Commentary Sexual Health

I Get Paid to Have Pelvic Exams So Yours Will Be Better

Alithea Howes

Wondering why your gynecologist keeps hurting you? Maybe they weren't trained on a real person who said “ouch."

My pelvic exam proceeds as normal. Well, sort of. I use a small mirror to watch the doctor’s hands as she examines me. I give her the speculum and squirt it with lube I brought from home. When she finishes, I thank her and smile. Then I get ready for the next one.

“How was that?” The instructor proctoring her test asks me.

“Pretty good,” I say. “She needs to put more posterior pressure on the speculum when she opens it. That’ll be a bit more comfortable for the patient.”

I go to the OB-GYN like it’s my job—because it is.

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As a gynecological teaching associate (GTA), my job is to teach medical students, registered nurses, and sexual assault nurse examiners (who collect evidence and care for survivors) how to conduct breast and pelvic exams in the most comfortable and empowering way possible. I act as the patient, but also a teacher, so a student can practice and get feedback in real time.

I heard about this job at a storytelling show. Most of the GTAs I work with have some medical training, mostly as doulas. I had no medical background, but I wasn’t afraid of public speaking or being naked in front of strangers, so I decided to look into it. I took a month-long training course that consisted of learning the techniques ourselves and a script about the best ways to interact with and educate patients. Soon I was on the road, teaching students all over New Jersey and New York.

A class usually has three to five students. I talk through each procedure, then the students practice on me. If it’s a more complicated or sensitive procedure, like any part of the pelvic component, I talk them through it as they go, watching their progress in a hand mirror. The students watch each other practice the exam so they can see and hear the instructions as each student goes through it. The visual and aural repetition, combined with the actual practice, helps the student retain the knowledge.

Sometimes a school will have GTAs come back a month or so later and act as patients to test the students on what they’ve learned. In those sessions, we save our feedback for after the exam, only stopping the students if they’re about to hurt us.

The teacher writes down my comments on the test, and we wait for the next student to be ready.

“I wish we’d had you guys back when I was a student,” he says to make small talk.

“Yeah, it’s still not as common a program as I’d like,” I admit. A 2016 survey of almost 100 medical schools found that more than 70 percent of those institutions used GTAs to teach pelvic or breast exams. “I don’t know how you would teach this without a GTA.”

“Usually we just practice on patients who are unconscious after surgery.” He says it so casually. Like it’s not the creepiest thing I have ever heard. I wonder how often this happens. There is not good data on this practice, but some medical schools have stopped doing exams on people who aren’t awake or without specific prior consent.

When I manage to speak again, I ask, “Do they get the patient’s consent for that?!”

“I’m sure it’s in the paperwork somewhere,” he says, shrugging. Never before have I been so compelled to read the fine print.

It’s not clear why GTA programs aren’t used in every school. But one reason is likely cost: Hiring someone and paying them per student is certainly more expensive than the alternatives. An anesthetized patient costs nothing. Some schools encourage their female students to let their peers practice on them, again at no cost to the school. But performing exams on unconscious patients or asking students to volunteer their bodies is ethically questionable.

Some medical schools take other approaches. Cadavers are useful for a large number of lessons across different medical specialities, so many schools use dead bodies. The practice of using corpses for teaching future doctors goes back to the earliest days of medicine. That demand once fueled the rise of “resurrection men,” who robbed graves for bodies (often those of poor or marginalized people) during the 19th century.

Today, latex models are also an option. In theory, a latex model is a one-time expense—a good investment. But in practice, the models are not as elastic as an actual vagina and tend to break if you insert a speculum correctly. So the student either breaks the model (incurring more costs) or learns to insert a speculum in a way that is painful for an actual person. So if you’re wondering why your gynecologist keeps hurting you, it may be because they’ve never heard someone say “ouch” before. Or they’ve never had someone tell them that this exam isn’t painful if done correctly.

There’s also a stigma around paying women for doing work with their bodies. Some people have argued that GTAs are sex workers (in previous times, sex workers were used to teach exams) and therefore should not be hired by medical institutions. Sex work can mean a lot of things, but the barebones definition of sex work is making money by actively working to turn someone on. I’m in a hospital gown under fluorescent lights. I usually don’t even brush my hair or wear makeup. I’m using clinical terms. If someone is getting turned on, it’s through no fault of mine. And even if you want to ignore my experience and say that this is sex work, what does that say about using unpaid students or unconscious patients?

Becoming a GTA has taught me a lot about my body. I learned that when I’m having sex and it feels like I’m getting hit in the belly, my partner is hitting my cervix and I should probably change positions if I want that to stop. I’ve learned where my urethra is and that I don’t want anything to come into contact with it.

But what matters to me more is the information I can give my students. I’ve taught countless women—medical professionals themselves—what Kegel muscles are and why you need to exercise them regularly. No one has admitted to this, but I’m quite sure I’ve shown a great many people where a clitoris is and how to find it. (Hint: Just push back the clitoral hood. It’s that easy.)

Most importantly, I’ve reminded my students that their patients are human, have feelings and histories, and want to know what’s going on with their body. Too many times, I’ve been to a doctor and had them judge my life choices or make me feel bad for being sick. Or they’ve written me a prescription without telling me what was wrong with me or how I could prevent it from happening again.

When I teach my students, I tell them how to talk to their patients. I tell them what words to avoid so that they don’t accidentally make their patients uncomfortable (for example, no one wants to hear “spread your legs” in this context.) I tell them how to educate their patients about their bodies so they can know what everything looks and feels like when it’s healthy and better identify problems when they arise.

And your health-care providers need this instruction. In many cases, practicing with a GTA is the first time they’ve done this procedure with a live patient. Medical students—often nervous, overworked, and exhausted—sometimes pass out during a GTA session.

Luckily, the only student to faint during my “exam” was uninjured; she just needed to sit down for a while and have some water. After the class, she stayed behind to thank me for the work I was doing.

“I had a really bad experience when I was a teenager,” she explained.

“That’s why I had to leave the room. I don’t know what the doctor did wrong, but it hurt so much, I’ve never been back. I know it’s important for my health,” she said. Her voice trailed off in shame. This was a future doctor who was afraid to go to the doctor.

“Well, would you like to take home a speculum?” I offered, grabbing my bag of disposables. “That way, you can practice it at home when you’re comfortable. And maybe that can take some of the fear away.”

“I can’t.” Her voice faltered, but she forced the words out. “I’ve never …  touched myself. Down there. I was so worried I would hurt myself like the doctor did.”

I was horrified into silence for a moment. One moment of negligence, something her doctor probably didn’t even remember, had affected this woman so negatively that she was afraid to touch her own body. I finally managed to say, “During an exam, most discomfort comes from making contact with the urethra, so make sure to avoid that.”

“I wasn’t here when you showed us where everything is.” She seemed scared, but asked, “Could you show me?”

I got back on the table. I showed her where she could find the clitoris, urethra, and the entrance to the vagina. I told her that the urethra is sensitive to pressure and probably the source of the pain she felt during her exam. I suggested she give herself some time with a hand mirror to get to know her body.

I will never forget the relief she showed just seeing and understanding actual female anatomy. Moments like that are the main reason that I do my job. Though students are learning, they’re usually very attentive and want to follow instructions to the letter. The work is physically demanding, but not as much as you may think. I only average about two classes a week, and having a job that helps people is worth a little soreness to me. As part-time jobs go, that’s pretty great.

I teach hundreds of medical professionals a year, and that helps the countless people they will see in their careers. The students I’ve met in my years of work have been so kind. They are so concerned with hurting me, so afraid of doing something wrong. I can’t imagine how nerve-racking it would be to try to perform a pelvic exam on an actual patient, having only seen a video of how to do it or only practiced on a disembodied latex vagina. My students are all so grateful for the opportunity to learn from me and to practice on an actual person. And I am incredibly grateful to have the opportunity to teach them.

I hope that someday every university will realize that it needs a GTA program. And that if you’re going to learn about the human body, it’s often best to learn on an actual human body. Preferably one that’s alive.

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