2:37 am - 06/30/2009

How to Make your Pelvic Exam Not Suck

A friend posted this article on Facebook yesterday, and I wanted to share. It's a really great article, and hopefully can help people here.

[Edit: A lot of people have commented on the language in this article. While the tone may be off-putting to some, it's also geared towards an audience that is inclusive of transmen who may be less comfortable with medical terminology used for female bodies. Check out this excellent comment for more details.]

How to make your pelvic exam not suck
-Leah Lakshmi Piepzna-Samarasinha

I’m a teacher at Pussy School, and I love my job! Okay, it’s not my official work title- but I am an educator with Project Prepare, one of a network of “gynecological teaching associations.” I have the most amazing, well-paid job teaching med students and doctors how to give pelvic exams that are pain-free, empowering and respectful of women’s and trans bodies and trauma histories. Emerging from the second wave feminist health care movement of the 70s, GTAs were started by dedicated feminists and lezzies who were appalled at the shitty standards of care given by most gynecologists, and the fact that back in the day, most med students learned how to give pelvics either on rubber models of the pussy (which can’t really say, “Ow, no, stop,”) or (even worse) on anesthetized surgery patients in teaching hospitals (who also are not awake women and trans people who talk back and have needs.)

In response, GTAs teach med students and medical professionals how to give pain-free pelvic exams in an empowering, respectful way. We are the most crazily empowered patients these students will ever meet- I get paid $75 an hour to be incredibly bossy, tell them they’re doing it wrong and reward them when they’re doing right. As such, I have a grip of tips to make your pap smear much better than the tension ridden, gross experience it may have been in the past. Read on:

Ask your practitioner to raise the back of the exam table so you can sit upright during your pelvic exam. Many practitioners were trained to keep the exam table flat, so that during your exam you are flat on your back, which makes many people feel disempowered and out of control of what is going on. There is absolutely no medical reason to lie on your back during the exam. Sitting up during the pelvic exam means that you can maintain eye contact with your practitioner, making you feel more in control and less likely to dissociate. Your abdominal muscles will relax, and it’ll be easier for you to focus on deep breathing and staying present.

Don’t take your clothes off and get into that freaking gown til you have to! Some practitioners will ask you to change right away. However, most annuals include a patient interview before it even gets to checking out your breasts/chest and genitals. If they ask you to change right away, ask if you’re doing the patient interview first and politely tell them that you’ll change when you get to the physical part of the exam. Doing the patient IV fully clothed makes you feel more empowered. The practitioner- or you- should drape a cotton drape over your knees just enough to make you feel like your shit is not on display to the entire universe, but not enough to make you feel like you’re drowning in fabric. You can hold or move the drape to where it’s comfy for you, as long as the doc can still get a look at your genitals.

Your practitioner should explain what s/he is doing every step of the way and ask you to guide any internal exams (with either their finger or a speculum) with your breath- asking you to take a deep breath, saying, “You’ll feel my touch/ you’ll feel my inserting the speculum”, and inserting on your exhale. They should also ask you to raise a hand or speak up right away if anything feels uncomfortable. If they don’t, fuck them! Don’t come back. But, make sure you say, “Hey, stop, I need you to withdraw your finger” if anything is hurting.

Speculums can be freaky. Many people take one look at the metal speculum and wince- it looks like something out of a Terminator movie. Believe me, I’ve felt the same way. However, it’s just a tool- a tool your practitioner, or you, uses to hold the walls of your vagina/cunt/junk open so they can see your cervix. The walls of the pussy/junk stick together so you can’t just take a look and see the cervix with the naked eye. Cervical cells are growing all the time, and sometimes they get wonky, and the whole point of the pelvic exam is that if you get your cervix checked out, any weird cervical cells can be treated way, way before they turn into cervical cancer. Try thinking of the speculum as a tool, just like a cordless drill or a ruler or a sewing machine. Play with one if you can- demystify it. Some folks freak less if your practitioner uses a plastic spec. They also come in different sizes- ask for a small if you know you have a history of painful exams. You can hell of use them at home, too. And if fantasizing about medical fetish play gets you through your exam, by all means, do it.

Minor discomfort during the pelvic exam (like if the practitioner is palpating your ovary and you have a cyst, or right when they collect the cervical cells during the pap smear) may be inevitable; severe pain is hella not. If you are hurting bad, tell the practitioner to STOP and withdraw their finger/spec. If you are hurting hella bad, they can do as much of the exam as they can- which may mean palpating your belly to feel your ovaries and uterus for any swelling and checking out your external genitals for any swelling, discharge etc- which is still a step towards your health.

A note about vaginismus, aka screaming intense pussy pain: Vaginismus is a brilliant survival mechanism your body may use when you’ve had pelvic trauma or survived abuse. In it, your pussy literally spasms shut at the first suggestion of any kind of penetration. I’m an incest survivor, and I hella had vaginismus, and I couldn’t have any penetrative sex or exams for almost a decade because of it. I got good therapy and did what I needed to do to heal, and I walked back into being able to be penetrated, slowly. I love getting fucked and I have totally pain-free exams now.

The pussy/ jam/ front hole is a muscle, and a really smart one. You know how when you’re fucking a girl or getting fucked, the more relaxed she/ you are the more the pussy opens up? Same principle for the pussy exam. Focus on being all yoga and taking deep breaths, releasing tension with each breath and visualizing when you’re inhaling that the deep breath is going to your genitals. It may help to get comfortable with penetration at home first- use a small cock or your fingers, breathe, and get used to the sensation. Check out Staci Haines’ body exercises in Healing Sex: How To Have An Empowered Sex Life After Abuse- they are awesome ways of changing your relationship to your body and pelvic region, whether you’ve lived through abuse or have an uncomfortable history with your pelvis for other reasons. I’ve also hella fantasized about good sex I’ve had in order to relax my pelvic muscles while on the table.

Give yourself a pep talk. Tell yourself that you’re doing this so you can live, that your body is your own, that you do not want to die of a totally preventable disease, that The Man wants you to die of cervical cancer but fuck that, you will not let him.
Bring a friend or advocate. Make an advanced plan about what you want, what your limits and triggers are, and why you are in the room. Think about what you would like your friend/ advocate to do- hold your hand during the exam? Tell you how tough and badass you are? Tell the practitioner to knock it off with certain things?

Your practitioner should use non-yucky terminology. At Project Prepare, we aggressively teach the students to use the words “healthy and normal” “genitals” “insert/withdraw” during the exam, because we DO NOT WANT any practitioners to say, “Everything looks so beautiful!” “You’re perfect down there!” “I’m going to penetrate you!” or other totally icky terms that are giant nos!

Ask questions: From my work website:
Project Prepare believes that all medical examinations should be interactive. GTAs encourage women to feel empowered to say or ask their health care providers any of the following:
I didn't understand that. Would you explain that to me?
Why are you asking me that question?
What are you doing?
Please stop, that is painful.
Is there anything I, or you, can do to make this more comfortable for me?
Why do you have to do that procedure?
What can I do to prevent this problem in the future?
Thank you for explaining that to me.
I appreciate the extra time or care you took with me.

If you are transmasculine or butch and you are not comfortable with the terms vagina, labia, etc being used to refer to your junk, ask them to refer to them as “genitals” (or whatever other term you prefer.) They should also refer to the bills of the speculum (the longer parts that open and hold the walls of your junk apart so they can see the cervix) as “bills” not “blades” - no one wants a sword in their cunt.

When you are booking your exam, ask them if they use the Cytobrush for the pap smear or the older, wet mount method- and try to go to someone who uses the Cytobrush! In the older wet mount paps, a small amount of cervix cells is gently scraped off your cervix, put on a slide, and checked out for abnormalities or cancer. However, in order for it to be a readable sample, there needs to be nothing else on the slide- which means they can’t use lube. Fuck that! Lube, as many of you know, makes everything easier. The Cytobrush, on the other hand, sweeps some cells off your cervix, which are then put through a centrifuge so all other cells (lube, blood, pussy juice) are swept away. Cytobrush= lube= more comfy!

Try to book your exam for right after your period is done. You can get a pelvic any time, but right at ovulation (around 14 days into your cycle) or when you’re PMSing you can be more sensitive and it can be more uncomfy.

Try to find a queer/trans or feminist clinic, or a practitioner who is listed as queer or kink approved in a directory. This does not mean they will be great or you will love them- I hated the willowy hippie lesbian feminist doctor who was at the queer free clinic in Toronto ten years ago. You will have to talk to any practitioner and tell them your needs. However, a queer/feminist clinic or practitioner is likely to be a lot less busted than someone you pick out of the phone book. There can definitely be good practitioners elsewhere- I loved the brisk, warm, no-nonsense, totally non-judgmental nurse practitioner who was my GP at my local Toronto neighborhood clinic (she’d say, “Okay, sex? Women, men, someone else, neither? Great!) If you live in an area with no queer or feminist clinic, try calling or emailing the closest LGBT center and asking them if they have a referral list of doctors- most do.
If you get a pap that is abnormal, showing dysplasia (abnormal cell growth, which can be a precursor to cervical cancer): go to a naturopath! Western medical science will want to give you a pap a month and treat the dysplasia by burning it off, but won’t really have a fucking clue about things you can do to heal it for good. You may need surgery, but taking herbs, supplements, quitting smoking and changing your diet helps A LOT with dysplasia. I arrested my stage 3 dysplasia by quitting smoking (chemicals in cigarettes show up in paps when you’re a smoker- meaning they go straight from your American Spirit to your cervix cells, ew) and going to a naturopath who put me on an awesome and affordable herb and diet regimen to maximize my immune system and help my cervix heal up. Other friends who’ve had the same condition and no naturopath have had hell of reoccurrences, but my shit is just fine. Many naturopaths offer sliding scale rates.

Buy yourself breakfast or flowers or a new leather implement afterwards as a reward.


Kink Aware Doctors: http://www.ncsfreedom.org/index.php?option=com_keyword&id=270
Callen-Lorde Community Health Center (LGBT clinic in New York): http://www.callen-lorde.org/
Lyon-Martin Health Clinic ( LGBT clinic in San Francisco): http://www.lyon-martin.org/
A New View of a Woman’s Body. Federation of Feminist Health Centers
The New Our Bodies, Ourselves. Boston Women’s Health Book Collective.
Hot Pantz
My job (refer your doctor!) http://www.projectprepare.org/
Our Guide to a Comfortable Speculum Exam: http://www.projectprepare.org/speculum.html
Website for At Your Cervix, a film about GTAs: http://www.atyourcervixmovie.com
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harro_der 30th-Jun-2009 10:23 am (UTC)
The language of this article is really a turn off. She uses "hella" way too much, along with other slang. It does NOT come off professionally - not to mention she tells you to leave your current doctor if dysplasia is shown! There are so many other tactful ways this could have been put together. I honestly wanted to stop reading in the first few paragraphs, but I didn't want to miss the information.
orelthyia81 30th-Jun-2009 11:35 am (UTC)

I stopped reading it after she referred to it as 'junk'.
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unicorn667 30th-Jun-2009 10:42 am (UTC)
Thank you so much for posting this. This is exactly the kind of article that makes this my one-stop journal for anything vag related. Tell your friend who posted it on facebook that she is awesome. I was starting to get a little worried about my first pap in a few months but this made me feel a lot better. Thank you so much. Everyone new to sexual activity should read this. It makes everything less scary. Thank you, thank you, thank you.
tyrsalvia 30th-Jun-2009 07:59 pm (UTC)
I'm glad you found this helpful. Absolutely feel free to pass it on anywhere you think others might find it helpful.
marionravenwood 30th-Jun-2009 11:49 am (UTC)
If they ask you to change right away, ask if you’re doing the patient interview first and politely tell them that you’ll change when you get to the physical part of the exam.

There's actually no medical reason to wear a gown, period. There's also no medical reason to use stirrups at all.

Tell yourself that you’re doing this so you can live, that your body is your own, that you do not want to die of a totally preventable disease, that The Man wants you to die of cervical cancer but fuck that, you will not let him.

This is a good argument for why people should get pap tests but it doesn't say anything about why (or why not) people should get pelvic exams. Pelvic exams do not prevent or diagnose any disease.
nightchild01 30th-Jun-2009 12:25 pm (UTC)
You don't have to use the stirrups?! Dude, that's awesome. I already knew there was no medical need for the pelvic exam but I didn't know you didn't need the stirrups.
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nightchild01 30th-Jun-2009 12:27 pm (UTC)
Interesting article but the language kept making me wince. I prefer medical terminology when referring to medical exams. Referring to it as "pussy" made me uncomfortable 'cause of how it's usually referred to as a "pussy" in either a sexual situation or as a derogatory term.
vdoeschallenge 30th-Jun-2009 02:12 pm (UTC)
Yeah I didn't really like the tone, but I did like how she offered a lot of alternatives to what you could call your genitals. And like in the article, you could tell your doctor to refer to it in medical terms, or ask them to use words that you are more comfortable with. All the "hellas" were unnecessary though. :|
incarnated_joy 30th-Jun-2009 01:08 pm (UTC)
The information was good, and had the chance to be empowering, but quite frankly the language being used was... regrettable. There is being casual in one's approach to writing, and then there is attempting to do an Eve Ensler by claiming back the word cunt and failing miserably to do so. Which is a shame, because it really is quite informative, and I know a lot of people would be put off from reading it, simply because of the language used.

And slightly off topic: I think I must be odd, because the word "pussy" has always bothered me more than "cunt" ever has. I'd rather my partner use the c-word for referring to my bits than the p-word. Of course vulva or vagina work even better, I'm willing to let it slide when he gets the two mixed up, so long as he never calls it "pussy" ever again.
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necromance 30th-Jun-2009 02:28 pm (UTC)
I liked the language, it could be my age but I feel disempowered by completely wholesome and politically correct language. It makes me feel like it was filtered through a PR and legal department and all of the personality and voice and caring got tossed in case it might offend.
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slidewithme 30th-Jun-2009 03:00 pm (UTC)
While I greatly applaud her desire to draw away from normal medical terminology, the phrases she uses are extremely harsh and a huge deterrent to actually reading the entire article.
sarahm87 30th-Jun-2009 11:29 pm (UTC)
mewsicfreak 30th-Jun-2009 03:10 pm (UTC)
wow, was i the only one who appreciated this article for it's wonderful mix of honest information with humor?
I thought this was brilliant...
Been through it all before and hearing it in terms such as these made me laugh about it all and nod through the entire thing :-)
THANKS for posting it :-)
paraxeni 30th-Jun-2009 03:39 pm (UTC)
Thanks for posting it. It's good to see that there are healthcare projects that are finally being aimed at the less privileged vag-owners in society. It's hard enough being young and marginalised because of your gender presentation or sexuality, harder still when those doing the marginalising are people who want access to your genitals. It can be a shaming, traumatic, disempowering experience for people who aren't considered 'mainstream' or (ugh) 'normal'. I only wish I'd had access to such resources when I was younger.

You may want to add a disclaimer or more info about how this came about/who it's aimed at though because it seems like some people are confused or offended because this approach doesn't resonate with their lifestyles or the way they're used to being approached.
buzzboomsplat 1st-Jul-2009 02:34 pm (UTC)
this comment = yay! i agree.
mydocuments 30th-Jun-2009 04:00 pm (UTC)
Not only did I find the language to be extremely off-putting, but I really disliked the continual references to modern/western medicine as The Man. I certainly understand a tendency for alternative paths of medicine to be critical of MDs and MD programs -- I'm a student in an osteopathic medical school, so I've been known to roll my eyes at some things DO vs MD -- but I just really feel that the entire thing was.... unprofessional. The author is coming from the perspective of a care provider, and I feel as though she could have been a bit more professional with her wording and with her endorsement and criticism of specific medical paths.
frolicnaked 30th-Jun-2009 05:35 pm (UTC)
... but I really disliked the continual references to modern/western medicine as The Man.

This. I especially disliked the statement, "Western medical science will want to give you a pap a month and treat the dysplasia by burning it off..." because that's an inaccurate portrayal of what the standard of care for dysplasia is.

Will you find modern/western medical professionals who are condescending, clueless, and overbearing in their attempts to perform relatively invasive procedures? Of course. Will you also find naturopaths who believe that paps are wholly unnecessary and that a vegan diet is enough to deter dysplasia from ever forming? Also yes. Is either one of these a fair representation of a "standard" opinion of either group, let alone the diversity of opinions within said groups? Probably not.
betterbebalboa 30th-Jun-2009 04:10 pm (UTC)
"The Man wants you to die of cervical cancer but fuck that, you will not let him."

I was a little turned off by the language and tone of this article, but I have to say, this made me laugh.

About the naturopathy advice at the end: there's no reason to pay someone to develop a special diet plan in order for you to treat your dysplasia, per se. There are plenty of easily accessible studies and articles online that show that fresh-brewed green tea, phytochemicals (cabbage, Brussels sprouts, broccoli, and kale), lutein (spinach, kale, turnips, mustard and collard greens), beta-cryptoxanthin (papaya, pumpkins, red peppers, tangerines), Vitamin C (oranges, grapefruit, peaches), Vitamin A (carrots, sweet potatoes, pumpkins, spinach), and lycopene (tomato and watermelon) can all help your body clear the HPV virus and associated cell changes. Quitting smoking and avoiding tampon use help as well. A quick search for "HPV diet" will tell you all this and more. You can eat the fresh fruits and veggies, or you can look for supplements with the same contents. I just... I don't understand why you would need to shell out to get someone to tell you all this when you can easily learn it yourself, I guess. Seems less empowering to me.
tyrsalvia 30th-Jun-2009 08:07 pm (UTC)
I think a lot of people have *no idea* that changing their diet or quitting smoking can help with HPV. To be honest, that's something that I didn't really know either - and I used to be an SSM here, so I know kind of a lot about vaginas.

I suspect that the suggestion to go to a naturopath is an attempt to take someone used to accepting Western medicine as total authority and have them find another medical provider who can give them this information, not at all intended to keep someone away from doing their own research!

Thanks very much for posting this comment, though. I bet a lot of people don't know this stuff, and it's really important information.
foureyedgirl 30th-Jun-2009 04:31 pm (UTC)
I’m a teacher at Pussy School
That's all I had to read to think.."Yeah..NO". I skimmed over a few parts. Didn't bother reading the rest. And this is coming from a person who curses like a sailor. I can't take it seriously. I hate the word pussy. blech.
__recidivist 30th-Jun-2009 04:49 pm (UTC)
As a transmasculine person, I really appreciated this article. Yeah, I agree that it was trying too hard at parts, but the tips ze gives are really good and the use of the words "junk" and "front hole," both of which are very common in transmasculine communities, gives her some credibility with me. I crossposted it to ftm.

Something that did bother me is in the first paragraph (and a couple other places when she talks about "women's and trans bodies," because that's not what she means. She means "women's and transmasculine bodies;" there's no mention of transwomen and the particular barriers they might face in post-operative care.
paraxeni 30th-Jun-2009 05:55 pm (UTC)
Yep, that was more grating than 'hella'! Hopefully they are doing work wrt MAAB individuals as well, it would be a shame for a great project like this to only focus on XX patients.
paraxeni HEADS UP! A note about the language used.30th-Jun-2009 05:51 pm (UTC)
I know most people read the comments before they post, and one of my earlier statements has been buried in a thread-pile so I'm reposting for the benefit of anyone who is concerned/feels alienated by the language used in the article.

It seems like the guide is written largely with FAAB genderqueers/FTMs in mind, as well as other sections of the queer community rather than more 'mainstream' female-identified individuals. It's quite common for dysphoric individuals to refer to to their genitals as their 'junk', 'front-hole' or 'shit' and avoid clinical or even euphemistic terms that are abjectly female in nature.
If you don't want to have a vagina, and the very mention of the word makes you shake and vomit, then, it's probably not best for someone to use it repeatedly at you while trying to swab your cervix. So it isn't coming from a place of disrespect, it's trying to encourage a group of people who often avoid such exams, and as such are at serious risk of developing complications that would've been picked up earlier in those of us who don't have those issues.

The problem with reacting negatively on impulse to these statements as 'disgusting', 'vulgar', 'unwholesome', 'immature' etc. without trying to understand the reasoning behind the language chosen, is that you run the risk of alienating and othering the very people who choose these terms for themselves as a way of empowering themselves, lessening the trauma and disgust they feel about those parts, and enabling themselves to make it through the process without too much psychological damage.

I feel that VP is a valuable resource, and should be welcoming and accepting of any poster, but too often in queer, lesbian and trans communities when I've referred people over here for help I get the response "Oh no way. I don't want them to assume I'm dating guys/that I identify as female/assume I have factory-issued parts and not the upgraded version". They don't want to be addressed as 'Ladies', or 'Girls', or to be constantly reminded that they're "different", or that some of them possess body parts that terrify them.
That's why this educator's approach is so important, because it addresses those concerns at the root, and actually goes out and demonstrates to HCPs how to treat patients like that.

Edited at 2009-06-30 05:53 pm (UTC)
tyrsalvia Re: HEADS UP! A note about the language used.30th-Jun-2009 07:51 pm (UTC)
Thank you so much for posting this comment, and others along these lines. It's very interesting to me how the language really resonated with some and really turned other people off. Anyways, I edited the post and added a link to this awesome comment in the top.
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