For Alexis Morgan, pelvic exams are “extremely traumatic.”
When she was a child, Morgan, now 36, said, she was sexually assaulted multiple times by a pediatrician under the guise of pelvic exams — a procedure in which doctors insert two fingers into the vagina to inspect irregularities in the uterus or ovaries. (Pelvic exams are not recommended for patients under 21.) As a child, she said, she was too afraid and embarrassed to tell anyone about the abuse, something she regrets. Now, pelvic exams are very difficult for her, Morgan said, and she sees no purpose for them. They’re “detrimental to my mental health,” she said.
The use of pelvic exams has been called into question in recent years: A 2020 study found that more than half of the bimanual pelvic exams conducted from 2011 to 2017 among U.S. women 15 to 20 were “potentially unnecessary.” The exams are most often used during prenatal care visits, if patients have symptoms such as abnormal bleeding or pelvic pain, or if patients have a history of gynecological conditions. The American College of Obstetricians and Gynecologists (ACOG) recommends women have pelvic exams only when they have symptoms or have a medical history that requires it.
Jocelyn Fitzgerald, a urogynecologist and pelvic reconstructive surgeon and assistant professor at the University of Pittsburgh, believes that pelvic exams should be conducted only if absolutely necessary. “The first step is to ask: I tell all patients they do not owe me an exam just because they are in my office,” she said.
When medical practitioners are not trauma-informed, the experience can be more damaging, patients say. A study conducted to understand attitudes and capacities of family doctors screening adult patients for childhood sexual or physical abuse found that of the 800 participating doctors, only 29.6 percent of those surveyed questioned their patients about the occurrence of childhood sexual or physical abuse. Emily Malling, an OB/GYN in Michigan, said she generally inquires whether a patient has had pelvic exams in the past, and if they’ve faced any issues or concerns. However, in general, trauma histories are recorded “not nearly enough,” she added.
This can leave patients who have experienced sexual trauma with no option but to advocate for themselves. Leela R. Magavi, a psychiatrist and regional medical director for Community Psychiatry and MindPath Care Centers, suggests that people with sexual trauma inform their physicians of their history, if they are comfortable doing so. “I encourage trauma survivors to write down their fears and questions and practice advocating for themselves during our sessions,” she said. “I then advise them to share these concerns with their physicians before any physical examination. Some of my patients have provided me with consent to speak with their gynecologists, so I can advocate for them as well.”
RaeAnn Ensworth, a 24-year-old living in D.C., said that during her first pelvic exam after sexual assault, she was “fine up until the moment I had to lean back with my feet in the stirrups.”
“I felt completely exposed and like the whole thing was out of my control. I asked to stop, and we did,” she said. “The doctor completely stepped back, and she even offered to step out of the room. We talked about what would happen, in what stages, and she promised to work quickly, so I didn’t have to spend much time in that position. Once I realized she was genuinely listening, I was able to power through and again remind myself why I was there.”
Fitzgerald said she has also found it important to keep the patients informed of what step of the procedure she is conducting. “I tell patients everything I am going to do and why before I do it,” she said. “I think the most important thing is taking the history to ask about triggers ahead of time and reassure patients they are in total control of the exam and they get to stop it at any time.”
Having a friend or trusted person in the room can also help make a patient more comfortable and manage triggers, according to experts. This person can also advocate for the patient when they are unable to, further ensuring full consent to every part of the procedure. For Morgan, that has been crucial in her experience with pelvic exams, and what she tells other women — that bringing a trusted person to be your advocate can really help.
However, in light of covid-19 regulations, having additional people in the room during a medical procedure can be difficult. Ensworth said she called her OB/GYN’s office ahead of an appointment to ask if she could have a support person in the room, or if there were trauma-informed doctors she could see. “Because of covid, I wasn’t allowed a support person, but they did have a trauma-informed doctor, and I was allowed to have a nurse in with me to hold my hand,” she said. “I had a lot of questions ... but the doctor was incredible, and so was the nurse.”
This can be rare, especially when trauma-informed care isn’t necessarily the norm. Malling and Fitzgerald both said that while they did receive some training in trauma-informed care during residency, it was not comprehensive. “I had a few lectures in medical school and residency about trauma-informed care and how to thoughtfully approach pelvic exams, but nothing extensive,” Malling said. In recent years, calls have increased for requiring trauma-informed care in medical settings.
In lieu of widespread trauma-informed care, there are ways to self-soothe during anxiety-inducing procedures, Magavi said. Patients can practice breathing exercises beforehand and visualize positive memories while in the doctor’s office, she said. Some of her patients bring music to listen to: “This helps divert their attention and assuage their discomfort,” she added.
Post-examination care can also be crucial, according to Magavi. She suggests scheduling a calming activity after the appointment, which can provide patients with “something to look forward to and an opportunity to practice self-gratitude.”