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
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'.
__recidivist 30th-Jun-2009 04:31 pm (UTC)
"Junk" is a common term for the vulva and vagina among trans men. It was an attempt to be inclusive of them.
paraxeni 30th-Jun-2009 04:44 pm (UTC)
Missed this one. I started from the bottom, worked up, tried to explain then lost heart. Maybe it's just me but I thought it seemed very obviously directed at trans/queer/lesbian/gq/ag XX individuals. Maybe It's not as obvious as I thought, but I can't read it through other eyes to check!
(no subject) - Anonymous - Expand
jennifer0246 30th-Jun-2009 11:56 am (UTC)
i totally agree. it's great information, but the presentation is unprofessional at best, and offensive at worst.
paraxeni 30th-Jun-2009 03:24 pm (UTC)
I commented to Beth underneath you in greater detail, but the language is the way it is for a very good reason. The article seems squarely aimed at a specific sector, and it is not the happily female-identified, heterosexual, middle-class people that most public sexual health campaigns are aimed at, and that make up the majority of posters here.

It may seen jarring to people who have a good, loving relationship with their bodies and their sexual health, but to someone who is completely traumatised by the knowledge that they even have a vagina, the last thing they want when someone's trying to access that particular area for a health check is for someone to say the word over and over again. People like that have died from preventable illness precisely because of prior bad experiences or fear of having one.
primal_pastry 30th-Jun-2009 04:40 pm (UTC)
Thank you so much for posting this comment and the other iterations below.
archangelbeth 30th-Jun-2009 01:19 pm (UTC)
Yeah, it's definitely coming from a language context that is, ah, "hella" more "swear-accepting" than I personally prefer. I'm going to assume that it's directly out of whatever communication sub-culture the author is in (because I really doubt that someone'd think that this was a "more comfortable, empowering" way of speech without feeling that) -- but I'm seeing the "your junk/shit" and going, "Y'know, I'm thinking that these are perhaps not the best words to feel empowered about one's genitals."

Aside from that, her tone suggests she's got a pretty good sense of humor and attitude. It's just coming from a kind of alien place that makes me want a global search/replace. (But then, I'm actually a total verbal prude, so I'm used to doing mental search/replace on VP all the time, not to mention the rest of the world. O:> )

I'm also dubious about the "go to a naturapath 'cause the Man doc'll wanna burn off the stuff" thing. Sure, it's a great idea to get your immune system in tip-top shape, but I'd want to be discussing the situation with both a trustworthy doctor and the nutritionist, to see when extra "how'er you healing?" paps might be extended to, versus "I don't need my paps no more, 'cause I gots a naturapath!"
paraxeni 30th-Jun-2009 01:57 pm (UTC)
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' 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.
(no subject) - Anonymous
tyrsalvia 30th-Jun-2009 07:58 pm (UTC)
I think it's still pretty useful for teens in rural areas to know that they can negotiate with their doctor about the specifics of what language is used, when to undress, what position to be in, and etc. A lot of us are conditioned to obey doctors unquestioningly as authority, and when someone is gender dysphoric or a survivor or has other issues involving their genitals, it can be really helpful just to hear that a doctor is a *person* who is willing to do things a little differently to make you comfortable.
(no subject) - Anonymous
paraxeni 30th-Jun-2009 02:07 pm (UTC)
I replied to Beth in detail about the language used above.

The word 'cunt' isn't used disrespectfully, but that and the other euphemisms are probably being used in an attempt to empower a traditionally neglected group. I can see it resonating better with the younger trans/gq/ag/queer patients that it's aimed at. It's not designed for the more mainstream heterosexual, female-identified people that make up the majority of somewhere like VP.
asunlitrose 30th-Jun-2009 03:08 pm (UTC)
Eh, for some of us cunt has become an empowering word, kind of a reclaiming of sorts. Cunt by Inga Muscio explains it well. I never used to like the word before, now I love it. :)
tokio 1st-Jul-2009 02:14 am (UTC)
Yeah, exactly. "Hella," "pussy," and "junk" were INCREDIBLY annoying to read throughout this. I just can't take her seriously at all. Oooh, you said cunt -- how edgy and hip. I totally feel at ease. (Cue eyerolling.)
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