[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.
and most importantly: REMEMBER THAT YOU ABSOLUTELY DESERVE TO BE TREATED WITH RESPECT,THAT PAIN FREE PAPS ARE HELLA POSSIBLE, AND THAT YOU ARE TOTALLY A VAG/JAM WARRIOR FOR MAKING YOU’RE YOUR SHIT IS HAPPY AND HEALTHY AND WILL BE AROUND TO FUCK ANOTHER DAY.
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.
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