Sexual And Reproductive Health

Recent events have shed light on the importance of sexual and reproductive health. The overturning of Roe v Wade disrupted access to safe and legal abortion. Several states passed laws restricting access to gender-affirming care for transgender youth. The COVID-19 pandemic impeded many women from obtaining contraceptives.(1) The consequences of these decisions and circumstances are significant.

The broad range of medical services addressing sexual and reproductive health affect individuals’ and the public’s health. Unfortunately, addressing these issues has been obstructed by stigma and political divisiveness. The importance of physicians in ensuring access to medical care of this type has never been higher.

PRACTICE SETTINGS AND SERVICES

The careers and practice scopes of physicians concentrating on sexual and reproductive health vary greatly. One doctor may see patients with a breadth of routine testing and treatment; another might have an entire practice dedicated to a select few services or a narrow patient population — hormone replacement therapy for menopausal women, for instance.

There is also diversity in practice settings, from large comprehensive sexual health centers to solo practices in rural areas. A handful of online care platforms for services like contraception and pre- and post-exposure prophylaxis such as Lemonaid Health and Nurx have entered the market in recent years.

Family planning and sexual health clinics

Family planning and sexual health clinics offer an array of sexual health services, usually without an appointment and sometimes without requiring health insurance. Services include contraception, pregnancy testing, screening and treatment for sexually transmitted infections, HIV testing and linkage to care, and counseling on reproductive health issues. Most of these clinics are run by nonprofit organizations or government-funded institutions and target individuals who cannot access affordable reproductive healthcare elsewhere. Nearly all employ at least one physician on a full- or part-time basis.

Planned Parenthood operates more than 600 centers across the United States.(2) They are funded through a combination of government funds, private donations, and fees for services. Programs like Medicaid and Title X allow them to provide affordable family planning services to low-income individuals.

Mobile reproductive health clinics are on the rise due to the increasing need for accessible services, especially in rural and low-income communities.

Employment with one of the several international organizations operating family planning and sexual health clinics in other countries is an option for physicians to work abroad.

Abortion services

Only 3% of family doctors provide abortion care,(3) so physicians who are willing and able to offer abortion services can meet that need in many communities. Abortion services are offered at some family planning clinics but are also provided at independent abortion clinics and healthcare systems, particularly in urban areas.

Laws and regulations related to pregnancy termination vary widely by state, and there is a limited ability to offer services in some areas. In states that have not banned abortion services, there may be specific licensing requirements for abortion clinics. A few federal regulations also apply, such as the Hyde Amendment, which prohibits the use of federal funds for most induced abortions.

Sexual minority health and gender-affirming treatment

Gay, lesbian, bisexual, and other sexual minority individuals have special healthcare needs and may face barriers to care. Several sexual and reproductive health issues disproportionately affect this population. For example, gay and bisexual men account for more than two-thirds of new HIV diagnoses in the United States,(4) and lesbian women are less likely to receive cervical cancer screenings.(5)

Reproductive and sexual health-related services often comprise the bulk of the care offered in practices catering to sexual and gender minority patients. They offer hormone replacement therapy and other gender-affirming treatment, as well as referrals for gender-affirming surgeries. They provide pre- and post-exposure prophylaxis and HIV treatment. Many offer treatment for mental health conditions that are more common in this population and that may be related to sexual health issues, such as depression and substance use disorders.

Sexual dysfunction and intimate wellness

Sexual dysfunction can negatively impact quality of life, yet medical help may not be available, comprehensive, or comfortable for patients in primary care or conventional OB/GYN and urology clinics. By focusing on a narrower range of health concerns, physicians with specialized practices in this area may be better equipped to provide the latest and most effective treatments. Services offered can include treatments for erectile dysfunction, premature ejaculation, low libido, low testosterone, painful intercourse, and more.

Many menopause symptoms relate to sexual health, including vaginal dryness, decreased sex drive, and painful intercourse, and are often addressed in the same setting as sexual and reproductive health issues. Due in part to lack of health insurance coverage, compounded bioidentical hormone replacement therapy is one popular treatment option frequently offered in specialized practices.

Surgical and procedural treatment for sexual dysfunction issues is an option for doctors with the appropriate training. The O-Shot for women and the P-Shot for men involve PRP injections to improve sexual response. ThermiVa uses radiofrequency energy to alleviate symptoms of vaginal dryness, itching, and pain.

Nonmedical services can add value to these practice types. For example, sex therapy can help patients address psychological or emotional factors contributing to their issue. Pelvic floor physical therapy treats some causes of pelvic pain.

GETTING INTO A CAREER IN SEXUAL AND REPRODUCTIVE HEALTH

OB/GYN and urology naturally fit as foundations for a career in this field due to the benefits of specialized training on management of conditions directly related to reproduction and sexual function. Another benefit is surgical training, which expands the menu of services these specialists can offer to patients as well as improved reimbursement to the practice.

There are several suitable subspecialties of both OB/GYN and urology. The American Board of Obstetrics and Gynecology offers certification in complex family planning, gynecologic oncology, maternal-fetal medicine, and reproductive endocrinology and infertility. They also offer Focused Practice Designations in pediatric and adolescent gynecology and in minimally invasive gynecologic surgery. The American Board of Urology offers pediatric urology certification. Both boards offer certification in female pelvic medicine and reconstructive surgery.

Family medicine and internal medicine provide good backgrounds as well, although some physicians may need more education in certain areas, depending on the scope of practice they are pursuing. Internal medicine physicians wishing to treat gender dysphoria or menopause symptoms may want to subspecialize in endocrinology. Infectious disease subspecialization is an option for internists who have an interest in HIV and sexually transmitted infections.

Psychiatry is a pathway for anyone with an interest in the mental health components of sexual and reproductive issues. Some doctors may wish to obtain certification in sex therapy from the American Association of Sexuality Educators, Counselors, and Therapists.

There are numerous continuing education courses on topics related to sexual and reproductive health. The National Abortion Federation and the National LGBTQIA+ Health Education Center are reputable sources.

Educate yourself on the relevant laws and regulations in the state in which you practice. Laws regulating abortion access, parental consent for reproductive health services, contraceptive insurance coverage, and infection reporting vary and can be confusing.

COMPENSATION

Income varies greatly depending on the type of practice and services offered. In 2021, the average annual salaries for a few of the most relevant specialties were $280,912 for endocrinologists, $377,416 for OB/GYNs, and $522,211 for urologists.(6)

Excerpted from 50 Unconventional Clinical Careers for Physicians: Unique Ways to Use Your Medical Degree Without Leaving Patient Care by Sylvie Stacy, MD, MPH.

References

1. Ahmed O. States Must Expand Telehealth to Improve Access to Sexual and Reproductive Health Care. Center for American Progress. May 21, 2020. https://www.americanprogress.org/article/states-must-expand-telehealth-improve-access-sexual-reproductive-health-care/

2. Planned Parenthood. Who We Are. Planned Parenthood website. https://www.plannedparenthood.org/about-us/who-we-are

3. Lague DC Casandra Cashman,Ian. Primary Care Providers Can Help Safeguard Abortion. Sci Am. June 24, 2022. https://www.scientificamerican.com/article/primary-care-providers-can-help-safeguard-abortion/

4. Pitasi MA, Beer L, Cha S, et al. Vital Signs: HIV Infection, Diagnosis, Treatment, and Prevention Among Gay, Bisexual, and Other Men Who Have Sex with Men — United States, 2010-2019. MMWR Morb Mortal Wkly Rep. 2021;70(48):1669– 1675. doi:10.15585/mmwr.mm7048e1

5. Matthews AK, Brandenburg DL, Johnson TP, Hughes TL. Correlates of Underutilization of Gynecological Cancer Screening Among Lesbian and Heterosexual Women. Prev Med. 2004;38(1):105–113. doi:10.1016/j.ypmed.2003.09.034

6. Pinnacle Health Group. 2021 Annual Physician Compensation Survey. Pinnacle Health Group; 2021. https://www.scribd.com/document/636713720/2021-Physician-Compensation-Report-updated-0821