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INTRODUCTION

This chapter describes the broad array of behavioral issues for women using a developmental framework. We discuss expected behavioral issues occurring as part of the normal life cycle, as well as problematic ones requiring medical surveillance or intervention.

ADOLESCENCE: A TIME OF POWER IN THE MIDST OF INSECURITY

The task of adolescence is to find one’s own beliefs, moving from childhood to adulthood physically and in relationships (see Chapter 13). Several events can occur during this time that will require the sensitive attention of the primary care provider, but numerous studies have demonstrated that confidentiality must be maintained for the provider to be trusted and helpful to an adolescent.

Approach to the Gynecologic Examination

Some women fear a pelvic examination, especially when they are undergoing it for the first time. Little research has been done on what strategies are best in performing a pelvic examination, but several techniques have been found to be helpful in clinical practice.

Before performing the examination, clinicians should make the patient as comfortable as possible when taking a history by asking open-ended questions, demonstrating empathetic communication skills such as eye contact and nonjudgmental reactions, and not making assumptions about sexual activity and orientation. In addition, they should ask if the patient has had a previous pelvic examination. When taking a complete sexual or gender identity history, they should inquire about prior sexual abuse or challenges with past examinations, inviting the patient to suggest techniques for making the exam more comfortable. The exam may need to be done at a separate visit after the clinician has built rapport with the patient.

It is useful for the clinician to describe exactly what is being done before and during the examination. Both female and male clinicians should consider offering to have a chaperone or support person present to reassure the patient about the professional content of the examination. Clinicians may also use chaperones at their discretion, such as in the case of adolescents or patients with development delay, psychiatric illness, or a history of physical or sexual abuse. Other techniques include draping all areas of the body not being examined; using a warm, lubricated speculum; using the narrowest speculum that will allow adequate visualization of the cervix; being as gentle as possible; and encouraging the patient to use relaxation techniques including abdominal breathing and mental imagery, techniques which are especially useful for young women and those who have experienced sexual abuse. In addition, elevating the head will facilitate communication and may help the patient feel less vulnerable. In situations where a patient has significant anxiety, an anxiolytic medication prior to the examination may be useful. Specific recommendations for examining patients with a history of trauma can be found at https://www.reproductiveaccess.org/resource/trauma-informed-pelvic-exams/.

Research has shown that the experience of the first pelvic examination influences attitudes about subsequent ...

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