Discerning Deinfibulation: Impact of Personal, Professional, and Familial Influences on Decision-Making.

The past decades have seen large numbers of Somali women migrate across the globe. It is critical for healthcare workers in host countries to understand healthcare needs of Somali women. The majority of Somali female migrants experience female genital cutting (FGC). The most common type in Somalia is Type 3 or infibulation, the narrowing of the vaginal introitus. Deinfibulation opens the introitus to reduce poor health outcomes and/or allow for vaginal births. In this study, we explored the perspectives of Somali women living in the United States about deinfibulation. We recruited 75 Somali women who had experienced FGC through community-based participatory research methods. Bilingual community researchers conducted qualitative interviews in Somali or English. University faculty and community-based researchers coded data together in a participatory-analysis process. We identified four themes. (1) Personal Views: participants reported positive attitudes toward deinfibulation and varied on the appropriateness of deinfibulation before marriage. (2) Benefits: identified benefits included alleviation of health problems; improved sexual health, in particular reduction or prevention of sexual pain; and reclamation of body and womanhood. (3) Barriers: these included associated stigma and lack of knowledge by providers. (4) Decision-Making: most reported that husbands, healthcare providers, and elder female community members may provide advice about if and/or when to seek deinfibulation, though some felt deinfibulation decisions are solely up to the impacted woman. An ecological framework is used to frame the findings and identify the importance of healthcare workers in assisting women who have been infibulated make decisions.

The Need for Standardized Nomenclature in Electronic Documentation of Female Genital Cutting in Health Records.

To evaluate the quality of Electronic Health Record (EHR) documentation practices of Female Genital Cutting (FGC) by medical providers. A retrospective chart review study of 99 patient encounter notes within the University of Minnesota health system (inclusive of 40 hospitals and clinics) was conducted. Extracted data included but was not limited to patient demographics, reason for patient visit, ICD code used in note, and provider description of FGC anatomy. Data was entered into REDCAP and categorized according to descriptive statistics. Out of 99 encounters, 45% used the unspecified code for FGC. The most common reason for patient visits was sexual pain, though many notes contained several reasons for the visit regarding reproductive, urological, or sexual concerns. 56% of visits discussed deinfibulation. 11 different terms for FGC were used, with "female circumcision" being the most common. 14 different terms for deinfibulation were found within 64 notes. 42% of encounters included a description of introitus size in the anatomical description, and only 38% of these provided a metric measurement. This study found significant variation in the quality of FGC documentation practices. Medical providers often used the unspecified FGC code, subjective and/or seemingly inaccurate descriptions of FGC/anatomy, and several different terms for both FGC and deinfibulation. Clearly, more education is needed in clinical training programs to (1) identify FGC type, (2) use the corresponding ICD code, and (3) use specific, objective descriptions (including presence/absence of structures and infibulation status).

Ultrasound study of natural progression of ovarian endometrioma.

OBJECTIVE: To determine the natural progression of ovarian endometrioma in women who are managed expectantly. METHODS: This was a retrospective cohort study of 83 women with evidence of ovarian endometrioma who were managed expectantly between April 2007 and May 2022. The study was conducted in the Department of Women's Health, University College London Hospitals and The Gynecology Ultrasound Centre, London, UK. We searched our ultrasound clinic databases to identify women aged 18 years or older with evidence of ovarian endometrioma who were managed expectantly for ≥ 6 months. All women attended for a minimum of two ultrasound scans performed by a single expert ultrasound operator. In addition to patient demographics, we recorded the number, mean diameter and location of each cyst. The cyst growth rate was expressed as annual change in the mean diameter. RESULTS: A total of 1922 women who attended our gynecology clinic during the study period were found to have evidence of moderate or severe endometriosis on pelvic ultrasound examination. Of those, 83 women had evidence of ovarian endometrioma and were managed expectantly. The median age of women was 39 (range, 26-51) years at the initial visit. Each woman had at least two ultrasound scans performed by a single expert operator at a minimum interval of ≥ 6 months. Of 83 women diagnosed with endometrioma, 50 (60% (95% CI, 49-71%)) had a single cyst and the remainder had multiple cysts. The median number of endometriomas per patient was 1 (range, 1-5) and the median follow-up time was 634 (range, 187-2984) days. A total of 39/83 (47% (95% CI, 36-58%)) women experienced an overall reduction in size of cysts, in 18/83 (22% (95% CI, 13-32%)) the cysts increased in size and in 26/83 (31% (95% CI, 22-42%)) women, no meaningful change in size was observed. The median change in mean cyst diameter per woman during the study period was -2.7 (range, -57.7 to 39.3) mm, with a median annual regression rate of -1.7 (range, -24.6 to 42.0) mm/year/woman. Overall, when compared with the initial visit, cysts were significantly smaller at follow-up (median diameter, 22.3 (range, 6.7-77.0) mm vs 18.5 (range, 5.0-72.0) mm; P = 0.009). We did not identify any clinical characteristics that could reliably predict the chance of endometrioma progression. CONCLUSIONS: In the majority of women with an ultrasound diagnosis of ovarian endometrioma, the cysts do not increase in size significantly over time and they could be managed expectantly. This evidence may help clinicians when counseling asymptomatic or minimally symptomatic women about management of ovarian endometrioma. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Our Body Our Health (Jirkeena, Caafimaadkeena): Somali Women's Narratives on Sexual Health.

Women across the globe have been subject to female genital cutting (FGC), with the highest rates in Somalia. FGC can result in sexual concerns, especially sexual pain and lower pleasure. Due to ongoing civil war and climate disasters, there is a large number of Somali immigrants and refugees living in countries where healthcare providers may be unfamiliar with the impact of FGC. In this qualitative study, sixty Somali women between the ages 20 and 45 and living in the U.S. shared their perspectives on how FGC has affected their sexual lives, including how they have coped with any complications attributed to FGC. Participants were recruited through convenience sampling and interviewed by a bilingual community researcher in either Somali or English. Data were analyzed through a participatory analysis process by academic and community researchers. Themes included sexual desire, arousal, and pleasure; sexual satisfaction; sexual pain at first intercourse; coping with sexual pain at first intercourse; long-term sexual pain, coping with long-term sexual pain. Results are discussed with a focus on agency of the participants, role of partners, and implications for healthcare professionals.

Female genital cutting (FGC) type: proposing a multifaceted, interactive method for FGC self-assessment.

BACKGROUND: Self-reporting female genital cutting (FGC) status and types by patients and clinicians is often inconsistent and inaccurate, particularly in community settings where clinically verifiable genital exams are not feasible or culturally appropriate. AIM: In this study we sought to discern whether integrating multiple dimensions of participant engagement through self-reflection, visual imagery, and iterative discourse informed the determination of FGC status by a panel of health and cultural experts using World Health Organization (WHO) typology. METHODS: Using community-based participatory research, we recruited 50 Somali women from the Minneapolis-St. Paul, MN, metropolitan area through convenience and snowball sampling to participate in semi-structured interviews. Participants were asked to discuss their recollection of their original circumcision-including the procedure itself and their assessment of the type of circumcision they experienced. Anatomical drawings of uncircumcised and circumcised vulvas were shown to participants to assist them in identifying their FGC type. A panel of health and cultural experts reviewed and independently assessed participant FGC type. Interrater reliability and degree of concordance between participants and panel were determined. OUTCOMES: Outcomes included the following: (1) development of WHO-informed, anatomically accurate visual depictions of vulvas representing FGC typology, (2) development of an iterative, self-reflective process by which participants self-described their own FGC status aided by visual depictions of vulvas, (3) application of WHO FGC typology by a panel of health and cultural experts, and (4) determination of the degree of concordance between participants and panel in the classification of FGC type. RESULTS: High interrater reliability (kappa = 0.64) and concordance (80%) between panel and participants were achieved. CLINICAL TRANSLATION: Incorporation of FGC visual imagery combined with women's empowered use of their own self-described FGC status would optimize clinical care, patient education, and informed decision making between patients and their providers when considering medical and/or surgical interventions, particularly among women possessing limited health and anatomic literacy. STRENGTHS AND LIMITATIONS: Strengths of this study include the incorporation of anatomically accurate visual representations of FGC types; the iterative, educational process by which participants qualitatively self-described their FGC status; and the high interrater reliability and concordance achieved between panel and participants. Study limitations include the inability to conduct clinical genital exams (due to the community-based methodology used), recall bias, and small sample size (n = 50). CONCLUSION: We propose a new patient-informed educational method for integrating anatomically accurate visual imagery and iterative self-reflective discourse to investigate sensitive topics and guide clinicians in providing patient-centered, culturally informed care for patients with FGC.

Beautiful vulvas: expanding illustrative visual imagery of female genital cutting types.

BACKGROUND: Visual imagery has been used to educate healthcare providers, patients, and the lay public on female genital cutting (FGC) typology and reconstructive procedures. However, culturally inclusive, diverse, and anatomically accurate representation of vulvas informed by women possessing lived experience of FGC is lacking. AIM: We sought to apply World Health Organization (WHO) FGC typology to the development of type-specific visual imagery designed by a graphic artist and culturally informed by women with lived experience of FGC alongside a panel of health experts in FGC-related care. METHODS: Over a 3-year process, a visual artist created watercolor renderings of vulvas with and without FGC across varying WHO types and subtypes using an iterative community-based approach. Somali women possessing lived experience of FGC were engaged alongside a team of clinician experts in FGC-related care. Women and clinicians provided descriptive input on skin color variation, texture, and skin tone, as well as the visual depiction of actions necessary in conducting a genital examination. OUTCOMES: A series of vulvar anatomic illustrations depicting WHO FGC typology. RESULTS: FGC types and subtypes are illustrated alongside culturally informed descriptors and clinical pearls to strengthen provider competency in the identification and documentation of FGC WHO typology, as well as facilitate patient education, counseling, shared decision making, and care. CLINICAL IMPLICATIONS: Ensuring equitable representation of race, gender, age, body type, and ability in medical illustrations may enhance patient education, counseling, and shared decision making in medical and/or surgical care. FGC provides a lens through which the incorporation of patient-informed and culturally relevant imagery and descriptors may enhance provider competency in the care of FGC-affected women and adolescents. STRENGTHS AND LIMITATIONS: The strengths of this study include the development of visual imagery through an iterative community-based process that engaged women with lived experience of FGC alongside clinicians with expertise in FGC-related care, as well as the representation of historically underrepresented bodies in the anatomical literature. Study limitations include the lack of generalizability to all possible forms or practices of FGC given the focus on one geographically distinct migrant community, as well as the reliance on self-report given the inability to clinically verify FGC status due to the community-based methodology employed. CONCLUSION: Patient-informed and culturally representative visual imagery of vulvas is essential to the provision of patient-centered sexual health care and education. Illustrations developed through this community-engaged work may inform future development of visual educational content that advances equity in diverse representation of medical illustrations.

Natural history of endometriosis in pregnancy: ultrasound study of morphology of deep endometriosis and ovarian endometrioma.

OBJECTIVE: To assess the morphological appearance of deep endometriosis and ovarian endometrioma in pregnancy using pelvic ultrasound examination. METHODS: This was a prospective observational cohort study conducted over 3 years at University College London Hospital, which is a tertiary level referral unit for early pregnancy complications and an accredited endometriosis center. All women who participated provided written consent and were invited for surveillance ultrasound examination at the time of their routine scans in pregnancy. All scans were performed by a single operator to eliminate interobserver variability. The change in size of ovarian endometrioma and nodules was reported as change in their mean diameter. Ovarian endometrioma with irregular thick inner walls, hyperechoic papillary projections and/or high vascularity and hyperechoic nodules with moderate to high vascularity were reported as decidualized. RESULTS: Sixty-five women with a live, normally sited pregnancy and concomitant ultrasound features of deep and/or ovarian endometriosis were included in the study. The median age of the study population was 34 (range, 23-44) years, and the median gestational age at presentation was 7 + 6 (range, 3 + 6 to 18 + 0) weeks. From the cohort, 47/65 (72%) were nulliparous, 48/65 (74%) had a previous diagnosis of endometriosis and 19/65 (29%) conceived via in-vitro fertilization. There were 10/65 (15% (95% CI, 7-24%)) women with ovarian endometrioma alone, 28/65 (43% (95% CI, 31-55%)) with endometriotic nodules alone and the remaining 27/65 (42% (95% CI, 30-54%)) had both. Of the women with ovarian endometrioma who underwent follow-up, 29/34 (85% (95% CI, 73-97%)) experienced cyst regression, 2/34 (6% (95% CI, 0-14%)) experienced cyst growth, and in 3/34 (9% (95% CI, 0.0-18%)) women, cyst size was unchanged. In 10/34 (29% (95% CI, 14-45%)), there was complete resolution of all cysts. Of the women with nodules who underwent follow-up, 43/51 (84% (95% CI, 74-94%)) experienced nodule regression, 2/51 (4% (95% CI, 0-9%)) experienced nodule growth and, in 6/51 (12% (95% CI, 3-21%)) women, nodule size was unchanged. In 4/51 (8% (95% CI, 0-15%)) women, there was complete resolution of all nodules. In 5/37 (14% (95% CI, 3-25%)) women who attended postnatal follow-up, complete resolution of all endometriotic lesions occurred during pregnancy. In 10/34 (29% (95% CI, 14-45%)) women with ovarian endometrioma and 27/51 (53% (95% CI, 39-67%)) women with nodules, a pattern of growth was observed in the first and second trimesters, followed by regression later in pregnancy. Features of decidualization were observed in 17/34 (50% (95% CI, 33-67%)) women with ovarian endometrioma, most commonly in the first trimester, and in 25/51 (49% (95% CI, 35-63%)) women with nodules, most commonly in the second trimester. CONCLUSIONS: For the majority of women, despite features of decidualization being common in the first and second trimesters, ovarian endometrioma and deep nodules regress during pregnancy. Morphological changes of endometriosis in pregnancy are difficult to differentiate from characteristics of malignant lesions. Better understanding of the appearance of endometriosis in pregnancy is vital to minimize intervention and help counsel women regarding their condition. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Reliability and Factor Structure of the Sex Offender Treatment Intervention and Progress Scale.

Assessment of risk of sexual recidivism has progressed from tools containing only static factors to tools including dynamic (i.e., changeable) risk factors. The psychometric properties and factor structure of one such scale, the Sex Offender Treatment Intervention and Progress Scale (SOTIPS) were explored. Seven hundred and thirty-one men assigned probation for sexual crimes in New York City and Maricopa County, Arizona were administered SOTIPS three times: intake into probation, six months later, and six months after that. SOTIPS showed good internal consistency (Time 1 ω = .87, Time 2 ω = .89, and Time 3 ω = .91), and acceptable inter-rater reliability (for the 26 cases rated in the same month, ICC =.821). An exploratory factor analysis did not result in the original factor structure proposed by the developers; instead, SOTIPS showed two factors: sexual risk and antisocial opposition. This factor structure required the averaging of two items to avoid collinearity. SOTIPS showed temporal invariance indicating that its factor structure and its association to underlying latent variables are consistent over time.

Prevalence of deep and ovarian endometriosis in early pregnancy: ultrasound diagnostic study.

OBJECTIVE: To assess the prevalence and morphological appearance of deep endometriosis and ovarian endometrioma using pelvic ultrasound examination in women attending for an early pregnancy assessment. METHODS: This was a prospective observational study set within a dedicated early pregnancy unit. The study included 1341 consecutive women who attended for an early pregnancy assessment for reassurance or because of suspected early pregnancy complications. All women underwent a transvaginal scan to assess the location and viability of their pregnancy. In addition, a detailed examination of pelvic organs was carried out to detect the presence of endometriosis and other gynecological abnormalities. Data analysis was performed using logistic regression and multivariable analysis. RESULTS: The prevalence of deep endometriosis and/or ovarian endometrioma in women attending our early pregnancy unit was 4.9% (95% CI, 3.8-6.2%). In 33/66 (50.0% (95% CI, 37.9-62.1%)) women with endometriosis, this was a new diagnosis that was made during their early pregnancy scan. On multivariable analysis, the presence of endometriosis was strongly associated with a history of subfertility (odds ratio (OR), 3.15 (95% CI, 1.63-6.07)) and presence of a congenital uterine anomaly (OR, 5.69 (95% CI, 2.17-14.9)) and uterine fibroids (OR, 2.37 (95% CI, 1.31-4.28)). Morphological changes typical of decidualization were seen in 11/33 (33.3% (95% CI, 17.2-49.4%)) women with ovarian endometrioma and 18/57 (31.6% (95% CI, 19.5-43.7%)) women with deep endometriotic nodules. CONCLUSIONS: Deep endometriosis and ovarian endometrioma were present in a significant proportion of women attending for early pregnancy assessment. The prevalence varied depending on a history of subfertility, and therefore is likely to differ significantly among populations, depending on their characteristics. Ultrasound is a useful tool for the detection of endometriosis in early pregnancy and the identification of women who may benefit from specialist antenatal care. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Imaging in gynecological disease (21): clinical and ultrasound characteristics of accessory cavitated uterine malformations.

OBJECTIVE: To describe the clinical and ultrasound characteristics of accessory cavitated uterine malformations (ACUMs). METHODS: This was a single-center observational study of consecutive patients diagnosed with an ACUM, who had undergone an ultrasound examination by an experienced ultrasound examiner between January 2013 and May 2019, identified retrospectively from medical records. ACUM was diagnosed when a cavitated lesion with a myometrial mantle and echogenic contents was seen within the anterolateral wall of the myometrium beneath the insertion of the round ligament. In all women, presenting symptoms and clinical history were recorded along with detailed descriptions of the lesions and any concomitant pelvic abnormalities. RESULTS: Twenty patients diagnosed with an ACUM were identified. Median age was 29.2 (interquartile range, 25.0-35.8) years. None of the women was premenarchal or postmenopausal. All of the women reported painful periods or pelvic pain and none of them reported subfertility. Twelve of the ACUMs were in the right anterolateral myometrium and eight were in the left anterolateral myometrium. Both a myometrial mantle and a fluid-filled cavity were considered to be defining features on ultrasound. The fluid contained within the cavity was either echogenic with a ground-glass appearance or hyperechoic. All of the lesions were spherical in shape. The Doppler flow seen in the outer rim was not markedly different from that of the surrounding myometrium, and the content of the cavity was avascular on Doppler examination. The mean outer cavity diameter of the ACUMs was 22.8 (95% CI, 20.9-24.8) mm and the mean internal cavity diameter was 14.1 (95% CI, 12.2-16.1) mm. Four women opted for transvaginal ultrasound-guided alcohol sclerotherapy. Surgical excision was carried out in eight cases, and the diagnosis was confirmed on histopathological examination in all of them. CONCLUSIONS: ACUMs are a uterine abnormality with a distinct ultrasound appearance, which are associated with dysmenorrhea and chronic pelvic pain. Knowledge of their typical appearance on ultrasound could facilitate early detection and treatment. There are several treatment options for ACUM, ranging from simple analgesia to complete excision. Further prospective and longitudinal studies are required to study the prevalence and natural history of this condition. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound diagnosis of endometrial cancer by subjective pattern recognition in women with postmenopausal bleeding: prospective inter-rater agreement and reliability study.

OBJECTIVES: To assess the inter-rater agreement and reliability of using subjective pattern recognition for diagnosing endometrial cancer (EC) on ultrasound in women with postmenopausal bleeding (PMB). METHODS: This was a prospective cross-sectional study conducted at a gynecological rapid-access clinic, between October 2016 and December 2017, in which consecutive women with PMB and endometrial thickness of ≥ 4.5 mm on transvaginal ultrasound examination were included. Women on hormone replacement therapy or tamoxifen and those with a history of primary gynecological malignancy were excluded. Two raters independently performed ultrasound examinations, blinded to each other's findings, and classified women as having uniformly thickened endometrium, benign endometrial polyp or EC, using subjective pattern recognition. Inter-rater reliability of ultrasound diagnosis was assessed using Cohen's kappa (κ) statistic. All women subsequently underwent either outpatient endometrial biopsy, hysteroscopy or hysterectomy. RESULTS: Forty women were included in the study, with a median age of 61 (interquartile range (IQR), 57-69) years and a median endometrial thickness of 11.0 (IQR, 6.2-20.3) mm. Final histological analysis confirmed 16 (40%) women with EC, 16 (40%) with benign endometrial polyp, four (10%) with atrophic endometrium, three (8%) with proliferative endometrium and one (3%) with endometrial hyperplasia. Inter-rater agreement for the ultrasound diagnoses of uniformly thickened endometrium, benign endometrial polyp and EC was 14/16 (87.5%), 22/30 (73.3%) and 28/34 (82.4%), respectively; inter-rater reliability was good (κ = 0.69; 95% CI, 0.49-0.88). When the ultrasound diagnoses were grouped as either cancer or no cancer, inter-rater agreement was 85% and inter-rater reliability was good (κ = 0.78; 95% CI, 0.61-0.95). Rater A correctly identified 14/16 cases of EC and Rater B identified 15/16. EC was misdiagnosed as benign polyps on ultrasound in two women by Rater A and in one woman by Rater B. The overall accuracies of Rater A and Rater B in differentiating between benign endometrial pathologies and malignancy were 90% and 90%, respectively. CONCLUSIONS: Our results show good inter-rater reliability of subjective pattern recognition in diagnosing uniformly thickened endometrium, benign endometrial polyp and EC on ultrasound in women with PMB. Our findings should facilitate wider use of subjective pattern recognition in routine clinical practice. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Understanding Women's Responses to Sexual Pain After Female Genital Cutting: An Integrative Psychological Pain Response Model.

The World Health Organization estimates that over 200 million women and girls have experienced female genital cutting (FGC). Many women and girls who have undergone FGC have migrated to areas of the world where providers are unfamiliar with the health needs associated with FGC. Both providers in Western healthcare systems and female immigrant and refugee patients report communication difficulties leading to distrust of providers by women who have experienced FGC. Sexual pain is one common problem requiring discussion with healthcare providers and possible intervention. Yet, existing clinical and research literature provides little guidance for assessment and intervention when sexual pain is a result of FGC. Several conceptual frameworks have been developed to conceptualize and guide treatments for other types of pain, such as back pain and headaches. In this article, we integrate four prominent models-the fear avoidance model, eustress endurance model, distress endurance model, and pain resilience model-to conceptualize sexual pain in women who have experienced FGC. The resulting integrative psychological pain response model will aid in providing culturally responsive clinical management of sexual pain to women who have experienced FGC. This integrative model also provides a theoretical foundation for future research in this population.

Does Reassessment Improve Prediction? A Prospective Study of the Sexual Offender Treatment Intervention and Progress Scale (SOTIPS).

This prospective study examined the predictive validity of the Sex Offender Treatment Intervention and Progress Scale (SOTIPS; McGrath et al., 2012), a sexual recidivism risk/need tool designed to identify dynamic (changeable) risk factors relevant to supervision and treatment. The SOTIPS risk tool was scored by probation officers at two sites (n = 565) for three time points: near the start of community supervision, at 6 months, and then at 12 months. Given that conventions for analyzing dynamic prediction studies have yet to be established, one of the goals of the current paper was to demonstrate promising statistical approaches for the analysis of longitudinal studies in corrections. In most analyses, static SOTIPS scores predicted all types of recidivism (sexual, violent, and general [any]). Dynamic SOTIPS scores, however, only improved the prediction of general recidivism, and only when the analyses with the greatest statistical power were used (Cox regression with time dependent covariates).

Female Genital Cutting and Deinfibulation: Applying the Theory of Planned Behavior to Research and Practice.

At least 200 million girls and women across the world have experienced female genital cutting (FGC). International migration has grown substantially in recent decades, leading to a need for health care providers in regions of the world that do not practice FGC to become knowledgeable and skilled in their care of women who have undergone the procedure. There are four commonly recognized types of FGC (Types I, II, III, and IV). To adhere to recommendations advanced by the World Health Organization (WHO) and numerous professional organizations, providers should discuss and offer deinfibulation to female patients who have undergone infibulation (Type III FGC), particularly before intercourse and childbirth. Infibulation involves narrowing the vaginal orifice through cutting and appositioning the labia minora and/or labia majora, and creating a covering seal over the vagina with appositioned tissue. The WHO has published a handbook for health care providers that includes guidance in counseling patients about deinfibulation and performing the procedure. Providers may benefit from additional guidance in how to discuss FGC and deinfibulation in a manner that is sensitive to each patient's culture, community, and values. Little research is available to describe decision-making about deinfibulation among women. This article introduces a theoretically informed conceptual model to guide future research and clinical conversations about FGC and deinfibulation with women who have undergone FGC, as well as their partners and families. This conceptual model, based on the Theory of Planned Behavior, may facilitate conversations that lead to shared decision-making between providers and patients.

Glycosylated fibronectin point-of-care test for diagnosis of pre-eclampsia in a low-resource setting: a prospective Southeast Asian population study.

OBJECTIVE: To determine the performance of a glycosylated fibronectin (GlyFn) point-of-care (POC) test for pre-eclampsia (PE) in a large Southeast Asian cohort (India) in comparison to previously described biomarkers. DESIGN: A total of 798 pregnant women at ≥20 weeks of gestation were enrolled in a prospective case-control study. Study participants included 469 normotensive women with urinary mg protein/mmol creatinine ratio <0.3, 135 with PE (hypertension with urinary mg protein/mmol creatinine ratio ≥0.3) and 194 with gestational hypertension (hypertension with urinary mg protein/mmol creatinine ratio <0.3). METHODS: GlyFn levels were determined using a POC device and PIGF, sFlt-1 and PAPPA2 levels were determined by immunoassay. Performance was assessed using logistic regression modelling and receiver-operating characteristic (ROC) curves. Classification performance and positive and negative predictive values are reported at specific thresholds. RESULTS: Increased levels of GlyFn, soluble fms-like tyrosine kinase-1 (sFlt-1) and pregnancy-associated placental protein A2 (PAPPA2), and decreased levels of placental growth factor (PlGF) were significantly associated (P < 0.01) with clinically defined PE. Area under the ROC (AUROC) values with 95% confidence intervals were: GlyFn, 0.99 (0.98-0.99); PlGF, 0.96 (0.94-0.98); sFlt-1, 0.86 (0.83-0.89); and PAPPA2, 0.96 (0.94-0.97). Of subjects with GH, 48% were positive for more than two PE biomarkers, and 70% of these delivered preterm. CONCLUSIONS: The Lumella™ GlyFn POC test has been validated in a low/middle-income country setting for PE diagnosis and may be a useful adjunctive tool for early identification, appropriate triage, and improved outcomes. TWEETABLE ABSTRACT: The Lumella™ point-of-care test had excellent performance in diagnosing PE in a large Southeast Asian cohort.

Psychosocial Factors Influence Sexual Satisfaction among Women with Vulvodynia.

Vulvodynia affects about 8% of women, many of whom report a negative impact on their ability to have sexually satisfying relationships. In this study, we examined predictors of sexual satisfaction in 207 women with clinically confirmed vulvodynia. We adapted a model examining resilience in chronic pain patients originally developed by Sturgeon and Zautra to include resilience factors (communication with partner about sexual health and coping strategies) and vulnerable factors (abuse history, pain intensity, rumination). These variables were regressed onto sexual satisfaction. In the full model, only emotion-based rumination was predictive of sexual satisfaction. Thus, focusing on emotion-based rumination in clinical intervention may improve sexual satisfaction.

Intra- and interobserver reproducibility of pelvic ultrasound for the detection and measurement of endometriotic lesions.

STUDY QUESTION: What is the interobserver and intraobserver reproducibility of pelvic ultrasound for the detection of endometriotic lesions? SUMMARY ANSWER: Pelvic ultrasound is highly reproducible for the detection of pelvic endometriotic lesions. WHAT IS KNOWN ALREADY: Transvaginal ultrasound (TVS) has been widely adopted as the first-line assessment for the diagnosis and assessment of pelvic endometriosis. Severity of endometriosis as assessed by ultrasound has been shown to have good concordance with laparoscopy (kappa 0.79). The reproducibility of TVS for assessment of ovarian mobility and pouch of Douglas obliteration using the 'sliding sign' has already been described in the literature. However, there is no available data in the literature to demonstrate the intraobserver repeatability of measurements for endometriotic cysts and nodules. STUDY DESIGN SIZE DURATION: This was a prospective observational cross-sectional study conducted over a period of 12 months. We included 50 consecutive women who were all examined by two operators (A and B) during their clinic attendance. PARTICIPANTS/MATERIALS SETTING METHODS: The study was carried out in a specialist endometriosis centre. We included all consecutive women who had ultrasound scans performed independently by two experienced operators during the same visit to the clinic. The outcomes of interest were the inter- and intraobserver reproducibility for the detection of endometriotic lesions. We also assessed repeatability of the measurements of lesion size. MAIN RESULTS AND THE ROLE OF CHANCE: There was a good level of agreement between operator A and operator B in detecting the presence of pelvic endometriotic lesions (k = 0.72). There was a very good level of agreement between operators in identifying endometriotic cysts (k = 0.88) and a good level of agreement in identifying endometriotic nodules (k = 0.61). The inter- and intraobserver repeatability of measuring endometriotic cysts was excellent (intra-class correlation (ICC) ≥ 0.98). There was good interobserver measurement repeatability for bowel nodules (ICC 0.88), but the results for nodules in the posterior compartment were poor (ICC 0.41). The intraobserver repeatability for nodule size measurements was good for both operators (ICC ≥0.86). LIMITATIONS REASONS FOR CAUTION: Within this cohort, there was insufficient data to perform a separate analysis for nodule size in the anterior compartment. All examinations were performed within a specialised unit with a high prevalence of deep endometriosis. Our findings may not apply to operators without intensive ultrasound training in the diagnosis of pelvic endometriosis. WIDER IMPLICATIONS OF THE FINDINGS: These findings are important because ultrasound has been widely accepted as the first-line investigation for the diagnosis of pelvic endometriosis, which often determines the need for future investigations and treatment. The detection and measurement of bowel nodules is essential for anticipation of surgical risk and planning surgical excision. STUDY FUNDING/COMPETING INTERESTS: The authors have no conflict of interest. No funding was obtained for this work.

The Transgender Identity Survey: A Measure of Internalized Transphobia.

Purpose: We describe the development of a measure of internalized transphobia, defined as discomfort with one's transgender identity as a result of internalizing society's normative gender expectations. Methods: An item pool was created based on responses from a small clinical sample (N = 12) to an open-ended questionnaire. Expert judges reviewed the items, resulting in a 60-item instrument for empirical testing. We conducted exploratory factor analysis (EFA) by using a community sample of 430 transgender individuals (aged 18-72, mean [M] = 37.4, standard deviation [SD] = 12.0), and confirmatory factor analysis (CFA) by using an online sample of 903 transgender individuals (aged 18-66, M = 31.6, SD = 11.1). Construct validity was examined by using correlations with instruments assessing related constructs administered to the online sample. Results: EFA resulted in a 52-item instrument with four subscales: Pride, Passing, Alienation, and Shame. CFA, after removal of half of the items, retained the four-factor structure. The final 26-item scale showed excellent internal consistency (0.90) and test-retest reliability (0.93). The factors showed a pattern of association with crossgender identity, gender ideology, outness, felt stigma, self-esteem, and psychological distress consistent with moderate-to-good construct validity. Conclusion: Internalized transphobia can be conceptualized as four inter-related dimensions: pride in transgender identity (reverse scored), investment in passing as a cisgender person, alienation from other transgender people, and shame. The Transgender Identity Survey reliably assesses this construct, useful in research to understand the impact of minority stress on transgender people's health. It can also be used in clinical practice to assess internalized transphobia at intake and follow-up.