Just Put Your Feet in These Stirrups

Then there was the Saturday I got up at six-thirty in the morning to go to the University of California Medical Center and get six or eight pelvic exams.

Yep, you heard me right. I took off my pants and lay on an exam table and put my feet in the stirrups, just like the nice doctor told me to. It wasn’t even an S/M party.

I bet for once you’re not the least bit jealous of my glamorous, jet-setting life.

Teaching doctors how to give pelvic exams is a gig that I get occasionally, though in the past I’ve had medical or nursing students. This time I taught actual physicians—pediatricians, no less—who were attending a workshop at a national conference.

And just why were pediatricians learning how to give pelvics?

Managed care, that’s why. Apparently a lot of HMOs will no longer allow pediatricians to refer a young woman to a gynecologist, as used to be the practice when she needed a pelvic exam. “You’re a doctor—you do it” is going to be the order of the day from here on out. Trouble is, lots of these folks don’t know how to give exams.

So I was called to do my bit for continued medical education. I’ve been told that, at one time, doctors never had the opportunity to practice on what we now call a “gynecological training associate”—that’s me with my pants off, ladies and gentlemen. Instead, they learned how to perform these exams at teaching hospitals on people who were knocked out for surgeries. I don’t know about you, but I think this is just as unsavory as being rectally probed by aliens. See why I was willing to get up so early? Thanks to me, seven docs got to practice their bedside manners on someone who could give them feedback—somebody conscious.

Don’t think you needn’t relate to my experience with empathy, guys—these docs have to learn how to check your prostate, too. In fact, my partner is a male teaching model for med students learning the ins and outs of proctology. (Heh heh. Pardon the pun.) I hear that aliens have better bedside manners than some physicians.

What qualifies me to do this? Well, first, I’m experienced at getting pelvic exams. I’ve had them at least annually for over twenty years. I’ve had some pretty competent ones, and I’ve had some bad ones. Boy, have I had some bad ones. So I know the difference between the two, and I know what sorts of things many physicians tend to get wrong. Also, I’m trained in sexual anatomy and sexual communication—and while doctors may have spent more class hours than I have learning how the head bone’s connected to the neck bone, I’ve had a lot more training in talking frankly about sex. Besides, I’m actually willing to take my pants off in a teaching context. Do you suppose Dr. Ruth does this on the weekends?

I suspect the doctors at the workshop might object to my using the term sexual in connection with this exam. The pelvic exam is a basic component of female health care, whether a woman or girl is sexually active or not, and I had the impression that most of these pediatricians, especially, would hesitate to do much or any sex education with their teenaged patients. One doctor had nearly been sued because a young patient had been under the impression that the pelvic procedures were supposed to “train her to have sex.” (Not true, of course—sex done right is infinitely nicer than even a competent pelvic exam.) Many of the doctors, especially the males, already included a nurse or parent as chaperon to avoid any impression of sexual impropriety. What they can’t control, of course, is the response of the adolescent, who might experience the exam as sexually abusive or even erotic, even if the doc has no intention of eliciting such feelings. (I’m not talking about doctors who do sexually molest or involve themselves with patients—that’s a separate and serious issue—but, rather, the repercussions that behavior has had on all doctors and on the kind of advice and care they are prepared to give.)

A few years ago the Kinsey Institute did a national survey that indicated American adults (and probably many adolescents) considered their family doctor the greatest authority on sexual functioning to whom they had access. Around forty-five percent would ask their doctor first if they had a sex question. Aside from the issue of whether the doctor would actually know the answer to the person’s question—I will come back to that not inconsequential matter—the heightened (and often justified) paranoia among health-care providers about sex-related malpractice lawsuits means that many docs will hesitate to give explicit sexual information to patients, especially young females.

When I was a newly sexually active adolescent, it was impossible for me to even get to a doctor for the first couple of years (yes, years) I was having sex. I lived in the country without transportation, I had no source of income, and like most youth, I was afraid to confide in my parents. In those days they still sent underage girls to Juvenile Hall for being sexually “incorrigible.” The upshot: I fucked without contraception for two years. I wasn’t completely irresponsible—I learned as much as I could about fertility cycles and nonintercourse sex. When I did get into doctors’ offices (I went straight to the student health center to get fitted for a diaphragm when I got to college), I had accumulated so much sex information from reading that many of the doctors’ questions and statements seemed ridiculous. It wasn’t until I got to the Sex Institute fifteen years later that I learned that most medical doctors get about twelve hours of sex information in medical school—timewise, that’s less than one-quarter of the training provided for the San Francisco Sex Information (SFSI) hotline volunteers.

Most doctors—with some notable, and noteworthy, exceptions—don’t know enough about sex, especially sexual practices, to be the great help their patients imagine them to be.

So there I was with my pants off. A cluster of nervous pediatricians surrounded me. I began to give them information and feedback about the way they did the procedure—their touch, use of language and so forth. The teaching doctor got off on the wrong foot with me immediately by saying, “This will be uncomfortable.” Well, in fact, it wasn’t especially uncomfortable, and even if it was, why set me up for greater tension? I also requested that, when they brought out the speculum, they describe the two separable pieces as bills, like a duck has—that’s what they look like—not blades. Would you want someone sticking something with “blades” into your soft parts? (At least they knew enough to ask me if the speculum was too cold—I guess Our Bodies, Ourselves has had a little influence even in the mainstream.) Another little pet peeve was their use of the Latin terms labia majora and labia minora—meaning “large” and “small” labia. I suggested they say “inner” and “outer” labia, since many women’s inner labia are actually larger than the outer, supposedly “major” ones. This nomenclature leads many women to feel abnormal or deformed, when in fact this variation is very much within the range of “normal” (another word the doctors liked a lot better than I did).

I talked about sex much more than the doctors did, mainly to scatter useful tidbits that hopefully one might pull out of his or her hat when a teen needed it. I reminded them that if a patient hadn’t peed before the exam, it was likely to be very painful—and that, in fact, intercourse would be, too. (It took me ridiculously long when I was a kid to figure that out. I’ve heard that the “bouncing bladder” feeling is sexy to some people, but I’ve never been one of them.)

One doctor described the lubricant she put on her fingers before the bi-manual exam (also known as “root around and find the ovaries”) as “like Vaseline.” “Please don’t ever describe Vaseline as a lubricant!” I begged. “It’s not good to use that way, it destroys condoms—and when I was a kid I was always looking for things to use as lube, so that kind of mention would have seemed to me like an endorsement.” Doctors, friends. These folks are doctors. What on earth do they learn in med school?

In the end, I gave more feedback about this sort of slip-up than about the doctors’ exam technique. I was left with the impression that doctors—at least this group—were much more aware of the physical ramifications of what they did than they were of their emotional role as experts. The physical skills prove easier to learn than the ability to scrutinize one’s speech for hidden sex-negative or simply incorrect messages. And this psychological component is what bedside manner is all about.

By the way, for all you patients out there: It’s easier if you put your toes into the stirrups, not your heels. Much easier to spread your legs that way.

Boy, this is almost enough to turn me off playing doctor.

While I didn’t invite you here for a lecture on class consciousness, I would like to point out that when you go to a public teaching hospital for health care, you essentially donate your body to science—before you’re dead—and small print in the admissions contract may allow hospital personnel to practice on you. Now, this is probably a good thing—doctors should have a chance to try out some of those hifalutin’ skills with a supervisor on hand, right? But remember who checks in to teaching hospitals: mostly folks who are poor. I, for one, am decidedly uncomfortable with a health-care industry that uses the less fortunate as guinea pigs.

You’ve heard of “recovered-memory syndrome,” no doubt. It is usually defined as a psychological state in which people who have had invasive or terrible experiences, especially as children, forget all about the bad things that happened to them. “The body remembers,” however, as the theory goes, and many cases of abuse have been unearthed by therapists who pursue recovered memories with their patients. For several years, these therapists have been in the news, their methods and theories controversial. High-profile legal cases have turned on whether or not recovered-memory syndrome is legitimate.

I’m not interested in getting in the middle of this argument. For my part, I feel pretty confident that people can and do repress painful memories. I’m also fairly sure that some therapists who specialize in this syndrome are self-aggrandizing ideologues, and I hope history sets them apart from the responsible therapists who don’t misuse and push this diagnosis.

To my knowledge, however, not a single therapist has considered this: Plenty of women and men have been subject to invasive medical procedures while out cold. Does “the body remember” multiple pelvic exams performed by not-yet-confident doctors? Might this feel, out of context, like abuse or rape? Might this practice result in physical memories that could be rather easily adapted to a script starring Dad or Uncle Bill?

Common sense suggests so. If a person must painstakingly collect fragments of suppressed memory of events that happened when s/he was originally conscious, piecing together a history of abuse in a process that sometimes takes years, how much more difficult would it be to unearth memories which were not originally accessible to consciousness? And how is a person supposed to process the impact on his or her sexual feelings of such an experience?

The medical establishment reassures us that there is no lasting impact of this practice: that events that happen under anesthetic leave no residue of memory, and it is as if they never happened at all. I’m not so convinced. Remember, this is the same industry that defends male circumcision without anesthetic because “the baby won’t remember the pain” (a hundred years ago they claimed, “The baby doesn’t feel the pain,” the evidence of thousands of howling, sobbing infants notwithstanding). This is also the same industry in which pediatricians arrange operations on intersexed children’s genitals so that they will look “normal” (remember I told you the pediatricians at UC Med liked that word an awful lot more than I did). The same doctors seem vexed when the intersexed children grow up and accuse them of irreparably damaging their sexual sensation—those testosterone-ridden little girls didn’t need all that extra clitoris, anyway!

My point in bringing this up here is not to undercut the work and achievements of responsible and educated therapists and their brave clients, but rather to remind us that in a sexist and sex-negative (not to mention classist and racist) culture, abuse can come from directions we might not think to look. Just as a power imbalance is built into adult-child and (especially) parent-child relationships of all kinds, whether sexualized or not, medical professionals, especially doctors, wield enormous power to harm as well as to heal. Ironic, isn’t it, that while pediatricians hesitate to give teens accurate sex information for fear of courting malpractice lawsuits, other physicians are gloving up in groups of six or eight to do bi-manuals on women knocked out for tonsillectomies? This is as bad as alien abductions—worse, really, because we expect MDs, unlike Martians, to abide by humanoid codes of conduct.

In fact, while almost half of all Americans look to doctors for sex information and advice, the medical profession as a whole is no more sex-positive and sexually enlightened than its patients. Considering how much power is vested in doctors—and how many seem ill-equipped by their training to use their influence positively—it’s surprising we haven’t heard a greater outcry about their more medieval practices.

In the meantime, I hope the people involved in the recovered-memory movement will consider this provocative new source of physical trauma. And I’ll keep putting my feet in those stirrups from time to time, so the folks down at General Hospital can get their tonsillectomies in peace.