Pelvic exams are really hard for a lot of people.
That statement should be self -evident, but I have had enough pelvics, and certainly conducted enough with other providers to know that not every midwife or physician truly understands this. Not just pays lip service to it, but truly understands how traumatizing and re-traumatizing the pelvic exam can be. For those of you with limited exposure to pelvics, or those of you who don’t have a vagina, I’ll provide you with the basics of what we do:
1) The external exam. Examine the external genitalia, make not of any sores, irritations or cysts.
2) The internal exam, conducted with either a plastic or a metal speculum. This is how we look at the vaginal walls, look at discharge, and look at the cervix and take any samples we might need to take (i.e.: pap smear, wet prep, or STD testing samples)
3) The bimanual exam. Here we insert two fingers into the vagina up to the cervix, check to make sure that it doesn’t hurt to move or touch the cervix (a sign of pelvic inflammatory disease), and feel the size, shape, and consistency of the uterus and ovaries.
Conducting a seamless, painless, and comforting pelvic exam is an incredibly difficult thing to do, and one of the arts that is difficult to pick up as a student. Each midwife develops her own rhythm and style for the pelvic, and each woman has vastly different needs during a pelvic exam.
A while ago I read a piece on the Feminist Midwife about how she conducts pelvic exams, and shamelessly stole the words she uses before starting her exam. She looks each woman in the eye and states. “I’m going to start the pelvic exam now. I want you to know that you’re completely in charge of this exam, and if it hurts or you want me to stop at any time, tell me to stop and I will stop.”
I use these words as often as I can, and with each woman I feel a small sigh of relief, or even sometimes surprise. One woman gave me a sharp laugh. I must have given her a quizzical look because she looked back at me and said, “No one has ever told me I was in control during one of these. They hurt me a lot, but I just endure them.” It turned out that she was having pain during intercourse, and thought that was a normal part of menopause that she also had to endure. So we talked about strategies to increase her pleasure and how her and her partner could make sex enjoyable for her again. Talking about how the pelvic exam feels can give a provider important information on their patient, and few providers I know talk to women about this.
The exams that are the most difficult are the ones in which a woman has a history of sexual assault. With one in four women being survivors of sexual assault, I find it one of my most important tasks that I never retraumatize a woman during a pelvic exam. When a woman discloses that she has a history, my immediate follow up questions are, “Are pelvic exams difficult for you?” (most often always yes) and if so, “Are you prepared to have a pelvic today? We don’t have to do it today if you’re not ready.” After providing these options, I have only ever had one woman tell me she wasn’t ready. And that one response is the reason that I ask every time.
A few months ago I was conducting a pelvic exam on a teenager, and it was her first exam. I absolutely love doing women’s first exams because studies show, unsurprisingly, that a woman’s first experience with a GYN health provider is likely to color her opinion of pelvics for the rest of her life, significantly impacting her follow-up and continued screening in the years to come. I like to show the woman the speculum, let her touch it if she wishes, and I explain everything I’m going to do before I do it, as well as while I’m doing it. I’ll never forget the look on her face as I told her everything looked healthy and normal and that she could sit up. She looked at her boyfriend, and said, “Woah, that was totally not that bad! I don’t know what everyone’s talking about!”
Earlier this week, I conducted an annual exam with a woman and simply explained every step of the way through the process, how many things I still had to do, and when we were going to be done. After she got dressed, she said, “It’s so nice to know everything that’s going on.” I thought for a moment and just replied, “Well, that’s the way I would want it to be done for me.”
In that moment, I took a step back and used it to remind myself of all the pelvics that I have had over the years. What was done to me? What did I wish had been done differently? I had a wham-bam-thank-ya-ma’am OB/GYN in high school, and in graduate school a provider who tried to do patient education while still doing the exam. For a lot of OB providers, we often forget that while we conduct pelvic exams all day long, and are immensely comfortable with them, each time a woman has one is a vulnerable, impressionable experience that will make her either very likely or very unlikely to come back for follow-up care.
These are the moments I absolutely live for in giving women options and proceeding slowly through my pelvic exams, and I feel as though I am a feminist incarnate. I try to practice applied feminism: giving women the control of their bodies that has been so long denied to them, even in the exam room.