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The general gynaecologist: an endangered species?
Vol. 12 No 1 | Autumn 2010
Feature
Family planning


This article is 8 years old and may no longer reflect current clinical practice.

Family Planning organisations originated as health and rights-based movements. In the early years of the 20th century, they arose primarily to provide women with contraceptive methods and advice, something that was frowned upon by the community at large and even by medical practitioners.

Married women (because unmarried women did not have sex!) had to ‘be in the know’ to prevent unwanted pregnancies by methods other than condoms, withdrawal or abstinence. Family Planning organisations saw themselves not only as healthcare providers, but as advocates for the rights of women.

While the historical development and current structures of the eight State and Territory-based Australian Family Planning organisations have some differences, the organisations share much in their past and present objectives, philosophies and range of services. Family Planning New South Wales started its life in 1926 and was staffed for many years by volunteers and interested medical practitioners. The fitting of the latex diaphragm was the primary woman-centred method in use.

‘… Family Planning organisations continue to take an active role in advocacy for women’s health rights.’

When ‘the pill’ became available in 1961 in Australia, contraception really became part of mainstream medicine and gynaecologists were at the forefront of its provision. Doctors who worked for Family Planning services in the 1970s were regarded even then as ‘playing’ at being real doctors, but they had a mission to make ‘every baby, a wanted baby’. They were prepared to see unmarried women and also to fight for the rights of women to terminate unwanted pregnancies. This advocacy put them into the role of ‘feminists’, even though there were a number of passionate men in the Family Planning fold.

Over the years, the politicisation of reproductive medicine has continued and Family Planning organisations continue to take an active role in advocacy for women’s health rights. Recent examples include the decriminalisation of abortion law in Victoria; lobbying for the use of Ru486 and the subsequent increased availability of medical terminations; and the revision of mandatory reporting requirements in the Northern Territory. Invaluable input is provided into a wide range of national and State policy developments, such as the national women’s and men’s health policy, and state sexual health and HIV prevention taskforces.

Interestingly, the development of ‘the pill’ and other hormonal contraceptives opened up a whole new world in medicine. Not only could we manage fertility more proactively, we could also manage a number of common gynaecological conditions, such as menorrhagia and dysmenorrhea, as medical knowledge and clinical experience with the non-contraceptive benefits of hormonal contraceptives grew. This change in the management of bleeding problems led to the need for fewer invasive procedures, such as dilatation/curettage and hysterectomy, and allowed primary care practitioners to manage conditions that would previously have been referred to a general gynaecologist.

Doctors prescribing the new pill also became proficient at managing the adverse and side effects of hormonal contraceptive methods, with the result that general practitioners often referred patients to Family Planning clinics for advice when their patients experienced problems. Information provision and the management of the consequences of ‘risk-taking’ behaviour, such as missing pills, unplanned pregnancy, unprotected sexual intercourse and common sexually transmissible infections, became an important element of our work.

What do Family Planning clinics do today?

Family Planning doctors are usually primary care physicians (often general practitioners in their ‘other’ lives). Many are Diplomates of RANZCOG and an increasing number are sexual health physicians (Fellows of the Australasian Chapter of Sexual Health Medicine in the RACP). Our clientele is predominantly female, so we are also known as ‘women’s health’ practitioners. We also see men for sexual and reproductive health issues and our services are inclusive of the needs of clients from sexual minorities. We have a team-based ethos and work alongside nurses who, as independent practitioners, have their own patient ‘lists’, generally managing the ‘well woman’ and providing invaluable clinical, counselling and educational services. In some States, legislation permits supply of limited medications including ongoing hormonal contraception by ‘endorsed’ nurses.

The core area of our work is still contraception and since we are designated ‘non-government organisations’ and receive some government funding, we target our services to disadvantaged communities and people, aiming to complement the work of our colleagues in primary healthcare and gynaecology. Groups for whom we provide tailored information, health education and clinical services in reproductive and sexual health include:

  • People from culturally and linguistically diverse (CALD) backgrounds
  • Aboriginal and Torres Strait Islander people
  • People living with a disability
  • Young people
  • Same sex attracted and gender diverse people.

Family Planning staff have specific contraception expertise and see women and couples with complex contraception needs, including intercurrent medical conditions or psychosocial issues requiring specific consideration. Apart from standard contraceptive prescription, we also provide ‘procedural contraception’, therefore, hormonal implant and intra-uterine device insertion and removal. As these long-acting methods that require clinical skills to insert have been developed and introduced to Australia, Family Planning organisations have become training centres for these procedures.

Individual Family Planning organisations have a state-wide charter and although we cannot provide services everywhere, we take a broad public health approach to preventative healthcare. This includes school and community-based health promotion programs; education programs for doctors, nurses, teachers and allied professionals; and clinical services which integrate all three elements.

An example of this broad approach is the promotion and provision of cervical screening, usually in partnership with other services: the education and upskilling of general practice registrars and practice nurses in taking Pap tests; ‘pushing’ opportunistic Pap test screening with our clients; and the management of recall systems for abnormal tests. On occasion, we have been congratulated by the local gynaecologist for doggedly following up women who have been thought to be ‘lost to follow-up’ for their high-grade changes. One State also provides a coloposcopy service. Family Planning organisations’ expertise in this area has been recognised by State and national cervical screening programs, with representation on key cervical screening advisory groups and being funded to support or provide medical and nursing education in this area.

‘The core area of our work is still contraception and since we are designated “non-government organisations” and receive some government funding, we target our services to disadvantaged communities and people, aiming to complement the work of our colleagues in primary healthcare and gynaecology.’

In other preventive services, we promote and offer opportunistic chlamydia testing to sexually active young people (25 years and under); screening for other sexually transmissible infections as appropriate; actively promote safe sex; provide preconception advice; and more recently, advocating for, and in some States, administering the HPV vaccine.

Our usual clinical services include ‘office’ gynaecology such as the management of menstrual problems, pelvic pain and dyspareunia, vaginal discharges, vulval conditions and genital warts. Women and their partners come to us to talk about pregnancy and while we do not provide ongoing antenatal care, we do provide preconception advice, carry out initial antenatal care and initial investigations for fertility problems. We test for and manage most common sexually transmissible infections. However, clients found to be HIV positive are referred to specialised clinics for ongoing management. In addition, many of our doctors have become experts in menopause, especially since general practitioners often appear to be anxious about the management of this area of women’s health.

Education and training have become core elements of our work across Australia. One of the Family Planning training doctors in the Northern Territory commented: ‘In the Territory, most of the long-standing general practitioners and rural doctors have either been trained or worked within Family Planning Welfare Association of Northern Territory (FPWNT), almost as a professional rite of passage.’

General practice registrars are encouraged to seek family planning training by their supervisors and the General Practice Registrars Association. The delivery of quality services to patients in sexual and reproductive health is acknowledged core business within primary healthcare and the skills required to operate effectively within this community are somewhat different to those developed within hospital-based O and G training formats. The Sexual Health and Family Planning Certificate in Sexual and Reproductive Health, with its competency-based clinical attachment, is recognised as a valuable precursor to this type of practice.

Finally, as organisations with clearly articulated guidelines of practice, based on expert evidence, we are regularly accessed for guidance on management, process and policy. Telephone and web-based information services are provided to both health professionals and the community. Handbooks such as Contraception: an Australian clinical practice handbook are published and used by increasing numbers of health professionals nationally.

More information about Family Planning services can be found at www.shfpa.org.au or on the individual State websites.


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