Provider Practices and Young Women's Experiences with Provider Self-disclosure during Emergency Contraceptive Visits

  • Morgan Cheeks
    Correspondence
    Correspondence to: Morgan Cheeks, BA, University of California San Francisco, School of Medicine, 513 Parnassus Ave, S-245, San Francisco, CA 94143. Phone: +1 323-450-6668.
    Affiliations
    University of California San Francisco, School of Medicine, San Francisco, California
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  • Shelly Kaller
    Affiliations
    Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, California
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  • Aisha Mays
    Affiliations
    UC Berkeley, UCSF Joint Medical Program, University of California at Berkeley, Berkeley, California
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  • M. Antonia Biggs
    Affiliations
    Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, California
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Open AccessPublished:June 05, 2020DOI:https://doi.org/10.1016/j.whi.2020.04.004

      Abstract

      Background

      Research on the impact of providers disclosing personal contraceptive experiences with patients is limited. In this study, we examine patient and provider perspectives about provider self-disclosure (PSD) of personal contraceptive experiences and its effects on contraceptive decision making and the provider–patient relationship.

      Methods

      We conducted 18 one-on-one telephone interviews with clinicians who provide contraceptive services to young women and 17 patients seeking emergency contraception from three Bay Area community-based, youth-friendly clinics regarding their contraceptive counseling practices and experiences, respectively. After transcribing and coding all interviews, we summarized structural codes related to contraceptive counseling and PSD.

      Results

      Although providers noted that PSD could help to build rapport and increase patient comfort, most did not report self-disclosing their contraceptive experiences, primarily owing to concerns that it might cross professional boundaries or compromise patient autonomy. All patients held positive attitudes toward and welcomed PSD practices, with many noting that it increased their comfort and trust in their provider.

      Conclusions

      There were notable differences between patient and provider attitudes toward PSD of contraceptive method use, with patients expressing more positive feelings about the practice than providers. Community-based providers should consider that many young women welcome self-disclosure of provider contraceptive experiences and that more research is needed to understand the effects of PSD practices around contraception on the patient–provider relationship and autonomous contraceptive decision making.
      When providers share personal experiences with contraception with their patients, this is a form of provider self-disclosure (PSD). Usually PSD stems from a desire to build rapport and improve provider–patient communication (
      • Arroll B.
      • Allen E.-C.F.
      To self-disclose or not self-disclose? A systematic review of clinical self-disclosure in primary care.
      ). However, there is some concern that PSD constitutes a boundary violation, and some experts recommend providers use it judiciously (
      • Arroll B.
      • Allen E.-C.F.
      To self-disclose or not self-disclose? A systematic review of clinical self-disclosure in primary care.
      ,
      • Epstein R.M.
      The Patient-physician relationship.
      ,
      • Nadelson C.
      • Notman M.T.
      Boundaries in the doctor-patient relationship.
      ).
      The impact of PSD on patient experiences in primary care settings varies and is highly dependent on the type of visit and self-disclosing statement (
      • Arroll B.
      • Allen E.-C.F.
      To self-disclose or not self-disclose? A systematic review of clinical self-disclosure in primary care.
      ,
      • Beach M.C.
      • Roter D.
      • Larson S.
      • Levinson W.
      • Ford D.E.
      • Frankel R.
      What do physicians tell patients about themselves? A qualitative analysis of physician self-disclosure.
      ,
      • Beach M.C.
      • Roter D.
      • Rubin H.
      • Frankel R.
      • Levinson W.
      • Ford D.E.
      Is physician self-disclosure related to patient evaluation of office visits?.
      ). In one study of self-disclosure during primary care visits, physicians presented with unannounced standardized patients disclosed personal information in approximately one-third of visits, and PSD was sometimes disruptive and not always patient focused. Information disclosed by providers in this study included personal emotions, experiences, relationships, and experiences with the patient's diagnosis (
      • McDaniel S.H.
      • Beckman H.B.
      • Morse D.S.
      • Silberman J.
      • Seaburn D.B.
      • Epstein R.M.
      Physician self-disclosure in primary care visits: Enough about you, what about me?.
      ). A study that assessed the impact of similar topics discussed during PSD in emergency department visits found that when PSD occurred, patients rated their interactions and communication with their providers more positively (
      • Zink K.L.
      • Perry M.
      • London K.
      • Floto O.
      • Bassin B.
      • Burkhardt J.
      • Santen S.A.
      “Let me tell you about my…” Provider self-disclosure in the emergency department builds patient rapport.
      ).
      In the setting of contraceptive counseling visits, women report a preference for a shared decision making model without pressure to adopt a particular method (
      • Biggs M.A.
      • Kimport K.
      • Mays A.
      • Kaller S.
      • Berglas N.F.
      Young women’s perspectives about the contraceptive counseling received during their emergency contraception visit.
      ,
      • Brown M.K.
      • Auerswald C.
      • Eyre S.L.
      • Deardorff J.
      • Dehlendorf C.
      Identifying counseling needs of nulliparous adolescent intrauterine contraceptive users: A qualitative approach.
      ,
      • Dehlendorf C.
      • Diedrich J.
      • Drey E.
      • Postone A.
      • Steinauer J.
      Preferences for decision-making about contraception and general health care among reproductive age women at an abortion clinic.
      ,
      • Fox E.
      • Reyna A.
      • Malcolm N.M.
      • Rosmarin R.B.
      • Zapata L.B.
      • Frederiksen B.N.
      • Moskosky S.B.
      • Dehlendorf C.
      Client preferences for contraceptive counseling: A systematic review.
      ). However, evidence on the impact of disclosing personal contraceptive experiences with patients is limited. Given that patients and providers may perceive disclosure of contraceptive experiences as more personal than that studied in the primary care literature, this topic warrants further investigation. PSD during contraceptive counseling may have similar benefits as those proposed in the peer provider model, which theorizes that peer educators may have a unique ability to destigmatize sensitive topics in special populations. In reproductive health care the peer provider model has been shown to impart empathy and trust (
      • Brindis C.D.
      • Geierstanger S.P.
      • Wilcox N.
      • McCarter V.
      • Hubbard A.
      Evaluation of a peer provider reproductive health service model for adolescents.
      ), and there is qualitative evidence suggesting some women prefer a friend-like relationship with their provider in this setting (
      • Dehlendorf C.
      • Levy K.
      • Kelley A.
      • Grumbach K.
      • Steinauer J.
      Women’s preferences for contraceptive counseling and decision making.
      ). One mixed-methods study specifically examined PSD in the context of contraceptive counseling and found some evidence of PSD in 9% of clinic visits, mostly related to sharing personal intrauterine device (IUD) use experiences. The authors found that all patients who reported PSD considered it appropriate, but that PSD was not significantly associated with patient satisfaction (
      • McLean M.
      • Steinauer J.
      • Schmittdiel J.
      • Chan P.
      • Dehlendorf C.
      Provider self-disclosure during contraceptive counseling.
      ).
      In the present study, we draw on qualitative interviews from community health center (CHC) providers and young female patients to examine their attitudes and perceptions of the effects of PSD on contraceptive method decision-making and the provider–patient relationship. CHCs are an important and growing source of care for women in need of reproductive health services (
      • Beeson T.
      • Wood S.
      • Bruen B.
      • Goldberg D.G.
      • Mead H.
      • Rosenbaum S.
      Accessibility of long-acting reversible contraceptives (LARCs) in Federally Qualified Health Centers (FQHCs).
      ,
      • Hasstedt K.
      Federally Qualified Health Centers: Vital sources of care, no substitute for the family planning safety net.
      ). This study specifically focuses on the experiences of young women, as they are a large share of CHC patients receiving contraceptive services (
      • Mead K.H.
      • Beeson T.
      • Wood S.F.
      • Goldberg D.G.
      • Shin P.
      • Rosenbaum S.
      The role of Federally Qualified Health Centers in delivering family planning services to adolescents.
      ) and may present distinctive counseling preferences and needs (
      • Potter J.
      • Santelli J.S.
      Adolescent contraception: Review and guidance for pediatric clinicians.
      ) given their unique developmental stage and barriers accessing care (
      • Dehlendorf C.
      • Diedrich J.
      • Drey E.
      • Postone A.
      • Steinauer J.
      Preferences for decision-making about contraception and general health care among reproductive age women at an abortion clinic.
      ,
      • Diedrich J.T.
      • Klein D.A.
      • Peipert J.F.
      Long-acting reversible contraception in adolescents: A systematic review and meta-analysis.
      ,
      • Fuentes L.
      • Ingerick M.
      • Jones R.
      • Lindberg L.
      Adolescents’ and young adults’ reports of barriers to confidential health care and receipt of contraceptive services.
      ,
      • McDaniel S.H.
      • Beckman H.B.
      • Morse D.S.
      • Silberman J.
      • Seaburn D.B.
      • Epstein R.M.
      Physician self-disclosure in primary care visits: Enough about you, what about me?.
      ).

      Methods

       Study Design

      For this analysis, we used data from two qualitative studies that we conducted as part of a larger project on contraceptive care in CHC settings. Through an in-clinic training program, the parent study aimed to identify and reduce barriers to contraceptive care provision, in particular IUDs and contraceptive implants, in a cohort of San Francisco Bay Area CHCs (
      • Biggs M.A.
      • Kaller S.
      • Harper C.C.
      • Freedman L.
      • Mays A.R.
      “Birth control can easily take a back seat”: Challenges providing IUDs in community health care settings.
      ). PSD was not included as a part of the training. The original two studies included in-depth interviews with clinicians and young women regarding their experiences with contraceptive counseling, with a particular focus on the IUD, the IUD when used as emergency contraception (EC), and oral EC. Although PSD was not a primary research question, we asked providers about their contraceptive disclosure practices and patients about their PSD preferences and contraceptive counseling experiences. The data relating to PSD have been analyzed for this article.
      We designed both semistructured interview guides to include open-ended and closed-ended items and to elicit participants' thoughts and experiences in an impartial way. This study received ethical approval from the Committee on Human Research at the University of California, San Francisco. The interviewers had no prior relationship with interviewees, and none of the patients interviewed were under the care of the clinician researchers.

       Participant Recruitment

       CHC clinicians

      From April to August 2015, using a convenience sampling approach, we aimed to recruit approximately 20 clinicians, a figure we deemed feasible and appropriate given the exploratory nature of our study, to participate in semistructured telephone interviews. Clinicians working in a CHC setting who provided primary care and contraceptive services and served adolescent and young women were eligible to participate. We recruited clinicians via an email that invited them to attend contraceptive trainings held by our group and during each training event. During the telephone interview, we first obtained verbal consent and requested participants' permission to audio-record the interviews. All but one clinician granted permission to be audio-recorded. Clinicians received a $50 gift card for their participation. We designed the clinician interview guide to be semistructured, allowing participants to share their thoughts and experiences and to introduce new ideas, while also ensuring that we asked all participants certain questions. The interview guide captured provider practices on counseling around contraception, including their PSD attitudes, experiences, and practices. Regarding PSD, we asked providers, “Do you ever talk to your patients about the method that you or your partner use, during counseling? What are your feelings about self-disclosure with a patient? What do you see as the advantages and disadvantages of self-disclosure?” Interviews averaged approximately 45 minutes. We only included data from 18 clinicians who answered PSD questions in this analysis.

       Patients seeking EC

      From September 2015 to January 2016, we recruited patients seeking EC from three Bay Area community-based, youth-friendly clinics to participate in semistructured telephone interviews regarding their contraceptive counseling experiences, using a purposive sampling approach. We aimed to recruit approximately 20 patients, evenly distributed between those choosing the IUD as EC and oral EC pills. We designed the patient interview guides to be semistructured, allowing participants to introduce new ideas and to guide the conversation. Specifically, the patient interview guide captured patients’ attitudes and experiences with contraception and accessing contraceptive services, as well as their experiences and attitudes around contraceptive counseling, including their opinions about PSD and their contraceptive decision making. Regarding PSD specifically, patients were asked, “Did your provider mention what birth control method he/she uses to prevent pregnancy? How do you feel about that?” and “How would you have felt if the provider had mentioned what method she/he uses to prevent pregnancy? Would you feel differently if the provider were male or female?”
      Female patients ages 30 and under who spoke English or Spanish and were seeking EC were eligible to participate. We oversampled for women who chose the IUD as EC at their EC visit to meet our overarching study aims. A health educator distributed recruitment flyers in waiting rooms and during EC counseling visits. The health educator screened interested patients for eligibility, obtained verbal consent, and shared contact information with the interviewers. Within two days of the visit, one of three trained interviewers, two of whom were bilingual, contacted the patient to schedule the telephone interview. They interviewed patients in their preferred language (English or Spanish), conducted informed consent with them by phone, and requested permission to audio-record the interview. All patients agreed to an audio-recording. Patients received a $25 gift card for their participation. Interviews lasted approximately 30 minutes. Patients received a different incentive than providers owing to separate design and budgeting processes for the two sets of interviews involved in this study.

       Qualitative Analysis

      The analytic team was composed of four of the study authors, two of whom participate in direct patient care and two of whom are dedicated researchers. All have extensive experience studying reproductive health topics. Two of the study authors, both trained and experienced in in-depth interviewing techniques, conducted the interviews. After each interview, the interviewer summarized each interview and their reflections on their interactions with the participant in a memo. For this particular analysis, we used mostly deductive methods, by relying mostly on structural codes. For analyses, we reviewed all transcribed audio-recorded interviews. We relied on typewritten notes for two of the clinician interviews: one in which the clinician refused audio-recording and the other owing to poor audio-recording quality. Three study authors independently generated a list of thematic and structural codes after reviewing an initial set of interviews and revised the code list iteratively after discussion and consensus. We applied the final list of codes to all interviews using the Dedoose research application. The first author reviewed and summarized the two codes related to provider contraceptive counseling practices and patients’ experiences with PSD. These summaries were reviewed and revised again after the analytic team reached agreement on interpretation. We use pseudonyms for participants to protect their confidentiality.

      Results

      We interviewed 18 clinicians and 17 patients. We ceased recruitment after we noted sufficient repetition of themes that meaningfully addressed the research question. Clinicians representing five CHCs shared their attitudes and experiences with self-disclosure when counseling patients. We discussed PSD with all 17 of the patients interviewed. One-half of providers interviewed identify as White, and a majority identify as female (14/18) and are trained as nurse practitioners (15/18). Eleven of 17 patients interviewed identify as Latina, three identify as Black, and three identify as Asian. Eight of the 17 patients interviewed have attended some college or have a college/technical degree. We present additional clinician and patient characteristics in Table 1, Table 2, respectively.
      Table 1Provider Characteristics (N = 18)
      CharacteristicNo.
      Race/ethnicity
       White9
       Black/African American1
       Asian/Pacific Islander4
       Latina/o1
       Mixed race/other/unknown3
      Gender
       Female14
       Male2
       Transgender2
      Age (y)
       29-346
       35-448
       45-594
      Training
       Physician3
       Nurse practitioner15
      Table 2Patient Characteristics (N = 17)
      CharacteristicNo.
      Race/ethnicity
       Latina11
       Black/African American3
       Asian3
      Age (y)
       16-175
       18-194
       20-246
       25-302
      Education
       Some high school5
       High school graduate/GED4
       College/technical degree2
       Some college6
      EC method choice
       Emergency contraceptive pill10
       IUD as EC7

       PSD Practices

      Providers revealed varying levels of comfort disclosing their personal contraceptive experiences to patients, with most (15/18) providers reporting little to no self-disclosure during contraceptive counseling. Only one provider, Lindsey, an advanced practice clinician, reported a general comfort with self-disclosing.
      Male clinicians reported their gender limited their ability to self-disclose. Of the four male clinicians responding to questions related to PSD, two discussed that they felt their gender added complexity to the topic of self-disclosure, and neither disclosed a partner's experience with contraception. Although Tom, an adolescent health nurse practitioner, did not self-disclose owing to limited personal experience with female contraception, he described gathering information from other women to share with his patients.

       Perceived Advantages and Disadvantages of PSD among Providers

      When asked about the advantages and disadvantages of PSD in contraceptive visits, clinician responses touched on two major themes: 1) how self-disclosure could impact the patient–provider relationship, and 2) how self-disclosure could affect patient autonomy.

       Perceived Influence on Patient–Provider Relationship

      Providers uniformly agreed that self-disclosure about personal experiences with contraception could affect their relationships with patients, although the perceived impacts on these relationships were complex. The most consistently reported benefits were the potential for self-disclosure to build trust and increase patient comfort with discussing sensitive topics. According to Tom, “I think an advantage [of self-disclosure] is that it, in my experience, increases rapport and also really normalizes the discussion.” Some female providers felt self-disclosure could be a helpful expression of empathy, particularly when discussing uncomfortable side effects, and to reassure patients their experiences are common. Sydney, a family nurse practitioner, explained, “I think there are situations where [PSD] can be helpful, especially if you've used an IUD before and someone comes in the first couple months [of using an IUD] and the spotting or the cramping is bothersome to them. I think there can be a place to say, ‘I know, I've been through that before, and for most women it gets better.’” Sylvia, an advanced practice clinician, pointed to the additional trust that comes from knowing your provider is offering a method that she would use: “I would say the advantages would be [making] people more comfortable because I'm not asking them to do something that I'm not also willing to do with my own body.”
      Many providers felt the impact of self-disclosure on the patient–provider relationship is influenced by the context of the patient encounter. Some felt self-disclosure is only appropriate when solicited by the patient but carries benefits when used judiciously in this way. According to Kierra, an advanced practice clinician working in a school-based health center, “It's a mixed bag. I think if a patient is asking, I think it [PSD] can be very trust-building. … I think it makes providers human … I do not think that self-disclosure has any part in the visit when offered by the provider without solicitation.” Providers felt it was important that patients' requests and preferences, rather than a provider's desire to share, determine PSD practices.
      A few providers expressed concern that self-disclosing contraceptive preferences could complicate relationships with patients and blur professional boundaries. When asked about the potential disadvantages of PSD during contraceptive counseling, Kaye, an advanced practice clinician said, “I think the boundary thing is a little tricky there with providers and patients, because it kind of leads to other boundary issues. I have to be careful.”

       Perceived Influence on Contraceptive Decision Making

      Many providers expressed concern that disclosing their own method choice inappropriately shifts the focus of the encounter from the patient's needs to the provider. As Tom explained, “I think a possible disadvantage [of PSD] is it takes the focus away from the patient and her preference or thought process.” Some providers also worried that patients would weigh the provider's experience too heavily in their own decision making process and had the potential to be coercive. Sydney shared her concerns about PSD:I think I read something a while back that people tend to put a lot of stock in what their providers are using and are more likely to select a method if their provider tells them that they themselves use that method. … If that's the only reason why someone's going to select a method, or that's a significant decision point for them, I would want to explore that a little bit more to really determine whether they think it's the right method for them.
      A number of providers also mentioned that the provider's reason for self-disclosing is important. In general, providers using personal anecdotes to validate a patient's decision was thought to be acceptable, but many cautioned that using personal experiences to guide a patient's decision pushes professional boundaries.
      Lilian, a family practice clinician, reported that PSD is difficult to use effectively because of the wide range of experiences a woman can have with contraception and the potential for the patient to misinterpret self-disclosure as pressure. “Well, every [contraceptive] method is different for every woman. So I don't feel like my personal view should influence someone else's, because I may really hate something, or really like something. But if the patient is going to be convinced based on my view, then that's not right.”
      In contrast, Lindsey felt self-disclosure of her contraceptive use could be an important tool to help prevent women from feeling pressured to choose a method, given historical reproductive health injustices. Lindsey, who identifies as a woman of color, felt self-disclosure about use of long-acting contraceptive methods like IUDs and implants can be particularly useful for building trust with patients who identify with communities that have been subjected to forced sterilization or coercive contraceptive counseling:They [patients] feel better knowing that you [the clinician] would put yourself through something that you're offering them. Because that's what's scary is when you're a patient and you feel like the clinician is just doing stuff and [and the patient is]’ just a number … not an actual human being … I don't like women feeling pressured to pick a method. I want them to feel completely safe about trusting us to do something to their body, because I'm coming from a perspective of also understanding reproductive injustices that have happened in the past.
      Similarly, Lilian felt that sharing her personal experiences with the contraceptive implant was useful for women who had not known someone who used that method. “I think it's really helpful, particularly with the Nexplanon [contraceptive implant] … I had one for a while, and being able to talk about that experience, I think, was helpful. Because my patients didn't necessarily know anyone who'd had it.” In this way, providers may be able to offer another “peer” perspective for women who do not have friends or family who have tried a particular method.

       Patient Experiences with PSD during Emergency Contraceptive Visits

      Just over one-half of patients (9/17) who responded to PSD questions reported PSD during their most recent emergency contraceptive counseling visit. Most patients felt their providers self-disclosed to either ease anxiety before IUD placement or to validate the patient's decision. When describing her experience with IUD placement, Sonia said, “I was a little bit nervous to get the IUD inserted, and so [the clinician] did try to relax me and let me know that she had a couple IUDs herself and that it's not as bad as it seems.”
      Nearly all women whose providers did not discuss their personal method choice said they would have benefited from that information in some way. When asked how she would have felt about PSD, Shawna responded, “I would have felt a bit more easy about the situation like I wasn't just going in blind because it's one thing to hear most women don't get pregnant, and that's one thing when you're actually with someone who's been using that method for a long time.” Another patient, Rebecca, was reluctant to ask about her provider's method choice, although she thought this information would have been helpful. “I think [my provider] had a Mirena IUD, because she knew what I was talking about. But, no, she didn't tell me anything about it. Like, and I don't ask … If I was a little bit more curious on birth control [I would have wanted to know my provider's method choice].”

       Patient Preferences and Perceived Impact of PSD

      Patient preferences for and perceived impact of PSD experiences centered around three major themes: curiosity about provider contraceptive choices, level of comfort with PSD varies by provider, and the perceived influence of PSD on their contraceptive decision making.

       Patient Preferences around PSD

      All women interviewed felt positively about PSD, with many noting more comfort speaking openly with their provider and increased trust when their provider self-disclosed. Sonia described the confidence she gained from hearing about her provider's experience with an IUD, “Yeah, it makes you feel a little bit more comfortable because if she can do it then I can too.” Another patient interviewed, Rosalina, appreciated knowing that her providers knew what it felt like to be a patient in her position: “They use Mirena [an IUD]. So, I guess it was cool because I [knew] in some shape or form, you know what it feels like to be laying on this table.” Most women said knowing about their provider's experiences with contraception would have helped them to feel more comfortable in their interactions with the provider and their decision about contraception.
      Patients had varying levels of comfort discussing contraception with male providers. In general, women who were comfortable being seen by male clinicians were also comfortable with PSD coming from male providers. Akari described how a male provider's disclosure of his partner's method increased her comfort level: “He mentioned that his wife had Mirena [an IUD] and he described how effective and how good it was for him and their relationship right now. … It definitely made the situation more comfortable [for me].”
      A couple of women expressed general discomfort speaking with male providers about contraceptive choices, either owing to a perception that men cannot relate to women on this topic or discomfort with being examined by a male provider. When describing her feelings about male providers, Sonia said, “I probably would have preferred a woman, just because I feel like we're all girls and we kind of understand our body parts more and understand how we're feeling. So, I wouldn't have minded a male, but I probably would have preferred a woman.”

       Patient Perceptions of PSD Influence on Contraceptive Decision Making

      Although patients were unanimous in their positive opinions of PSD, they reported varying levels of impact of this practice on their own method choice. Some women felt their provider's experiences were unlikely to influence their personal decisions, whereas others said the additional information was helpful. Maura explained, “Well, it would have been nice to know [what method my provider used], but I wouldn't have changed my mind. [I would have liked] to know the side effects that they have, how it affects them and if they ever have gotten pregnant using it.” Another patient, Imelda, described learning about potential side effects she did not know about through her provider's personal experiences: “Yeah [I felt comfortable], because they're telling me about what they've already experienced. Yeah [it influenced my decision].” In this way, providers' experiences seem to serve as an educational tool.

      Discussion

      In this study, providers and patients reported notably different perspectives on PSD during contraceptive counseling. Providers described infrequent use of PSD, but when employed, it was mostly used to build rapport, reassure patients, and to provide guidance, similar to what has been found among primary care physicians and surgeons (
      • Beach M.C.
      • Roter D.
      • Larson S.
      • Levinson W.
      • Ford D.E.
      • Frankel R.
      What do physicians tell patients about themselves? A qualitative analysis of physician self-disclosure.
      ). Although providers pointed to the benefits of building trust and rapport with patients, many providers were also concerned that PSD could compromise patient autonomy and lead to a professional boundary violation.
      Although it is critical for providers to always ensure that they are carefully engaging with patients in a manner that does not compromise patient autonomy, particularly given the long professional history of and ongoing reproductive coercion by the medical system in the United States (), they must also consider that an essential element of patient-centered care requires addressing patient preferences. When considering whether or not to self-disclose personal contraceptive information with patients, providers should be mindful that their concerns and priorities may differ from those of their patients. At the same time, in this study most patients described having had a recent PSD experience, a preference and appreciation for the PSD experiences they had had, and an interest in learning from their providers’ personal experiences with contraception.
      Although the literature examining PSD in contraceptive counseling is sparse, our findings are consistent with prior analyses. A qualitative study conducted in the UK found that women tend to view female health professionals as experts in contraception, not because of their medical expertise, but because female providers are presumed contraceptive users (
      • Lowe P.
      Embodied expertise: Women’s perceptions of the contraception consultation.
      ). This is consistent with our finding that both patients and providers were less comfortable with PSD when the provider is male, though some patients described positive PSD experiences with male providers and were open to learning about their male providers’ personal contraceptive experiences. One qualitative study conducted by
      • Brown M.K.
      • Auerswald C.
      • Eyre S.L.
      • Deardorff J.
      • Dehlendorf C.
      Identifying counseling needs of nulliparous adolescent intrauterine contraceptive users: A qualitative approach.
      included semistructured interviews with 20 nulliparous adolescents to elucidate the role of providers in IUD adoption. These data revealed that some adolescents were comforted by PSD regarding IUD use, which is consistent with our finding that young women generally find PSD appropriate and helpful. Similarly, a previously mentioned study found that just over one-third of providers self-disclosed their contraceptive use in at least one recorded visit, usually disclosures were related to IUD use, and patients considered the PSD they experienced appropriate (
      • McLean M.
      • Steinauer J.
      • Schmittdiel J.
      • Chan P.
      • Dehlendorf C.
      Provider self-disclosure during contraceptive counseling.
      ). This is consistent with our finding that patients overall have positive feelings about their experiences with PSD.
      A major strength of our study is that we captured both provider and patient perspectives on PSD in this setting. This study is the first to our knowledge to qualitatively explore provider perspectives on PSD during contraceptive counseling. Further, the use of in-depth interviews allowed us to unveil the nuances of patient and provider attitudes and experiences with PSD. Limitations of this study include the small sample of providers, particularly male providers, which limited our ability to fully assess how gender may impact provider perspectives on self-disclosure. Further, we were only able to capture providers’ reflections on the appropriateness of PSD and did not measure actual provider PSD practices. Additionally, we did not systematically collect information from the patients or providers on the types of contraceptive methods providers disclosed or would be willing to disclose, nor did we ask about whether attitudes about PSD would differ by method type. However, we found that patients mostly described PSD experiences where the provider mentioned IUDs, which is consistent with the study
      • McLean M.
      • Steinauer J.
      • Schmittdiel J.
      • Chan P.
      • Dehlendorf C.
      Provider self-disclosure during contraceptive counseling.
      conducted that identified IUDs as the most common method disclosed by providers in counseling. The type of method disclosed and possible reasons behind the decision to disclose a particular contraceptive method warrants future study to further understand PSD in this setting.

      Conclusions

      There are significant differences between provider and patient perceptions of PSD during contraceptive counseling visits. Although we found evidence that many patients welcome PSD as a way to gain trusted information about contraception, most providers were cautious before disclosing their personal experiences with contraception with patients.

       Implications for Practice and/or Policy

      Our study provides preliminary support for PSD of contraceptive experiences. Providers should consider that many young people may welcome PSD in the CHC setting, while continuing to be mindful that more research is needed to understand if and how disclosure practices affect the patient–provider relationship and autonomous contraceptive decision making. Our findings suggest that providers have an important role to play in supporting patient preferences while helping people choose a method and should continue to use PSD cautiously until we have a better understanding about the effects of PSD on patient experiences and whether such effects differ by the type of method disclosed and the gender of the provider.

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      Biography

      Morgan Cheeks, BA, is an MD Candidate at the University of California San Francisco School of Medicine. Her research interests include reproductive health policy, preterm birth prevention, health disparities, and contraceptive access.

      Biography

      Shelly Kaller, MPH, is a Project Director at Advancing New Standards in Reproductive Health (ANSIRH), where she implements research and evaluation related to contraception and abortion access. Her areas of focus include contraceptive decision-making, abortion and mental health, school-based health programs, and alternative models for providing family planning and abortion services.

      Biography

      Aisha Mays, MD, is a family physician and faculty in the University of California-Berkeley/UCSF Joint Medical Program. Her research interests include optimizing adolescent contraceptive care in school-based health centers and improving access to comprehensive reproductive health care for adolescents and young women in community health centers.

      Biography

      M. Antonia Biggs, PhD, is a social psychologist researcher with Advancing New Standards in Reproductive Health, University of California, San Francisco (ANSIRH-UCSF). Her research focuses on understanding women's experiences accessing reproductive health as well as their contraceptive decision making.