Bogaert Kelly, Kaplowitz Elianna, Wagner Sara, Carroll-Bennett Rachel, Fernando Dinali, McVane Ben, Maru Sheela
Division of Hospital Medicine, University of California San Francisco, 505 Parnassus Ave, San Francisco, CA, USA.
Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, 1425 Madison Ave, New York, NY, USA.
J Migr Health. 2022 May 29;6:100116. doi: 10.1016/j.jmh.2022.100116. eCollection 2022.
Over 25,000 individuals are granted asylum status in the United States annually. Gender-based violence (GBV) has historically been supported as a claim for persecution to apply for asylum. In women, GBV is a known risk factor for sexually transmitted infections, poor mental health, and worse perinatal outcomes. Less is known about the links between GBV, asylum seekers, and gynecologic outcomes or care utilization. Reported rates of gynecologic care-seeking are low in asylum-seeking women and women with histories of GBV often experience barriers to care. We hypothesized that asylum-seeking women with a history of GBV at the Libertas Center, a comprehensive center for survivors of torture in New York City, would receive low rates of recommended gynecologic screening and infrequent gynecologic care.
This retrospective cross-sectional study included adult self-identified female patients who had completed intake at the Libertas Center from 2005-2020. In order to examine the relationship between GBV and gynecologic care use, patients were included if they had an electronic medical record (EMR) at Elmhurst Hospital, were female, 18 years of age and older, and had ever experienced GBV in their lifetime. EMRs were reviewed for medical and psychiatric diagnoses as well as routine components of gynecologic care and were linked to intake data from the Libertas Center characterizing patients' torture history. The primary outcome of this study was whether or not patients attended a gynecology visit. Demographic characteristics, medical histories, adequacy of gynecologic care, and gynecologic care-seeking behavior were compared between the gynecologic care group and the no gynecologic care group.
A total of 249 female patients were seen at the Libertas Center from December 2005 until January 2020 at the time of data collection. The prevalence of GBV in this population was 48%. Among women who suffered GBV, 81 received medical care at Elmhurst Hospital and 44 (54%) received gynecologic care. Nearly 50% of those patients who sought care at Elmhurst carried a diagnosis of post-traumatic stress disorder or depression. Women who received gynecologic care were significantly more likely than those who did not receive gynecologic care to have had an Emergency Room visit (68% vs. 41%), an obstetric visit (32% vs 3%), and/or have been seen by a social worker (46% vs 24%; all < 0.05). Women who saw a gynecologist were significantly more likely to have completed four basic gynecologic care measures (Pap smear, gonorrhea/chlamydia screen, pelvic exam, and mammogram if applicable) compared to women who did not (77% vs 8%, < 0.05).
This study characterizes the gynecologic care utilization of female patients within a comprehensive care center for survivors of torture. We found a high lifetime rate of gender-based violence of 48% in this population. Adequate gynecologic care was uncommon among those who experienced GBV. However, gynecologic care was significantly more likely in patients receiving gynecologic specialty care, which frequently occurred after initial interaction with another provider (i.e. Emergency Department providers). These findings highlight the importance of trauma-informed care and establishing pathways to help asylum seeking and refugee women receive adequate gynecologic care. Further research is needed to explore specific barriers to gynecologic care in this population, how programs for asylum-seekers can integrate gynecologic care into existing structures for medical and mental healthcare, and how to increase awareness amongst providers on the prevalence of GBV and the gynecologic needs of these patients.
美国每年有超过25000人获得庇护身份。基于性别的暴力（GBV）在历史上一直被作为申请庇护的迫害理由而得到支持。在女性中，GBV是已知的性传播感染、心理健康不佳和围产期结局较差的风险因素。关于GBV、寻求庇护者与妇科结局或医疗服务利用之间的联系，人们了解较少。据报道，寻求庇护的女性寻求妇科护理的比例较低，有GBV病史的女性往往在获得护理方面面临障碍。我们假设，在纽约市利伯塔斯中心（一个为酷刑幸存者提供综合服务的中心）有GBV病史的寻求庇护女性，接受推荐的妇科筛查的比例较低，且很少接受妇科护理。
这项回顾性横断面研究纳入了2005年至2020年在利伯塔斯中心完成入院登记的成年自我认定为女性的患者。为了研究GBV与妇科护理利用之间的关系，如果患者在埃尔姆赫斯特医院有电子病历（EMR）、为女性、年龄在18岁及以上且一生中曾经历过GBV，则将其纳入研究。对EMR进行审查，以获取医疗和精神科诊断以及妇科护理的常规组成部分，并将其与利伯塔斯中心的入院数据相联系，这些数据描述了患者的酷刑历史。本研究的主要结局是患者是否就诊于妇科。比较了妇科护理组和未接受妇科护理组之间的人口统计学特征、病史、妇科护理的充分性以及寻求妇科护理的行为。
在数据收集时，2005年12月至2020年1月期间，利伯塔斯中心共接待了249名女性患者。该人群中GBV的患病率为48%。在遭受GBV的女性中，81人在埃尔姆赫斯特医院接受了医疗护理，44人（54%）接受了妇科护理。在埃尔姆赫斯特医院寻求治疗的患者中，近50%被诊断患有创伤后应激障碍或抑郁症。接受妇科护理的女性比未接受妇科护理的女性更有可能去过急诊室（68%对41%）、进行过产科检查（32%对3%）和/或看过社会工作者（46%对24%；所有P<0.05）。与未看过妇科医生的女性相比，看过妇科医生的女性更有可能完成四项基本的妇科护理措施（巴氏涂片检查、淋病/衣原体筛查、盆腔检查以及适用时的乳房X光检查）（77%对8%，P<0.05）。
本研究描述了一个为酷刑幸存者提供综合护理的中心内女性患者的妇科护理利用情况。我们发现该人群中基于性别的暴力终身患病率高达48%。在经历过GBV的人群中，充分的妇科护理并不常见。然而，接受妇科专科护理的患者接受妇科护理的可能性显著更高，这种情况通常在与其他提供者（即急诊科提供者）初次接触后发生。这些发现凸显了创伤知情护理的重要性，以及建立途径以帮助寻求庇护和难民妇女获得充分的妇科护理的重要性。需要进一步研究探索该人群中获得妇科护理的具体障碍、寻求庇护者项目如何将妇科护理纳入现有的医疗和心理保健结构，以及如何提高提供者对GBV患病率和这些患者妇科需求的认识。
