Domestic Refugee Health Screening Guidance
Sexual and Reproductive Health Screening
Last updated: July 2022
On this page:
Minnesota sexual and reproductive health screening recommendations
Microlearning series: Female genital mutilation/cutting
Microlearning series: Sexually transmitted infections and pregnancy
Labs
Best practices
Background and epidemiology
Resources
Minnesota sexual and reproductive health screening recommendations
- Urine pregnancy test should be performed for all women of childbearing age and pubescent adolescent girls. Repeat pregnancy test if date of last unprotected sex is within 14 days and first test was negative (if menses is not reported since last unprotected sex).
- Refer pregnant refugees who wish to continue with their pregnancy to an obstetric provider.
- Discuss family planning and available contraceptive methods, including accessibility, efficacy, and cost. Condoms should be offered to avoid unintended pregnancy and sexually transmitted diseases (STDs), also known as sexually transmitted infections (STIs).
- Screen women and girls from countries where female genital mutilation/cutting (FGM/C) is practiced (UNICEF: Female Genital Mutilation (FGM) Statistics) for possible FGM/C-associated medical complications, including chronic pain, recurrent urinary tract infections, and obstetric issues, as well as prepare for pelvic examinations.
- Clinicians should inform refugees that FGM/C is considered child abuse, and that it is illegal to perform FGM/C on a child in the United States or to take a child out of the country to undergo the procedure (“vacation cutting”).
- Clear documentation of FGM/C in the medical record soon after US arrival, including a description of physical findings and ICD-10 coding, may help protect against future suspicions of “vacation cutting” and abuse accusations.
- Test refugees ages 15 and older for syphilis unless there is a documented history of recent syphilis diagnosis and treatment overseas. This includes re-testing if there was a documented negative results overseas.
- For patients with documented history of syphilis diagnosis and treatment overseas, ensure appropriate treatment and follow-up (refer to labs below).
- Children younger than 15 years of age should be evaluated if they:
- are at risk for congenital syphilis (i.e., mother who tests positive for syphilis, if the mother’s syphilis results are not available, or the child is unaccompanied) (refer to CDC: Congenital Syphilis STI Treatment Guidelines);
- disclose sexual activity; OR
- have been sexually assaulted.
- Follow Minnesota Department of Health reporting guidance on Minnesota Confidential Syphilis Report Form for all syphilis diagnoses. All patients should be fully treated following current CDC: Syphilis STI Treatment Guidelines.
- Screen female refugees younger than 25 years of age who are sexually active and do not have documented pre-departure testing for chlamydia and gonorrhea.
- Screen female refugees with abnormal vaginal or rectal discharge, intermenstrual vaginal bleeding, or lower abdominal or pelvic pain, and male refugees with urethral discharge, dysuria, or rectal pain or discharge.
- Follow Minnesota Department of Health reporting guidance on Minnesota Confidential Chlamydia and Gonorrhea Report Form for all chlamydia and gonorrhea diagnoses.
Microlearning series: Female genital mutilation/cutting
This video (under 5 minutes) is meant to serve as a summary of female genital mutilation/cutting screening guidance and resources for providers completing the refugee health screening and all those serving new arrivals.
Refugee Health Microlearning Series: : Female Genital Mutilation/Cutting Transcript (PDF)
Microlearning series: Sexually transmitted infections and pregnancy
This video (under 5 minutes) is meant to serve as a summary of sexually transmitted infections and pregnancy screening guidance and resources for providers completing the refugee health screening and all those serving new arrivals.
Refugee Health Microlearning Series: Sexually Transmitted Infections and Pregnancy Transcript (PDF)
Labs
- Syphilis Screening Recommendations for Newly Arrived Refugees (PDF)
For syphilis screening, providers should use either "reverse screening" (Figure 1) or traditional screening algorithm (Figure 2), following their clinic protocol.- For more details, refer to CDC: Sexual and Reproductive Health | Refugee Health Domestic Guidance.
- For those with a recent history of treated syphilis: Perform nontreponemal serologic reevaluation for all adults at six and 12 months after treatment (and also at three, nine, and 24 months if HIV positive and treated for primary or secondary syphilis) and for pediatric patients every two to three months after treatment until tests are negative, following CDC: Syphilis STI Treatment Guidelines. More frequent evaluation might be prudent if follow-up is uncertain or if repeat infection is a concern and additional follow-up is required for neurosyphilis. It is important to help the patient establish a primary care home.
Best practices
- Review local confidentiality laws with all adult and adolescent patients and explain how confidentiality covers sexual and reproductive health histories, examinations, and testing.
- A complete evaluation for all STDs includes a thorough medical history, physical examination, and testing as appropriate, as many infections are asymptomatic. The optimal medical history includes asking about sexual history, including any contact with a person who has, or had, a known STD, and asking about any history of signs or symptoms suggestive of an STD. This is usually done with the patient alone, rather than with other family members present.
- External genital exams are an important component of the refugee health screening for all pediatric patients. Providers should explain the exam to children and caregivers, particularly mothers, and obtain consent. Caregivers and/or the child may request to defer the genital exam for a future visit, with assurance that timely follow-up will occur. The deferred exam should also be documented.
- Start conversations on FGM/C with information-gathering questions before more intimate and sensitive questions, framing questions carefully so that the patient does not feel that she is being interrogated. A thoughtful and open approach will allow clinicians to discern the patient’s awareness and of FGM/C (some individuals may not be aware that they have undergone the procedure), level of concern, cultural value of the practice, and health goals. Clinicians engaging in this dialogue are encouraged to use silences and allow for patients to take their time responding to questions. Clinicians should educate patients and caregivers (in pediatric cases) about possible medical complications related to FGM/C, including the need for urgent evaluation if signs or symptoms of urinary obstruction or pyelonephritis develop. If complications are identified, refer children to a gynecologist or urologist with experience caring for children with FGM/C.
Background and epidemiology
Female genital mutilation/cutting
Some refugee women and girls may have experienced, or be at risk for, female genital mutilation or cutting (FGM/C). The World Health Organization (WHO) defines FGM/C as any procedure that involves partial or total removal of external female genitalia or other injury to female genital organs for cultural or nontherapeutic reasons. FGM/C is a cultural custom, not a religious tenet. FGM/C is deeply ingrained in some cultures and is not isolated to one ethnic or religious group. It is estimated that more than 200 million women worldwide have undergone FGM/C. The age at which FGM/C is performed varies among countries, as well as communities. In some instances, FGM/C is performed in children from infancy to 5 years of age, but in others, FGM/C is performed in older girls and adolescents, and rarely, just prior to marriage.
FGM/C has been reported in more than 30 countries, including numerous countries where refugees originate: UNICEF: Female Genital Mutilation (FGM) Statistics. The majority of cases occur in parts of East and West Africa, as well as select countries in Southeast Asia, North Africa, and the Middle East. FGM/C has no known health benefits and can result in both immediate and long-term sequelae. FGM/C is associated with many health complications including severe bleeding, difficulty urinating, cysts, and infection (including viral hepatitis and HIV), as well as complications during childbirth and increased risk of newborn death. Due to the time between when the procedure is usually performed and US arrival, US clinicians are more likely to see patients with long-term complications. The WHO has defined 4 types of FGM/C: types I and II (sometimes referred to as Sunna), type III (also known as pharaonic), and type IV. Refer to CDC Table 3: FGM/C Types and Clinical Description.
When discussing FGM/C with patients, it is critical that clinicians employ a non-judgmental, straightforward approach (e.g. asking about history of “circumcision or cutting” as one of many questions when obtaining past medical history), and should be knowledgeable about FGM/C, cognizant of their own views on FGM/C, and aware of how their opinions may affect verbal communication and body language.
It is critical to develop relationships with social service agencies and health professionals who have expertise in working with FGM/C-affected communities. These relationships can help facilitate timely referral, answer questions, provide additional counseling and information, and address health concerns as they arise. Referrals should be documented in the medical record, in addition to findings of FGM/C and ICD-10 code, as well as documentation of communication with all providers involved. Women and girls who have undergone FGM/C may require a care team including any of the following specialists: obstetrician/gynecologists (including adolescent gynecology), urogynecologists, urologists, sexologists, mental health professionals, and physical therapists.
Overseas Screening for STDs
The overseas medical history and physical examination includes a review for signs and symptoms consistent with STDs; however, many STDs may be asymptomatic. Routine laboratory testing for syphilis and gonorrhea is performed for all applicants 15 years of age and older. Applicants younger than 15 years of age are tested if there is reason to suspect infection, or if there is a history of infection. Syphilis serologic testing (including confirmatory testing, if warranted) is done according to the CDC: Syphilis Technical Instructions for Panel Physicians.
An external genital exam is not routinely performed unless there is a medical history suggestive of recent syphilis diagnosis, physical examination findings consistent with early syphilis (e.g., rash, oral lesions), or positive nontreponemal and treponemal test results. Gonorrhea testing is done according to the CDC: Gonorrhea Technical Instructions for Panel Physicians. Chlamydia trachomatis testing is not required (as it is not a disease of public health significance under 42 Code of Federal Regulations Part 34). However, many panel physicians use testing kits that screen for both chlamydia and gonorrhea. When these tests are used, panel physicians are directed by CDC to document the test results in the remarks section of the DS-3026.
Chlamydia and gonorrhea are the first and second most commonly reported STDs in Minnesota, respectively. In 2020, 21,942 cases of chlamydia were reported among Minnesotans and 10,217 cases of gonorrhea. The majority of cases occurred among teens and young adults 15 to 24 years of age. Current data for Minnesota is available at STD Statistics.
In 2020, 1,093 syphilis cases were reported in Minnesota. While infections were centered within the Twin Cities metropolitan area and males, particularly men who have sex with men, the presence of syphilis among females of child-bearing age is of concern.
Among refugee arrivals to Minnesota from 2009-2019, 7,130 (36%) were tested for gonorrhea, and 7,329 (37%) for chlamydia at their post-arrival RHA. The most commonly tested age groups were adolescents and adults 15 years and older. Very few refugees tested positive for gonorrhea or chlamydia (<1% and 1%, respectively).
Among 20,067 refugee arrivals to Minnesota from 2009-2019, 9,685 (48%) were tested for syphilis at their post-arrival RHA. These excluded 30 individuals who were positive and treated for syphilis overseas. Among those tested for syphilis, 50 (1%) tested positive and were treated appropriately. The prevalence of syphilis was ≤1% among refugees from all regions of origin.
Prevalence of Gonorrhea and Chlamydia among Primary Refugees to Minnesota, 2009-2019
Age at RHA* | Received RHA | Tested for Gonorrhea** | Positive for Gonorrhea at RHA (%) | Tested for Chlamydia** | Positive for Chlamydia at RHA (%) |
---|---|---|---|---|---|
Under 15 | 7,660 | 349 (5%) | 0 (0%) | 353 (5%) | 0 (0%) |
15-24 | 4,491 | 2,457 (55%) | 6 (<1%) | 2,605 (58%) | 36 (1%) |
25-44 | 5,565 | 3,084 (55%) | 2 (<1%) | 3,124 (56%) | 31 (1%) |
45-64 | 1,902 | 1,032 (54%) | 1 (<1%) | 1,037 (55%) | 6 (1%) |
65 and older | 439 | 208 (47%) | 0 (0%) | 210 (48%) | 0 (0%) |
Total | 20,067 | 7,130 (36%) | 9 (<1%) | 7,329 (37%) | 73 (1%) |
Prevalence of Syphilis among Primary Refugees to Minnesota, 2009-2019
Region of Origin*** | Received RHA* | Tested for Syphilis(%)**† | Positive at RHA and Treated (%) |
---|---|---|---|
East Asia/Pacific | 38 | 19 (50%) | 0 (0%) |
Eastern Europe | 778 | 443 (57%) | 3 (1%) |
Latin America/Caribbean | 223 | 151 (68%) | 1 (1%) |
North Africa/Middle East | 1,368 | 806 (59%) | 1 (<1%) |
South/Southeast Asia | 8,531 | 3,745 (44%) | 5 (<1%) |
Sub-Saharan Africa | 9,129 | 4,522 (50%) | 40 (1%) |
Total | 20,067 | 9,685 (48%) | 50 (1%) |
**Refugee Health Assessment (RHA): health screening done in U.S., usually within 90 days of U.S. arrival
**Tested during post-arrival Refugee Health Assessment
***Based on MDH's world regions
† Excludes 30 refugees who tested positive for syphilis overseas and were treated prior to U.S. arrival and then re-evaluated in the U.S.
Resources
- Sexually Transmitted Diseases (STDs)
MDH Sexually Transmitted Disease Program. - CDC: STI Treatment Guidelines, 2021
For an overview of important changes, review the 2021 STI Treatment Guideline Highlights (PDF). - Female Genital Mutilation/Cutting in Children and Adolescents
Open access book and illustrated multidisciplinary guide on FGM/C in children and adolescents.