Pediatric and Adolescent Gynecologic Problems Continue During the COVID-19 Pandemic.

Greetings, dear readers, from shelter-in-place COVID-19 land, a very different place from where we all were (literally, and figuratively) when I wrote my last editorial on Pediatric and adolescent gynecology (PAG) in the time of a pandemic. Most of us are still reeling from the many changes that COVID-19 infections have necessitated.

Some of you might have been infected yourselves. Others have had family members who were infected, and some of you have undoubtedly lost friends, colleagues, family members, or patients to complications of the viral infection. My heart goes out to you. This is a time of tragedies. Together we mourn.

The economic consequences of the pandemic are also widespread and devasting, particularly to our most vulnerable populations—people of color and those who are economically disadvantaged. When I chose to go to medical school, I remember thinking that I would always have a job. Illness and suffering are part of the human condition, and physicians, nurses, and other healers have been needed throughout time, and are especially needed today. Some of you who care for adults as well as children and teens are still in the thick of COVID-19 infections. I am fearful that the policies of “opening up” that are being promoted by many politicians are happening in the context of still rising rates of infection. When we listen to the authorities who base their recommendations on science, we hear that the effect will be even greater numbers of infections and deaths.

The current effect of COVID-19 on our PAG patients here in California is determined by the fear that parents have of coming to our offices and hospitals. COVID-19 infections in the San Francisco Bay Area appear to have peaked, and the surge in adult patients was mostly avoided through early shelter-in-place orders. Fortunately, children and teens appear to have less severe infections, although concerns about specific morbidities are being raised. But unfortunately, “routine” healthcare is now being neglected, sometimes with the results that patients with emergent problems present later than they otherwise would. Although our operating rooms are now open, patients and families are still deferring the surgeries that had been postponed. I am eager to institute some of the elements of enhanced recovery after surgery that are described in this issue of the Journal of Pediatric and Adolescent Gynecology (JPAG). Our patients are still experiencing the usual PAG concerns that are also addressed in this issue: symptomatic labial adhesions, prepubertal vaginal bleeding, chronic pelvic pain, sexually transmitted infections, issues related to contraception and induced abortion,9, 10, 11, 12, 13, 14 adnexal masses, , differences of sex development, and Müllerian anomalies, , among many other problems. The NASPAG Position Statement, published in this issue, highlights the ongoing reproductive health needs of adolescents during a pandemic, including the need for contraception and confidential healthcare, even when using telehealth platforms.

This issue's Review article on dating violence and its implications for girls' sexual health provides definitions of dating violence and its many manifestations, estimates of prevalence, and reminders of the severe consequences of morbidity and mortality, but also the complex links with behaviors. The author notes that adolescent girls with a history of sexual coercion are more likely to engage in sexual risk behaviors and vice versa.

This review reminded me of past PAG patients. I recall from years ago, the saga of a physician's daughter who was terrified of her ex-boyfriend, who was stalking her. The psychological aggressions that she described included manipulation and coercion, which she ultimately recognized. Reproductive coercion might not always be recognized. One of the reasons that I devised my structure of a first gynecologic visit in which I speak first with the adolescent and her parent (usually mom), then with the parent(s) without the teen, and subsequently with the adolescent confidentially, completing the visit all together, with a summary of the visit (sometimes with parameters elicited from the teen about what is permissible to share with the parent), is that I learned how valuable the parent's perspective can be. I remember one of the first moms who opened my eyes to the value of a parent's perspective when mom described her daughter's boyfriend as belittling her and undermining her daughter's self-esteem. I realized that had I spoken only to the daughter, I might not have heard that assessment.

Experts tell us that during the pandemic, intimate partner violence and child abuse may be more easily hidden with families in isolation. , The pandemic is clearly leading to high levels of stress, and more domestic violence might be the result. We need to keep these issues in mind; as physicians, we might be the only ones to observe these effects.

Please continue to stay safe in COVID-19 times. May JPAG inform your clinical care.