are few treatment options, a lack of adequate clinical time to obtain a sexual history, patients’ reluctance to initiate the conversation, and the underestimation of the prevalence of sexual dysfunction. However, data on reproductive and sexual health morbidity suggest sexual health is an important health care issue. Each year, an estimated 45,000 new cases of human immunodeficiency virus (HIV) and approximately 20 million sexually transmitted infections occur, 3 million women experience unintended pregnancies, and 1 million women are sexually assaulted. Openly discussing sexual health has the potential to prevent these unnecessary sexual health-related outcomes. Clinical conversations should acknowledge the contributions of sexuality, relationships, and sexual behavior to overall health. Obstetrician–gynecologists can address sexual health issues across a lifespan with their patients and encourage a strategic foundation for women’s sexual health issues, resulting in improved public health overall. Obstetrician–gynecologists also can support policies that broaden the coalition for effective prevention of sexually transmitted infections and promote healthy sexuality, with the ultimate goal of improving health outcomes and public health.

Committee Opinion, #707, “Access to Emergency Contraception”

Emergency contraception refers to contraceptive methods used to prevent pregnancy in the first few days after unprotected intercourse, sexual assault, or contraceptive failure. Although the U.S. Food and Drug Administration approved the first dedicated product for emergency contraception in 1998, numerous barriers to emergency contraception remain. The purpose of this Committee Opinion is to examine barriers to the use of emergency contraception, emphasize the importance of increasing access, and review new methods of emergency contraception and limitations in efficacy in special populations.

Practice Bulletin #179, “Breast Cancer Risk Assessment and Screening in Average Risk Women”

Breast cancer is the most commonly diagnosed cancer in women in the United States and the second leading cause of cancer death in American women. Regular screening mammography starting at age 40 years reduces breast cancer mortality in average-risk women. Screening, however, also exposes women to harm through false-positive test results and over diagnosis of biologically indolent lesions. Differences in balancing benefits and harms have led to differences among major guidelines about what age to start, what age to stop, and low frequently to recommend mammography screening in average-risk women. Breast cancer risk assessment is very important for identifying women who may benefit from more intensive breast cancer surveillance; however, there is no standardized approach to office-based breast cancer risk assessment in the United States. This can lead to missed opportunities to identify women at high risk of breast cancer and may result in applying average-risk screening recommendations to high-risk women. Risk assessment and identification of women at high risk allow for referral to health care providers with expertise in cancer genetics counseling and testing for breast cancer-related germline mutations (e.g., BRCA), patient counseling about risk-reduction options, and cascade testing to identify family members who also may be at increased risk. The purpose of this Practice Bulletin is to discuss breast cancer risk assessment, review breast cancer screening guidelines in average-risk women, and outline some of the controversies surrounding breast cancer screening. It will present recommendations for using a framework of shared decision making to assist women in balancing their personal values regarding benefits and harms of screening at various ages and intervals to make personal screening choices from within a range of reasonable options. Recommendations for women at elevated risk and discussion of new technologies, such as tomosynthesis, are beyond the scope of this document and are addressed in other publications of the American College of Obstetricians and Gynecologists.

Practice Bulletin #180, “Gestational Diabetes Mellitus”

Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. However, debate continues to surround the diagnosis and treatment of GDM despite several recent large-scale studies addressing these issues. The purposes of this document are the following: 1) provide a brief overview of the understanding of GDM, 2) review management guidelines that have been validated by appropriately conducted clinical research, and 3) identify gaps in current knowledge toward which future research can be directed

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org