After requests to detail the language I use in different midwifery care scenarios, I am starting a series of “scripts.” With these example texts, I seek to provide a springboard for providers, care seekers, and reproductive health workers to discuss possible best practices for language and approach in different scenarios. I will update each script with language and ideas shared here and on social media to work toward creating an environment of true empowerment, respect, and care in obstetrical and gynecological health.
Gonorrhea (GC), chlamydia (CT), and trichomoniasis (TV) (also known as trichomonas) are sexually transmitted infections (STIs). The three are often grouped together clinically and conversationally for many reason: transmission, commonality, overlapping symptoms, recommended testing frequency, treatability and curability, short- and long-term health impacts, and population focus. This post, when discussing STIs* is referencing these three specifically, as the health and emotional impacts of other STIs, such as HIV and syphilis, among others, necessitate other types of conversations.
Despite the commonality and curability of these infections from a provider standpoint, the weight for those receiving the diagnosis should never be presumed. For some, the diagnosis could confirm a suspicion of their partner’s infidelity. For others, a positive test result could be their first ever STI and could be difficult news to absorb and understand. For still others, if this is a repeat infection or if they have a history of multiple infections, every diagnosis is an opportunity to discuss ways to increase health and well-being in the future, and discuss protection efforts and healthy sexual relationships going forward.
I recently worked in a practice where many providers gave positive STI* results over the phone. Seemingly, some providers equate gonorrhea, chlamydia, and trichomoniasis to the same diagnostic severity as Vitamin D deficiency, anemia, and urine infections. To be fair, I am a clinician who will selectively discuss even these “easier” results over the phone, as the population I serve often has a lower health literacy and, I think, benefits from in-person time to discuss test results, their meaning, and options for next steps. Perhaps this is generational, but I think phone conversations feel blunt and give the provider control over the conversation. Feministically, providing results over the phone provides little opportunity to effectively transfer power and diminishes the clinician’s ability to read body language, evaluate for (mis)understanding, and keep the conversation open to paths the person receiving the results might need to explore.
Perhaps I have a low threshold for results-sharing based on the fact that I like to talk over anything in person, but really I think an STI* diagnosis merits a full visit. Ideally, the script below will explain for itself why that is so. There is often the weight of the diagnosis, fully understanding transmission and prevention, and being able to weigh the commonality and curability of the diagnosis with the acute and chronic health concerns related to its infection process.
A few notes:
- A sexually transmitted infection diagnosis should be given with clear clinical language and an empathic approach, and never, under any circumstance, utilize shame as a strategy for behavior change.
- Often, at different points in the script and depending on the person’s response, I will say something along the lines of “My whole job is to take care of you and to help you determine your needs and goals. Please let me know if there’s something you need me to do differently to provide the best care for you.” I don’t include this specifically below because it is a line I bring up depending on the circumstance.
- I use some gendered language in this script, for a few reasons discussed below, but also because for the majority of the community I serve, gender-free or -neutral language would be confusing and detrimental to providing the information clearly and concisely, so this script is direct to the conversations I often have. In the footnotes I discuss the importance of clarifying gendered language with clients before assuming preferred terminology, which I do, and modifying the script appropriately based on your clients. Importantly, queer and trans people are more likely to experience shame, discrimination, misinformation, and delay care related to sexual health, so working toward language equality with every patient every time is important to provide a safe space for all to seek health and well-being.
Now, the script. I’ll set this up as if someone received a call about a positive chlamydia test result and is waiting in the clinic room to receive that result.
Hi, I’m Stephanie, the midwife here with you today. (Or Hi, I’m Stephanie, it’s good to see you again.)
You received a phone call to come back in for abnormal test results. At your last visit, you tested positive for chlamydia. Do you know what chlamydia is?
(Wait. If they need to be quiet, let the silence exist. If the silence prolongs, consider initiating the conversation by discussing that chlamydia is a sexually transmitted infection, which means that they had sex with someone who also has the infection. Mention that any kind of sex can transmit the infection, whether oral, vaginal, or anal. Specifically saying all three types of sex where mucosal membranes and fluids can pass the infection shows your comfort with talking about sex – saying the words is important to normalize sex as well as open the conversation.)
How are you feeling about testing positive for chlamydia?
(For everyone, but especially for those whose response normalizes the infection in their life, such as “Oh I’ve had it before, so whatever,” ask about history of chlamydia and other STIs (all of them) to make sure counseling about short-term and long-term health continues appropriately.)
So, a few things I go over with anyone who tests positive for chlamydia. It is treatable and curable, which means you take medication and it goes away. It is a very common infection and is common in this community. Some people have symptoms, and some people don’t. Usually women** have symptoms more often than men. Most importantly, the health impact is greater for the uterus and fallopian tubes than for the penis, though research on that is underway.
Do you have any questions about any of that information?
(I specifically discuss commonality and symptoms to normalize the infection. Shaming someone for the infection is clinically inappropriate and detrimental to care. I review the issue of symptoms to initiate the discussion that their partner may contest the diagnosis when they bring it up with them. See further below for partner notification.
In my community I find it important to say that women have symptoms more than men, due to the overwhelming response from male partners that lead to blaming the woman because they themselves don’t have symptoms. It’s an important thing to call out to prepare the woman for said response.)
Some other things to know. Sometimes this infection can be really strong, or when combined with other infections, can cause serious short- and long-term health problems. The short-term problem is called pelvic inflammatory disease, or PID. Have you heard of that before?
Like chlamydia, PID is treatable in the short-term, but is known to have long-term health impacts. Sometimes, but not always, that means untreatable pelvic pain later in life, difficulties becoming pregnant in the future if you desire, or an increased risk of a pregnancy growing in the fallopian tubes, called an ectopic pregnancy, which is not a normal pregnancy and must be removed, as it is a medical emergency.
With every repeat chlamydia infection, risks of these problems increases, particularly for infertility.
Do you have any questions about that information?
If pregnant, or if they are someone who could become pregnant in the future:
During pregnancy, this infection can have other effects. Chlamydia can cause your bag of waters to break too early in the pregnancy, cause your body to go into labor too early, and for babies who pass by chlamydia during the birth they are at risk for an infection of the chlamydia in their eyes or lungs.
(Specify this conversation to the specific infection, as gonorrhea and trichomoniasis have different fetal and neonatal effects than chlamydia.)
Do you have any questions about that information?
Chlamydia, and any sexually transmitted infection, does increase risk for other infections, like HIV and syphilis. Let’s take a look at the last time you were tested for other infections and see what other testing you might be due for and when you might want to be re-tested.
How are you feeling about discussing these results with your partner(s)? How do you think they will react?
If the partner with whom they will discuss results is a man**:
As I mentioned briefly, often men do not have symptoms. Many of my patients have told me their partners tell them they do not have symptoms so they must not have the infection, and then blame the woman or try to shame them for the infection. Remember that symptoms are not always present, for you or for them. If you have the infection, your partner does too, so do not let them lead the conversation down that path.
I recommend to everyone that if, for any reason, you think your partner(s) will become angry or violent, to tell them in a public place where there are other people around. A library is sometimes a good place, because you can talk quietly about the results but there are still other people around. Some other people have told me that a common restaurant, like a McDonald’s or Dunkin’ Donuts, is better because then the partner is surrounded by people they know and would be embarrassed to act out or would be held accountable for being violent.
You can also bring your partner here and I can discuss the results with both of you. I can also see them on their own for this issue. For some people this approach is easier than discussing it with their partners on their own.
There’s a balance for how common and treatable this infection is, and how serious it can be in the long-term, like we talked about. Decreasing the number of times you have the infection, or the length of the infection, are all important for your long-term health. Discussing safer sex with your partner(s) can include lots of different options: condom use, honesty and agreement on monogamy or number of partners and protection with those partners, and regular testing.
Do you have any questions about how to discuss those options with your partner?
So here’s where we go from here. I’m going to send the medication to your pharmacy. It’s important you take the full prescription today, and do not split the pills with your partner. The refill is for them to take tomorrow, or they can come in and see me anytime to discuss the diagnosis and their treatment separately if you or they would prefer that. What do you think would work best for you?
You both need to take the medication as prescribed, and then wait a full week to have sex again, to allow the infection to clear. Sometimes people have sex during that week: if that happens, call me and I’ll send another prescription because we would need to start the treatment process over again.
If you want to return and make sure the treatment worked, we can make an appointment for you to come back in 4 weeks for a quick urine test. I have many people who see me every 3 months, or a few times per year, just for testing, so please do so if you would like.
Also, I know we went over a lot of information today. Some people come see me again in a week with follow-up questions or to have me repeat what I said today, or we can go over all of it again when you come back in a month.
Do you have any questions about anything we have talked about?
If I cannot get someone back in for a visit, for whatever reason (work, childcare, inability to pay), I will give results over the phone. I try to negotiate this during the in-person visit, allowing an opportunity to understand they might not be able to make it back in and, if so, how they might want to receive their results. My phone script, when discussing anything medical over the phone, is as follows:
Hi, this is Stephanie, the midwife you saw at the health center. Could you verify your date of birth please?
Is now an okay time to talk about results from your last visit? You can call back if there’s a better time for you, or contact me through the online portal.
(I try never to assume that they are in a calm space, a safe space, emotionally or logistically ready to receive results. I always offer an option other than that which was convenient for me.)
Your test result was positive for chlamydia… (insert the rest of the above script here).
Readers, looking forward to your comments! – Stephanie
*Here, I am focusing on gonorrhea, chlamydia, and trichomoniasis. All other STIs (the list is lengthy, but including herpes, HIV, syphilis, hepatitis, genital warts, etc.) would follow a different script specific to their bodily and, possibly, emotional impact.
**In my community, I largely serve cis-identifying women and men. Gendered language should always be used with careful consideration, and ideally an initial clarification in prior visits about preferred pronouns and reference language. In any circumstance (which could be any) where someone has a uterus and fallopian tubes and ovaries, discussing the impact of one of these three infections on those organs, rather than focusing unnecessarily on gendered the language, should be utilized.