In Conversation with Dr. Ashley Waddington: On Obstetrics and Gynecology, Access to Care, and Stigma
Sex is everywhere in the media, but no one actually talks about it. This is nothing new, sexual and reproductive health has long been stigmatized and considered a taboo subject by many cultures around the world. Even in today’s comparatively more open society, women still regularly hide menstrual hygiene products, and talking openly about sexual interactions is considered shameful. Despite the prevalence of sex in pop culture and media, we don’t like to talk about sex.
With the academic semester coming to a wrap before the holidays, UTIHI's Speaker Series would like to welcome Dr. Ashley Waddington, an OB-GYN at Queen's University focusing on contraception, family planning, and transgender healthcare. This written interview will debunk some of the common misconceptions about the field, discuss the crisis in healthcare we are facing, and delve into some common barriers to seeking gynecological care.
We hope you enjoy this interview as much as we did!
Dr. Ashley Waddington is an associate professor at Queen’s University in the Department of Obstetrics and Gynecology. She is a general obstetrician-gynecologist, with a focus on contraception, family planning, and transgender health. In July 2017, Dr. Waddington opened the first clinic for transgender patients in Kingston out of her practice at Kingston General Hospital, serving the local community. This clinic has since expanded to become the Kingston Trans Health Clinic, operated by the Kingston Community Health Centres (KCHC) in collaboration with Queen's Family Health Team and the Kingston Health Sciences Centre (KHSC) Gender Clinic. Dr. Waddington is also the co-director of the CARE (Contraceptive Advice, Research and Education) Fellowship program, Canada’s only Fellowship devoted to contraception and family planning, training the next generation of specialists in the field.
Can you tell us a bit about yourself and your practice?
My name is Ashley Waddington and I'm a general OB-GYN but my practice mainly focuses on contraception and family planning. I also run a fellowship program in contraception and family planning called the CARE fellowship (Contraceptive Advice, Research and Education), training new specialists in the field.
A more recent part of my practice is transgender health care. I started to get more referrals coming into my contraception clinic for menstrual suppression for gender dysphoria, or surgical procedures for gender affirmation. It became evident to me that there is a need in our community for somebody to provide that care. I prescribe a lot of hormones in my contraception practice for a variety of reasons, and [transgender health care] is just an additional way of prescribing hormones to meet someone’s health needs.
What is obstetrics and gynecological care?
Obstetrics and gynecology is a broad field. The obstetrics side mostly focuses on pregnancies and patients who are trying to or trying not to reproduce. The gynecological side has more to do with all of the organs that exist in somebody born with female reproductive organs. This includes managing conditions like urinary incontinence, prolapse, endocrinologic conditions that can lead to abnormal menstruation or fertility concerns, etc. We care for people throughout their entire lifetime, from children who might go through precocious puberty all the way up to elderly people who might be experiencing things like reproductive cancers, or menopausal symptoms that needs to be managed. So, it's a very broad specialty, which is one of the things that makes it very exciting.
What are some common misconceptions about your field?
One that often comes up is that people don't always recognize that it is a surgical specialty. We are fully trained surgeons and provide surgical care from things like C sections and hysterectomies, to surgeries to remove cancers. We also have a lot of interesting subspecialties like Gynecologic Oncology and Reproductive Endocrinology. As you can imagine, there’s a lot of reproductive tract cancers. Not only do gynecologic oncologists do the surgical procedures to remove malignancies, but they also manage the chemotherapy, so they’re both surgeons and medical oncologists. Reproductive endocrinologists work with hormones to try to get them to behave in a certain way or to prevent them from causing harm or other unpleasant conditions.
Obstetrics and gynecology is a very procedural and hands-on specialty, and many people don't recognize the level of knowledge and skill that goes into it.
How accessible is gynecological and contraceptive care in Canada?
There is a crisis in access to healthcare in Canada and it has been brewing for decades. Our healthcare system is underfunded, and our workforce can’t keep up with the needs of the population. It's not just that we don't have enough OBGYNs, we don't have enough trained nurses, or surgical wards either. That manifests itself in long wait lists to see an OB-GYN, and then long waitlists for surgical procedures. Now, obstetric care can't wait, a 10-month waitlist won’t work for them. So, what happens when you have high volumes of obstetric patients, is that you see fewer gynecologic consultations. We’re always trying to juggle the severity of people’s conditions and providing timely care to patients.
I spend a lot of my time doing clinical work and I see a lot of patients in a week. But the reality is most consultations take 30 minutes or more so you can only see so many patients in a day. Right now, I have the capacity to see about 20 to 24 new patients per week and an additional number of follow up patients, but I'm receiving between 50 to 70 referrals per week. The math just doesn't add up.
Right now, I have the capacity to see about 20 to 24 new patients per week and an additional number of follow up patients, but I'm receiving between 50 to 70 referrals per week. The math just doesn't add up
You mentioned that your waitlist is out of control. What are some factors that contribute to the long waitlist?
It’s aggravated by a lack of access to primary care; we simply do not have enough family doctors in Canada to meet the needs of our communities. A lot of contraception care takes place in primary care, a lot of patients can access prescriptions and chronic conditions can be managed through there. Not everyone needs to see a gynecologist, but when you can't access primary care, and you're going through a walk-in clinic or phone based walk-in clinics, you get referred to a gynecologist. I'm happy to see those patients but sometimes that care could have taken place in another setting with a different care provider.
For example, I get a lot of referrals for pap tests which should really be done in primary care. Everybody should have a family doctor that can provide them with their pap tests every three years to find signs of potential cervical cancer before it develops into cervical cancer. But when people don't have a family doctor, they get referred to a gynecologist. I can do paps all day long, but if I'm spending a whole day doing pap tests, that's 20 contraception referrals that I'm not seeing. In a system with limited resources, it doesn’t make sense.
There’s a lot of stigma around reproductive care. Is there a topic in obstetrics or gynecology that you think people should talk about more?
I think our culture and our society has made it uncomfortable for people to discuss their reproductive parts, or their sexual activities and their sexual satisfaction. This results in a broad range of people not accessing care, and it is a real problem in our field.
We have people who are too embarrassed to talk about their menstrual periods because they've been taught that it’s shameful or embarrassing. They might suffer from painful or heavy menstrual periods that are really disrupting their quality of life, but they don't want to bring that up with a physician or healthcare provider. They may also just not know that there are options available because people don't talk about it. Same thing with sexual concerns. People are having unsatisfying sexual interactions; perhaps it's painful or they're unable to achieve orgasm, or they're having challenges achieving arousal, etc. But again, people don't bring that forward because they think that they're going to be shamed or judged for asking those questions.
[T]here's a lot of stigma around abortion care...[a]bout one in three reproductive age women will have an abortion at some point during their lives... I expect other healthcare fields...don't deal as much with the kind of stigmatization that we see
Obviously, there's a lot of stigma around abortion care where people are judged for seeking it, even though it's very common in Canada. About one in three reproductive age women will have an abortion at some point during their lives, but people consider it shameful or something that you can't talk about. I expect other healthcare fields like cardiology and oncology probably don't deal as much with the kind of stigmatization that we see, particularly around female reproduction and female reproductive parts.
With all of the stigma around this subject, there must be a lot of patients who don't even make it on to the wait list. What options do those patients have?
I think all of us would love to be able to do more patient outreach or advocacy, but it's hard to advocate for more patients to seek medical care when that care is not available. When I went into medicine, I had the heart of an advocate—I really wanted to be somebody who could advocate for better access to care, for better care in general. But you get bogged down with the patients in front of you and it’s hard to go out and educate the public and help people recognize the things they can do. There are some good websites that are directed at patients to help them understand things like their contraceptive options, or what normal menstrual periods are like, and what would be concerning, and when to seek medical care.
As a clinician, you feel very guilty taking a step back from your patients to do something else that might try to advocate for better patient care, when the most obvious need is that binder full of referrals that my secretary has in her office. Part of our role as a physician is to advocate for our patients. But in a healthcare system where there's a constant avalanche of patients who need to be seen, it's very hard to get your head above water and find the time and the energy to do so.
This interview was edited for length and clarity.
Contraception/sexual health resources:
Menstrual cycle resources:
letstalkperiod.ca (specifically for heavy menstrual periods)
Gender diversity and LGBTQ2S+ resources: