The results of a recent study revealed that providers might think they are promoting their young patients’ decision-making, but their focus on intrauterine devices (IUDs) and other long-acting reversible contraceptives can come across as coercive.1
Researchers interviewed 20 clinicians from 11 community health centers in the Bay Area of California.
“We were interested in their approaches to IUD counseling,” says Antonia Biggs, PhD, associate professor in the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. “What we found was that the clinicians really talked about valuing patient-centered contraceptive counseling approaches, and they talked about how that was important. But, when it came to IUD removals, we found they described dissuading patients from removing the IUD and downplayed side effects.”
There were inconsistencies between what the effects clinicians said they desired and their actual practices in engaging patients, particularly with IUD removal. “We found they wanted to provide comprehensive information to patients and inform them about all kinds of methods, without prioritizing any particular method, and they wanted their patients to feel empowered,” Biggs explains. “But we also found that many reported how they would try to guide their patients toward higher-efficacy methods and guide them away from lower-efficacy ones, like withdrawal, and they discouraged IUD removal if it was within a year of placement.”
These actions could be described as coercive, and run counter to the principles of medical ethics and reproductive justice that say providers should respect a person’s bodily autonomy and decision-making, she says.
“Clinicians told researchers how they tried to talk with patients about IUDs like they were the best thing on earth, and they didn’t talk about the withdrawal method because they knew it doesn’t work,” Biggs explains. “I asked, ‘How do you talk to a patient about IUDs?’ and they would talk about a frustration they feel if their patients didn’t adopt an IUD.”
The providers saw the inability to successfully market the IUD as a failure. Instead, the focus should be on patient-centered counseling sessions. “We meet patients where they are and meet where their preferences are,” she says. “People have different preferences regarding contraceptives. We need to follow the patient’s lead, giving them the information they want and giving them objective information.”
For instance, explaining how withdrawal might not be as effective as an IUD is appropriate. But it also is important not to allow one’s biases to shade the way each contraceptive method is presented. “Some patients might not want an IUD because they’re not comfortable with that device’s placement in a private area,” Biggs explains. “Especially if they’re young, they might not be comfortable with that.”
But all patients want information delivered without bias and judgment. For example, tiered-effectiveness counseling can be a way to present information accurately and without bias.
“You talk about the most effective methods first, and then go down the list,” Biggs explains. “That type of counseling became popular in the early 2000s, but I don’t think it’s been studied to see how patients feel about it.”
The key is to reduce stigma and build trust with patients. “From the research I’ve done, the sense I get is that patients don’t really like it when they feel their provider has a predetermined method in mind for them. That turns them off,” Biggs says.
For instance, the withdrawal method might be better than nothing. But if a provider shows a lot of judgment, then patients might feel less comfortable asking questions about how to do this and may choose not to access contraceptive counseling and care.
“When you think about young people who often do not plan to have sex, and they’re uncomfortable having a discussion with their partners about sex and contraception, they might not have a contraceptive, but they can have withdrawal,” Biggs says. “I tell my teens they should use withdrawal over nothing, and it has benefits that can be used in combination with condoms.”
Biggs has heard anecdotal experiences from young women who felt so much judgment from their contraception provider that they avoided visiting the provider for three years and ended up pregnant.
“The woman wanted to ask questions, but didn’t because she felt someone would judge her,” Biggs adds.
Maintain Patient Trust
Clinicians who strongly steer their patients away from an IUD removal within the year after insertion can lose patients’ trust.
“They described resisting that removal and trying to urge women to not remove the IUD. I didn’t hear a lot of listening to patients about reasons why they wanted it removed,” Biggs says. “One provider said, ‘Unless they have a really good reason, I’m not taking it out.’”
Biggs also heard providers talk about downplaying IUD side effects, which also erodes trust and can backfire.
“The issue with the IUD and implant is that they’re a provider-controlled method, so removal requires medical intervention,” Biggs says. “It’s different from other methods for that reason, and if the provider resists the removal, they’re stuck and have no choice, or have to go to another provider.”
Instead, providers should talk with patients and find out what is bothering them about the IUD. Then they could empower the patient and say that it is their decision and the clinician is there to do whatever the patient wants them to do, she adds.
- Biggs MA, Tome L, Mays A, et al. The fine line between informing and coercing: Community health center clinicians’ approaches to counseling young people about IUDs. Perspect Sex Reprod Health 2020;doi: 10.1363/psrh.12161. [Online ahead of print].