A story of love, loss and second chances by Nikita Singh, releasing this Valentine’s Day.
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Most women are anxious about their first pelvic exam at a gynaecologist’s. What happens? How does it feel? What are the doctors like? Find out.
I did not see an OB/GYN till I was 27, in the US. I wanted to get a PAP test done. I knew a swab of the cervix had to be taken, but I wasn’t prepared for what I saw. The cold, shiny, metal speculum that the doctor was holding. It looked like an instrument of torture. My husband was with me. He is very good at reading my expressions and immediately held my hand to comfort me, but even a stranger could have decoded that look of terror on my face.
My knees started shaking and my muscles became tense. I tried to calm down but my muscles would not co-operate. The doctor was very patient and reassuring, but the exam was a lot more painful than I had anticipated.
I returned to India mid pregnancy. In my personal experience, I have found that doctors here tend to be relatively less patient with questions, probably as a result of a heavy patient load, but are also more skilled.
With time, I realized that when it comes to the dreaded internal exam, I prefer a competent doctor over a nice one. Of course the combination would be ideal. I want a doctor who can do it well, causing me minimal discomfort. Someone who knows his/her way around a vagina and can diagnose problems quickly and correctly. The less the doctor fumbles around my insides, the better I rate the experience.
Namrata, who had her first visit to plan her pregnancy says, “I was nervous about my first internal exam because I honestly did not know what to expect. No one had prepared me, and I guess I was old enough to read up and prepare myself but I was in denial so didn’t! I was utterly shocked at the pain and severity, although my doctor was extremely gentle and kind.”
But sometimes knowing a lot can make you quite anxious. Sonali says, “I was a little nervous even though I had some idea how it would play out. But surrounded by a bunch of pamphlets that talked about various vaginal diseases made me more anxious. I wasn’t too concerned about physical pain. Maybe a little embarrassed but I felt terrified after I had read some of the pamphlets.”
Shipra found it comforting that the doctor talked to her throughout the procedure. Jaya was examined by an old family friend, and she trusted her doctor and had no trepidation.
Akshata screamed in fear when her doctor started the internal exam. She did however appreciate that the doctor tried to distract her by asking her about her college and talking about the weather.
But not every one is lucky enough to have a sympathetic or gentle doctor.
Jannet was examined by a man who was training under his father and doing all the procedures. “He was like a bull in a china shop. Their clinic was extremely unhygienic. Rusted metal tables, washed but stained sheets, metal instruments that looked like instruments of medieval torture, no mattresses, cold everything.”
Most women find the invasive vaginal and pelvic exams unpleasant, but some find it traumatic to the extent that it deters future visits.
Usually an internal exam requires you to lie in a vulnerable position on your back with your legs spread wide apart, possibly on stirrups. Many girls are taught from a young age about the shamefulness of keeping their legs spread wide. This position goes against the values and upbringing of most women. Many feel demeaned and violated. Yet often gynaecologists expect compliance with little explanation, while women battle deeply ingrained ideas of decency and modesty.
Further since gynaecologists do this every day, it is difficult for them to coddle and handhold every patient. Some might even take an urgent phone call in the middle of an exam leaving the woman in a state of great emotional discomfort.
In India there is the additional problem of heavy patient load. Doctors must balance between making patients comfortable and attending to as many patients as possible.
According to this article doctors in India are not trained in a bedside manner. Having insensitive doctors can be difficult in case of injuries or disease but the issue is compounded when dealing with awkward issues like a pelvic exam, in a society that still considers sex to be taboo subject.
I asked one doctor, “Were you taught anything about bedside manner as apart of medical school? Was there a course or a workshop? Was this demonstrated to you during your residency?”
She responded saying, “We were just expected to pick it up by observing the professors. There was no course or workshop. Though our situation was slightly different. Since we worked in a public hospital the goal was to treat as many patients as possible per day there wasn’t a lot of emphasis on bedside manners.” When there is a heavy load of patients one has to prioritize, and bedside manners takes a back seat.
The problem is many women go for an internal exam completely unaware of what is to come. Sometimes they may visit an OB/GYN for a different reason and have a pelvic exam thrust upon them. These cases are particularly difficult. The doctor who does these exams every day doesn’t think of it as a big deal, but a patient not expecting it at all is thrown in to a state of panic and confusion. Doctors are sometimes impatient with such cases and brusque saying that every one has it so don’t make such a fuss.
In India, considering patient loads, it is not realistic to expect doctors to be sufficiently patient and sensitive with every patient. It is impractical to expect a doctor never to take an urgent personal phone call or to display genuine sympathy and give detailed explanations for every exam given that they may be doing around 40 or more a day.
However it is possible, at least in busy hospitals and large medical facilities, to employ some one just to prepare patients on their first visit for these exams.
It could be a counsellor or a professional trained to be sensitive and patiently address all the questions and concerns a first time patient might have. The person can explain what to expect and why it is necessary. Many women prefer a woman gynaecologist for their first visit, though they may be neutral for later visits. So it might make sense that the counsellor is a woman too. The counselling session should probably be one one with the patient and the patient should be assured about confidentiality so they feel comfortable about speaking freely.
Dr. Jain says, “A patient’s confidentiality should be maintained even when it comes to family members.”
Victims of sexual abuse or suffering any form of PTSD experience unusually high anxiety, stress and pain during a pelvic exam. Special steps should be taken to make them feel safe and they should be given pelvic exams only if absolutely necessary.
Pelvic exams are almost a routine process during a visit to an OB/GYN.
Knowing how unpleasant pelvic exams are, begs the question, are they really necessary? If so, how often? What conditions are they useful in diagnosing?
According to this article:
A pelvic examination is often conducted in asymptomatic women to screen for pathology. The examination consists of inspection of the external genitalia; speculum examination of the vagina and cervix; bimanual examination of the adnexa, uterus, ovaries, and bladder; and sometimes rectal or rectovaginal examination.
These exams are supposed to help detect ovarian cancer and bacterial vaginosis. However recent studies show that a pelvic exam is not very reliable at diagnosing either of these conditions.
The above study still recommends a regular HPV test using a swab of the cervix.
On this issue Dr. Jain adds, “Nowadays the cervical cancer vaccine is recommended for women between the ages of 9 and 45.”
Invasive exams are also often performed on pregnant women and are sometimes necessary but there are also reasons to avoid such exams and doctors have to balance various considerations. This article outlines the pros an cons of pelvic exams during pregnancy as well as reasons that make it necessary. The article mentions these reasons to avoid pelvic exams during pregnancy: that they are particularly uncomfortable for pregnant women, they increase the risk of infection, and they may prematurely stimulate the cervix.
On the other extreme, sometimes an invasive exam is quite necessary. But in India many doctors refrain from performing them on unmarried women to protect their virginity. Some doctors go so far as to replace the question “Are you sexually active?” with “Are you married?” This seems quite irresponsible, given that marital status can be of little medical relevance, while accurate information about sexual activity could assist in correct diagnosis.
But things are improving . Dr Jain does not beat around he bush when it comes to getting asking relevant lifestyle questions. She says, “Nowadays women don’t mind these questions as they realize that we need to know certain things before giving treatment.”
The number of molestation and rape cases reported for KG and primary school children are on the rise. Many of these kids are too young to fully understand or express their horror or fear. Most won’t say anything about it, until they have been subjected to assault several times. These children, for obvious reasons, have trouble trusting people.
But the horrors they are subjected to, do not end with the crimes being reported. Soon after, victims are subjected to a battery of traumatic medical tests, the results of which are often used against them.
“Oh! It was just a small rape – it’s no big deal,” is what a lady doctor told 12-year-old Krishna (name changed) after a medical examination in which she was put through the infamous “two-finger test”. The Supreme Court has ordered that this test must not be carried out to establish rape but it’s still in vogue. — source
According to Wikipedia:
A form of virginity tests involves testing for laxity of vaginal muscles with fingers (the “two–finger test“). A doctor performs the test by inserting a finger into the female’s vagina to check the level of vaginal laxity, which is used to determine if she is “habituated to sexual intercourse”.
“The problem with tests like the two finger test and a test which tests for the tear of the hymen moves the issue from sexual assault to the woman’s sexual history,” Sana Contractor, associate co-ordinator at the NGO Centre for Enquiry into Health & Allied Themes told Firstpost.
The medical examination can be so rough and traumatic that it deters parents from reporting these crimes so as to spare their children more trauma. — see Deputy Commissioner Suman Nawla’s account.
There seems to be a need to sensitize medical professionals in government hospitals when it comes to dealing with victims of sexual assault and rape. After what these victims, some of who are little children, have gone through, they deserve compassion and a safe environment, not judgement, humiliation and rough treatment.
On the other hand, some doctors say that an internal examination is important to judge the extent of trauma and check for bleeding or pain for the safety of the patient. The Delhi government has stated similar reasons for reinstating the test.
In my opinion, the test should only be done, if it is absolutely needed, for the safety of the patient. The results should be kept confidential, and made inadmissible in court. Judgements about the victims sexual history or character, though irrelevant, nevertheless, succeed in colouring the perception about the victim.
A victim’s life style choices do not diminish the heinousness of the crime, like the prosecutors would like to have one believe. Besides, we are all entitled to our privacy and there is no reason a victim of sexual abuse should be deprived of it.
Sadly, as it stands today, prosecution uses the information to suggest that the sex was consensual and harass the victim on the stand, by shaming her for her lifestyle choices, at a time that they are emotionally fragile as a result of an atrocity committed against them.
It is however, a welcome development that, the textbook that recommended the two-finger test, and set the tone of dealing with rape victims, has now been edited to remove the requirement for this test. The text book has been further edited, to include the need for sensitivity on the part of medical personnel, in dealing with rape victims, sex workers, homosexuality and more. In addition to providing medical and psychological treatment, medical personal are now supposed to assist with medico-legal procedures.
Names of some patients have been changed at their request.
Image source: young woman with doctor by Shutterstock.
Kanika G, a physicist by training and a mother of 2 girls, started writing to
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