the unethical methods used by medical and nursing schools to teach students how to perform pelvic exams; the most egregious being on unconsenting, anaesthetized women.

Wow. I...hate these people. I really do. I thought we'd all settled the question of whether or not being unconscious due to drugs meant that random people could grab my genitals.

Also--that is crappy training! Examining the pelvis of an anesthetized, unconscious woman is nothing like examining the pelvis of a wide awake woman who is capable of moving around, objecting to what you're doing, having memories that make your actions disturbing, and, you know, feeling pain.

"At Your Cervix breaks the silence around the unethical methods used by medical and nursing schools to teach students how to perform pelvic exams; the most egregious being on unconsenting, anaesthetized women."

The first thing that came to mind was "oh hells no." I'm still working on something more eloquent...

...EG pretty much covered it already.

Although at my last annual I kind of wish I was anesthetized. Or at least drunk.

On that note, a plug for midwives! Contrary to what many people believe, you can go to midwives for well woman care. Pap smears, pelvic exams, birth control etc. I find they are really great, attentive and also have some expertise in non-traditional treatments for things.

I'm a second year medical student, and I just performed my first gyn (practice) exam a few weeks ago. Before the session, we had a discussion about patient-centered care, and had a reading (linked here). The horror story of examining anaesthetized women is scary, but more or less defunct at reputable medical schools.

At my school and many others, professional (and well paid!) standardized patients help students learn the pelvic and breast exams. The woman I worked with was extremely experienced, direct, and took an active approach to teaching us students. Most importantly, she was funny! I can't imagine learning to perform such an intimate and emotionally complex exam when the patient is asleep.

[The article is in the New England Journal of Medicine, so you might not be able to see it. If you want a pdf, I can tell you how to get one. :o)]

That's good to hear, novinda, and I'm so glad that there are medical students and doctors like you who understand the complexities of these exams. I know that when my doctor was being shadowed by a med student or a novice doctor (I forget the exact title) I didn't mind giving permission for her to practice an exam on me (with the doctor supervising, of course!). I completely understand that everybody needs practice--as long as we're all conscious and consenting!

novinda, what does "standardized patient" mean exactly in that context?

Contrary to what many people believe, you can go to midwives for well woman care.

I will totally be checking into this the next time I need a pap smear, etc.

I've a a few annual pap smears now, with my GP practice before I moved (from West Michigan, now in Boston). I actually had pretty decent experiences with both my nurse practitioner (a woman) and my GP (a man) . . . at least when it came to physical comfort and respect. But I like the midwifery model of care for women's health, so it would be nice to be able to make use of their services before I'm in need of prenatal or birthing support :).

The first time I had a pelvic exam was funny because this really sweet British nurse who worked a the office came in beforehand and took my medical history, and when she'd found out I'd never had intercourse she was like, "oh, well we'll get you a smaller one of these!" and replaced the speculum they had sitting in the warm water. I was like, "uh, okay, whatever." I think they were used to girls who were really weirded out by the whole thing.

Standardized patients are community members trained, and paid, by medical schools to assist in the education of med students. Sometimes they play a role so we can practice how to approach a certain patient (for example, a patient being physically abused by her partner who presents to her primarmy care doc). Sometimes they help us learn how to do exams, like pelvics or prostate exams.

I'll second that in my experience as a med student (I'm finishing my 4th year now), doing a pelvic exam on an unconsented anesthetized patient does not occur any more.

The times that I have done a pelvic on an anesthetized patient is when a woman undergoing gyn surgery consented to having a med student be part of the team taking care of her. If a pelvic needed to be done before the surgery could start (for example, to place certain instruments), I would often be the one to do that.

At my med school, we actually had a meeting with our Dean to discuss the ethics of this.
An awesome feminist med student made the excellent point that if a woman agreed to have you as part of surgical team taking care of her (meaning that you're going to have your hands in her internal sexual organs), why was it necessary to specifically as if you could examine her external genitalia as far as it was needed for the procedure.

I concur with everything novinda said.

When I was in med school, I had an extremely professional and sensitive course on the breast\genital\rectal exam (for both males and females). The utmost attention was paid to the aspects of appropriate language, behavior, interaction, symbols, etc.

Here are some examples of things we were taught that I think the readers of this post will find very interesting and informative:

Never say "stirrups". instead you should say "foot rests". Never use euphemisms to refer to parts of the genitalia (e.g., it is highly inappropriate to say “can I examine your ‘dick’, rather you should say “can I examine your ‘penis’). Never leave a patient un-draped. Don’t use cold equipment. Ask permission before any procedure. Explain every procedure before you do it. E.g., "For this next exam, I need to examine your vagina, cervix and ovaries. It involves my inserting one finger into your vagina, you may sense some coldness from the lubricant, and you might feel some discomfort from the pressure. Do I have your permission to do this exam?".

Etc.

A major part of the course was taught by these extremely talented, professional actors who taught us how to conduct the exam. I imagine these actors are just like the actors from the agency referred to in Miriam’s post. They would teach us in small groups of 2-3 students per actor over the course of several hours. One evening was spent on the female exam (exclusively with female actors) and another evening was spent on the male exam (exclusively with male actors). Those actors hop from med school to med school around the country teaching this course. That training was amongst the clearest, most respectful, insightful, and useful training I received in med school. As novinda mentioned, these actors are extremely expensive—reason being b\c they’re fantastic teachers and are small in number.

Sadly, though, sensitive training is one thing and reality is another. I don't think reality has come even close to matching the standard set by that type of training. It's good to know, though, that an improved standard is being taught at many medical schools around the country. Change has to start somewhere!

Okay, so I totally misread that title at first. I thought that there was a documentary taking place at my cervix. I was halfway to reaching for my hand mirror, when I began reading the rest of the article and realized that I made a mistake.

I'm facinated and pleased to read about the intensive small group training that goes on for these exams. It sounds like a good way to learn for the med students.

But cervical exam actor is going on my list of worst jobs ever! I can't imagine spending my days going from med school to med school having pap smears and similar procedure!! Wow - I don't like going to my GP every couple of years and he does a very good job.

when she'd found out I'd never had intercourse she was like, "oh, well we'll get you a smaller one of these!" and replaced the speculum they had sitting in the warm water. I was like, "uh, okay, whatever." I think they were used to girls who were really weirded out by the whole thing.

Actually, it's not a comfort issue; it is a SEVERE PAIN issue.

I used to have a doctor who would not use a small speculum. She kept telling me to "just relax" and "it will be over soon." If she was feeling really nice, she would warm it up for me. Well, that's great, but tampons hurt me, so a little warm water isn't going to do much to alleviate my discomfort.

Many doctors refuse to perform trans-vaginal ultrasounds on virginal women; again, it's a pain issue, not a comfort issue.

I once woke up for surgery aching down there. I had no idea when they put me out that there would be a need to insert anything into my vagina, so I can say with a high degree of certainty that it's not an emotional comfort issue when you're anaesthised.

Thankfully, the doctors at the Student Health Center order speculums made for teenagers (as there are mostly undergrads here), which are significantly less painful.

As the 4th med student to post on this thread, let me state once again that unauthorized pelvics during anesthesia are a thing of the past. SPs are used nowadays.

But cervical exam actor is going on my list of worst jobs ever! I can't imagine spending my days going from med school to med school having pap smears and similar procedure!!

Most med schools have to do a fair amount of recruiting for this position, and it pays quite well. I think our school pays about $300 for each exam.

Actually, it's not a comfort issue; it is a SEVERE PAIN issue.

Good to know, oenophile. I didn't mean to make it sound like this was a dumb thing for them to do--it just seemed funny to me at the time, in my late teens. It had never occurred to me that there would be a difference. And it was mostly just the "just-between-us-girls" way she handled it.

I cannot wait for this documentary to come out! I am a Gynecological Teaching Associate (and a Standard Patient, they're two different things here), and I love the work. Not only well paid, I also feel really good about what I do. I think the concept is pretty revolutionary, that women can teach medical students how to perform excellent breast and pelvic exams. Our stated purpose within the curriculum is awesome too: to educate students on performing woman-centered exams.
We cover language use (as someone mentioned above) and patient comfort, as well as the logistics of the exams. We work with about 3-4 medical students per session and try to keep things informal. Especially important, I believe, is that we teach medical students to ask patients if they feel safe in their relationship. And we teach the "power statement," which states that while the exam might be uncomfortable, it should never hurt, but if it does hurt to speak up and the clinician will stop. Essentially, we try to instill future physicians with the attitude that the patient should be in control of what is happening to her body.
The only that bugs me is when students close the speculum too quickly and pinch my cervix. That hurts!

This topic is so important. I have to say that I have a huge hang-up with getting my annual pap. So much so that I avoid it a lot. I always think that I am a great advocate for others but when it comes to me and standing my ground, it's as if I am mush and all of my assertiveness fizzles. Like oenophile, I have pain issues. And the last exam I had was so horrible, I had a break-down afterwards. I specifically asked for the doctor without any medical student present. I know they need to learn, but I have a right to have them in the room or not...or so I thought. When I again repeated myself, this look passed between them and - sigh, after a lot of things were said that I still don't understand, I ended up with a med student and an assistant in the room. A room used by others that wasn't locked. I asked if it would be, so no one else could enter since my angle basically gave an entering person a clear shot of my lower half. I was reassured of that, but we were interrupted several times by others who didn't knock and came in. The assistant directed the med student...who did something wrong. It hurt so bad I cried...they freaked out and got the doctor, I was left alone to get over my nervousness. I had people there I didn't want, a bad room, and was in pain. I thought the doctor would be sensitive, but he then took it upon himself to bring in other med students to show them the mistake the student made. I wasn't really there, I had to pretend I was elsewhere. I was made to feel like some weird specimen being stared at, uncomfortable, shaking, and in discomfort. And to top it off, the med student said "yeah, she has a lump in her breast, too" not even directly to me! It turned out to be nothing, thank god. Breast cancer runs in my family.

I was really hard on myself afterwards for not standing my ground. I don't go to that clinic anymore, and I should've gotten an exam by now, but I honestly can't bring myself to deal with even the possibility of that situation again.

I know this is a long comment, but let me finish with a request to all the med students who read this and have piped in...some women such as myself are simply not comfortable with multiple folks being in that room for that exam. Please make sure you honor their requests. At the very least, ensure her body language indicates that she's ok with you being there. But it already sounds like those who are here do that, so...pass it on?

Pap smears can be pain-free?!? glee!!!

I also use a midwife for "well visits" and both I've had were lovely people, happy to discuss anything I wanted, and made it as painless as I thought it could be. Not pain free, but pain minimized.

The physician who did my first-ever pap smear when I was first getting birth control pills, she wasn't quite as nice about it. Not much pain, but it felt a lot less emotionally comfortable somehow.

The best way to get your annual exam is with a person you trust. For me, that's my midwife. I hope that physicians and nurses all over can be educated to treat this procedure with the thoughtfulness it deserves, for the comfort of all women!!!

Interesting ideas here. I have stopped going for pelvic exams and pap smears, and at 38, I've already been through many and also had a LEEP procedure at one point.

I just got fed up with it. Fed up with the pain, and no matter how much I try to undo the social conditioning centered on "spreading your legs" and "letting people stick their fingers in there" and all the other shame women are taught to feel about their bodies, at the end of the day, I look at the risk and think, "fuck it." I don't care if I die from cervical cancer.

Society has always hated my vagina and uterus for as long as I can remember, so if it kills me, I suppose that's some validation to the hatred. Which is, for me, a bit easier to take than just being hated for no reason at all. If that makes any sense.

Add to that physicians who have not so delicately shoved cold metal speculums into my vagina, scolded me to stay still while they sliced through my unaanaesthised cervix, and other assorted charming experiences associated with pelvic and gyn exams, and I'd rather have my gums scraped for the money. I'm at more risk of dying from a heart attack anyway. At least that's what comforts me.

My God, Jem. I'm so sorry.

If anyone's interested in a book on a similar topic, I really recommend Public Privates: Performing Gynecology from Both Ends of the Speculum, by Terri Kapsalis. It starts with the history of the speculum (invented by a slaveholder who operated on slave in his backyard "clinic," trying to repair fistulas) and then moves into a discussion of some reproductive technology and gynecology as a performance. It highlights the role the doctor and the patient are expected to play, and the power dynamics inherent in them.

Weirdest Request Ever:

For all of you doctor types out there:

How do you BECOME a Standard Patient?

I'm a poor grad student with a great background in anatomy (I TA'd Gross), I've had 2 kids, and I am a Happy Cervix/Vagina Person. My campus has a huuge medical school, and I'm already accustomed to having students perform exams on me.

Wow. Horrifying and violating. Furthermore, it's not particularly helpful to students in the long run. As doctors, they will be dealing, at least part of the time, with patients who are awake. A doctor with no people skills is an incredibly poor one. (The show "House", while entertaining, is fiction.)

This form of patient assault is also unnecessary. There are women who will, if asked respectfully, allow the presence of a student or two. Years ago, I had an excellent gynecologist. When he informed me that he had taken on a student, I was pretty happy to see that he was giving someone else the benefit of his knowledge and experience. I consented to the student's presence in the room AND to her giving me a pelvic under the doc's guidance. She has definitely graduated by now. If she has combined her knowledge with his bedside manner, she has no shortage of patients.

Wow! Big thanks to Miriam for posting about our film, "At Your Cervix," and our upcoming event in DC/Maryland on Feb 15. It's super great to see all the comments about the post, the issues the film raises and medical education in particular. We began the project with our focus on the GTA work, which is feminist work we are all super committed to. But as we rolled out how to tell the story, it became clear that viewers would need the cultural context and the "alternatives" in order to fully appreciate why it's so important. The more we have researched and interviewed folks, the more disheartened we have been to find that actually, it is still quite common for students to practice on anesthetized women--we have a number of people talking about this practice on camera--and that major institutions and organizations have avoided making strong statements or policies against the practice. We still have a long way to go and our film is a part of our commitment to changing these practices from the inside. It starts with docs/nurses being unwilling to ask students, and with students being unwilling to do it if it's unclear whether the woman has consented.

I am sorry to hear of the experiences that some of the readers wrote of and our hope is that people will begin to demand more of these exams and realize we don't have to accept sub-standard care! I would not work as a GTA if I went to work and got hurt. GTAs are living proof pelvic exams should be comfortable. I know it's hard to believe for many who haven't had that experience.

If you are in or near DC next weekend, please come out and you'll see some new clips we've been working on. If you can't please do check us out at www.atyourcervixmovie.com. We'd love to have you on board with us. We really need financial support to finish our film so if you can pitch in at all, please know it will be greatly appreciated.

Warmest Regards Feministas!
Amy Jo Goddard
Director/Producer, At Your Cervix

"I think our school pays about $300 for each exam."

Wow. My university in the 80s paid only $11 an hour. And in nursing clinical rotations, naturally we were examining women including postpartum, for free, with their permission.

"Weirdest Request Ever:"

Not at all. If I believed it was safe and dignified, I'd try it myself if I could. Normally, I'd need to work about two shifts or two days just to make $300. Damn.

AnneThropologist,

I became an SP and GTA after I saw a sign posted on my campus. I work through a local hospital and was trained by the director of the program and other SPs and GTAs.

You might check if the medical school on your campus has an "Office of Medical Education." They would be the folks to get in touch with if you're interested in being an SP.

Sorry about the duplicate posts (which are also somehow under an incorrect ID, and should've shown up under "moominmuppet" instead).

-- from a friend of moominmuppet's.

Sorry about the duplicate posts (which are also somehow under an incorrect ID, and should've shown up under "moominmuppet" instead).

Experiences with three doctors (one funny, one not, one good):

First pap and first gyno: I was eighteen and terrified. While the doctor was in the vaginal part of the exam, she asked, "Do you smoke?" I replied, "Whuh? Yeah." After this, she continued to lecture me about smoking -- with her fingers and a speculum in my vagina. I kept thinking, "What does that have to do with THAT?" Now, I've quit and I'm older and I think this story is kind of funny, though she was still rude. For whatever reason, I associate this with the image of a cigarette-smoking vagina.

Pap and Doc #2: Whoa. This guy was rough. I mean, I felt like he was trying to pull a hair clot out of a drain. I experienced a lot of pain in the exam and he didn't speak once during the exam, leaving me clueless as to what the hell he was doing.

Doc #3 (who I have had many exams with): She is AWESOME, and I told her that after my last pap. (I've been seeing her for many years.) She replied that she had a very traumatic first pap herself and knew afterwards that there had to be a better way. She conducts the entire exam without the slightest discomfort and is very quick. She talks you through the exam and keeps you physically and emotionally comfortable. When I consider moving in a couple of years, I always think about how much I'm going to miss this Gen. Prac. doctor who has always been respectful, informative, practical and kind.

Like others, I'm interested in the practices of a midwife for well care. How can one find one nearby? Please keep in mind that I'm in Kentucky.

I have my yearly gyno exam on Feb 14, so I think it's kind of appropriate considering it's V-Day. I know last time I went in, the doctor was very professional and respectful... considering it was my first exam it went very well. I moved so I'm going to a new clinic and I hope everything works out well.

I'm excited to be taking my vag out for a date on Valentine's Day... figures, since my boyfriend sometimes thinks I love it more than him.

Years ago, I had an excellent gynecologist. When he informed me that he had taken on a student, I was pretty happy to see that he was giving someone else the benefit of his knowledge and experience. I consented to the student's presence in the room AND to her giving me a pelvic under the doc's guidance.

Would you have been as willing if the med student was a male?

The first time I went to my last gyno, she seemed (at first) really cool and down-to-earth. She tried to get me relaxed by talking randomly about movies, BUT, she picked some story about a date she went on with a guy when they saw a double header of Clockwork Orange and Deliverance and how scary and disturbing those films were to her and how they made her never want to have sex again. And delivered this news while surprising my rectum with an exam after the pap! WTF?! She apologized for not warning me about the rectal exam beforehand after I basically shouted, but still...In retrospect, I think she was not comfortable herself with being explicit about what she was doing, and instead got chatty and weird. I would have MUCH preferred her to acknowledge what the hell she was doing and include me in that process. It is my body after all, sheesh!

I wish that novinda was right, but as of two years ago, when I got my tubal, the University of Wisconsin-Madison hospital (which as far as I know is quite a respectable institution) still did pelvic exams on anaesthetized women, without their knowledge. I brought the issue up to my surgeon ("umm, this might sound crazy, but I heard on some TV program that this happens...") and he said yes, there would be students giving me a pelvic while I was out--why, did I not want them to?

I told him that I didn't mind now that I knew, but I was very mad that I wasn't asked for my permission first. I have no problem with students participating in my care, as long as I'm able to make an informed choice about it.

Apparently, when patients sign consent forms for gynecological surgery in some teaching hospitals, they're allowing students to perform "related" functions: exams, etc. My surgery, by the way, did not involve my vagina or cervix--it was laparoscopic, one insertion through my bellybutton and another in my abdomen. In this case, a pelvic wasn't necessary for my care. It was done solely for the benefit of the student(s).

And I still have a problem with how doctors give exams when I AM conscious: what's up with the paper curtain, shielding me from viewing what's going on down there? Is it because they think we're afraid to see our own parts? Or because if we can't SEE the doctor looking at and prodding us, it's as though it's not really happening? I always move the paper down, so I can see what the doctor's doing.

Gynecological care has a long way to go. I'm lucky that my first gyno experiences were with awesome women who gave me mirrors and were informative and nice, because the experiences I've had in the last 5 years could have ruined me for gynos, otherwise.

To all the women who have said they won't get GYN exams anymore because of poor treatment by their doctors - please reconsider. I had bad experiences with my gyno, the last straw being the way she literally laughed at me when I asked her for information about sterilization and refused to discuss the topic with me because I was "too young and would change my mind" (I was 29 or 30 at the time). I got copies of my medical records, left the practice, and found a wonderful new doctor who now provides me with excellent care. In three office visits he diagnosed me with a condition that gives me a higher risk of endometrial cancer, something my previous doctor never noticed in over 5 years of my being her patient. There are great doctors out there; don't let the bad ones prevent you from being an advocate for your own health.

To all the women who have said they won't get GYN exams anymore because of poor treatment by their doctors - please reconsider. I had bad experiences with my gyno, the last straw being the way she literally laughed at me when I asked her for information about sterilization and refused to discuss the topic with me because I was "too young and would change my mind" (I was 29 or 30 at the time). I got copies of my medical records, left the practice, and found a wonderful new doctor who now provides me with excellent care. In three office visits he diagnosed me with a condition that gives me a higher risk of endometrial cancer, something my previous doctor never noticed in over 5 years of my being her patient. There are great doctors out there; don't let the bad ones prevent you from being an advocate for your own health.

i had no idea what was going on. creepy and so wrong.

i'm going in for my first pap test in a week (i've put it off for over a year b/c due to my amazing fear of doctors, clinics, and anything related-really i'm terrified of a basic physical little alone someone messing in my vag) any advice for a first timer who's terrified? thanks

The most important thing is to make sure your doctor is respectful of you. A doctor who respects you will be perfectly happy to come in, meet you, and chat with you before asking you to take your clothing off. Many, many offices and clinics have the nurse/PA show you in and ask you to strip from the waist down and prop your legs up before the doctor comes in, I guess to streamline the process and make it more time-efficient. But the cost in dignity and human respect to the patient is, in my opinion, immense. If a doctor can't take the time to talk to me face-to-face while I'm fully clothed, but expects me to strip off and open my legs so she/he can just get straight to my vagina without interacting with me as a human being, that doctor is not one I want to see. So you can start by telling the nurse/receptionist that you want to meet with the doctor before you get undressed.

Then a really important thing to do is to tell the doctor "You know, this is my very first pap smear/pelvic exam, and I'm feeling anxious about it. I'm concerned that it'll hurt (or whatever else your concerns may be)." If there are special reasons for your anxiety and fear that you feel comfortable telling the doctor about, you should. If you're not comfortable, then don't force yourself, I think, but the more information a good doctor has, the better she/he will be able to accommodate your needs.

A doctor worth seeing will take that seriously and you can ask her/him to go more slowly than usual, to show you all the implements first and explain what they do, that kind of thing, and to tell you exactly what he/she is doing and what it will probably feel like as he/she is doing it and why he/she is doing it.

If anything hurts, tell the doctor to stop. In my experience, a pap smear isn't a walk in the park with sunshine and daisies, but it shouldn't be more than mildly uncomfortable or weird feeling either. If she/he won't stop, either kick up a fuss or just never go back to that doctor again and let him/her know why (there are times when you just feel too weird to kick up a fuss).

But a good doctor will be utterly sympathetic to a first-timer's feelings of anxiety--hell, to anybody's feelings of anxiety. Also...make sure to ask if you can warm up the lubricant by holding the packet between your hands.

All this said...you might get a lousy doctor. I think it has happened to every woman at one point or another. If that happens and you have any choice in the matter at all--don't go back to him/her.

Oh, one more thing. If you think it might help you to bring a good-luck charm, or to have a person you love and trust in the room with you to advocate for you or just for moral/emotional support and hand-holding (and I don't mean any disrespect by that term--hand-holding is a great source of strength), a good doctor should have no objection as long as you give permission.