I was browsing the news this week when I came across a news story discussing how Dr. Robert Hadden sexually assaulted hundreds of girls and women during their pelvic exams over a 19 year period.
Read the formal indictment here – please note that this includes graphic descriptions of the abuse Dr. Hadden inflicted on his victims. News stories omit such details, so here’s a link to a news article in case you’d rather get an overview of the case.
This case is deeply disturbing –
(1) That a doctor would even think to do this,
(2) He’d be able to continue doing it for over 19 years before being caught.
The failure of the healthcare system in this situation is absolutely awful.
The worst offense, however, is that these girls and women likely had no idea that the treatment they were receiving was wrong.
Why?
Because girls and women are never taught what to expect during a pelvic exam. We are not taught that we have rights, including the right to decline a pelvic exam in part or in its entirety.
You are entirely in control of who touches your body and when.
A good doctor will ALWAYS communicate:
- What they are doing
- Why they need to do it
- Ask for consent before touching or doing anything to your body
What to Expect During a Well Woman Pelvic Exam
So let’s go over what’s expected during a normal, routine pelvic exam.
Key takeaway – good doctors ALWAYS ask for consent before taking any action.
This sounds like: “I’m about to do [XYZ thing], is that okay with you?”
(1) Have your vitals taken.
This includes your height, weight, blood pressure, temperature, oxygenation level.
Did you know that you can absolutely decline having your vitals taken, especially your weight?
There is absolutely medical benefit to having your vitals taken, and some doctors will require all or most of these vitals, however, you can still decline them.
You likely will be asked for a reason for why you are declining them but also do not need to provide one.
(2) Meet with nurse/medical assistant to review medical history.
If you have any symptoms, you’ll want to share them with the nurse. You’ll also want to ask them what to expect and go over your expectations.
Accommodations such as:
- A chaperone to be present. This is usually a female staff member if you did not have anyone accompany you to the appointment. And yes, even if the doctor or healthcare professional is female, you can still ask for a chaperone.
- Communicate any areas of discomfort that you may not want touched/examined.
- You can ask for a smaller speculum.
- You can ask for lubricant for the speculum.
- You can ask for no lubricant to be used at all (some women react poorly to certain lubes).
- You can ask to insert the speculum yourself.
Ideally you will have met with the doctor prior to the exam and confirmed that they will honor such requests. Not all doctors will.
Note for those who ask for accommodations:
Most often it is survivors of sexual assault who self-disclose their experience and ask for accommodations.
You do not need to disclose anything when asking for your needs and wants to be honored and respected.
You do not need to disclose your why.
You are, however, asking for someone to change their procedure and potentially do more work or take more time to honor and respect your needs. It can improve the experience for them (and you) if you provide some context for your request.
I have been in several situations where someone has disclosed their previous history of sexual assault and several healthcare professionals have been judgmental, unkind or outright disrespectful. I now suggest that if you are a survivor of sexual assault, to not immediately disclose that information.
Use these scripts to self-advocate for your needs and wants:
“I would feel more comfortable if I/we…..”
“Last time it really hurt when [XYZ thing happened], this time I need [XYZ accommodation]”
“My [insert name of body part] really hurts (is sore), I do not want [XYZ exam] and would like to discuss alternative ways to evaluate my issue.
(3) You’ll be asked to get undressed and put on a patient gown.
For a breast exam, you’ll need to remove all of your clothing.
For a pelvic exam only, can keep bra on and you can ask the nurse if you can keep your shirt on. A shirt may need to be removed if your belly needs to be examined.
(4) Doctor will enter the exam room and conduct the breast and/or pelvic exam.
When they first enter the room, they will likely greet you, go over your medical history with you, and discuss their for the pelvic exam. Listen to their plan for it and then tell them about your needs and wants for the exam. Be ready to engage in a conversation and potentially advocate for your needs and wants.
The Breast Exam
Breast exams are usually only conducted during a well woman exam or if there are breast and/or nipple concerns. They are not usually conducted if there are just pelvic-related concerns, i.e. if you have an issue with pelvis only, you should not be asked to expose your breasts.
Here’s a video from Stanford Medicine showing a full breast exam that is used to train other doctors. I love seeing how doctors are taught because this shows exactly how a doctor is supposed to behave and what they are supposed to do during an exam.
Also – some doctors may use gloves to conduct the exam, others may use their bare hands. If you’d prefer your doctor to use gloves (skin-on-skin contact can be uncomfortable for some), ask them to wear them.
Things to note: At no point in time should a doctor ever sexualize a breast exam to include grouping a breast or touching a nipple. Nipples should only be touched if there is obvious signs of discharge that needs further evaluation. Doctors should also ask the patient to touch the nipple and express the discharge themselves.
The Pelvic Exam
Here’s a video from Stanford Medicine showing a full pelvic exam that is used to train other doctors. This video contains graphic material including pictures of a woman’s labia and vagina and is therefore NOT safe to view at work (NSFW).
Generally there are 3-4 parts (link is safe for work) of a pelvic exam:
The External Exam
This is when the doctor looks at the outside of your pelvis including your labia.
The Speculum Exam
This is when the doctor inserts the speculum and will observe the cervix and inner walls of the vagina. They also may insert a spatula or brush to collect a sample of any discharge, fluid or cells.
This part of the pelvic exam can be uncomfortable for many people.
Tell your doctor what’s going on and if you need them to stop. They might be able to add lubricant, reposition the speculum, swap out the speculum for a smaller one or walk you through relaxing your muscles if they are too tense.
The Bi-Manual Exam
This is when the doctor inserts 1-2 lubricated fingers into your vagina and puts the other hand on top of your belly and pushes. It is necessary in order to gather information about your uterus and ovaries.
For some women, this exam is one they want to skip the most. It can be very personal having someone else’s body inserted into theirs. I’ve found this especially true for survivors of sexual assault.
If you want to skip this exam, ask the doctor if there are other options for examination. If there are other clinical signs or concerns, a trans-vaginal ultrasound could be ordered.
In this test, an ultrasound probe is inserted into the vagina and can evaluate a cervix, uterus and other reproductive organs. You can also request to insert this probe yourself.
The Recto-Vaginal Exam
For this part of the pelvic exam, a doctor will insert one finger into your rectum (butthole) and another into your vagina. It is done to check for muscle tone and/or possible tumors behind your vagina.
Once again, this can be a very uncomfortable for some people. You can always have a conversation with your doctor regarding why it’s medically necessary, discuss alternative ways to conduct the exam, or decline this part of the pelvic exam entirely.
As a Board Certified Patient Advocate, I’ve worked with many women to help them become more comfortable with pelvic exams and procedures such as trans-vaginal ultrasounds. See the section “Tips for Making Your Next Pelvic Exam a Better Experience” below for ways to make the overall experience easier and more comfortable.
If you’re looking for personalized support, let’s meet and discuss how we can make your next pelvic exam a better experience.
(5) You’ll discuss next steps.
After your doctor completes your pelvic exam, they will go over next steps with you. This may include when to expect any results, how you can get those results, referrals for any additional testing or to other healthcare professionals.
You’ll then likely told to get dressed and where to schedule any follow-ups.
This is a great opportunity to check and make sure that you have online portal access so that you can receive your results online and communicate with your doctor.
Now that you have a better idea of what a routine and typical pelvic exam should include, what can you do to make it a better experience?
Tips For Making Your Next Pelvic Exam a Better Experience
The key steps in making your next pelvic exam a better experience:
(1) Pick the right doctor or healthcare professional for you.
This is such a critical step and not often discussed. For many women, having their reproductive organs cared for requires a greater level of comfort than having their general health evaluated. The personality of the person you’re seeing for your reproductive care matters.
Keep in mind that OBGYNs are technically surgeons. They are specialists who are trained to do procedures and surgery for female reproductive concerns. While you can see an OBGYN for routine pelvic exams, you do not have to see one.
Certified Nurse Midwives (CNMs) and Certified Professional Midwives (CPMs) are also able to provide pelvic exams, some even come to your home.
Need to find a new doctor or healthcare professional to handle your next pelvic exam? Check out my article on Get More Out of Your Primary Care Doctor’s Visit for guidance on how to find the best healthcare professional for you.
(2) Ask for a new patient consultation or meet and greet before setting up a pelvic exam.
If you will be requesting anything during your pelvic exam that is a non-negotiable meaning that it has to happen or you will not proceed with the exam, schedule a consultation or “meet & greet” appointment before scheduling a pelvic exam.
Many, many doctors will not allow changes to how they conduct their exams. I find this especially true amongst OBGYNs. Midwives I’ve found generally more accommodating.
There are absolutely incredibly compassionate OBGYNs who want nothing more than to make your pelvic exam as stress free and comfortable as possible – you just have to find them.
Schedule a quick consultation, can even be over telehealth, and ask your new doctor or healthcare professional about their practice philosophy and how they feel about your requests.
(3) Practice enforcing your boundaries prior to your appointment.
Role play with a friend or partner. You do not want the first time you hold your boundary to be when you encounter it being violated. Most women in that situation freeze and are unable to speak.
Practice self-advocating with someone you trust so that you feel confident to advocate for yourself if the need arises.
Situations to practice:
- Ask the other person to accommodate your needs and wants, how will you handle their objections?
- Have the other person start touching your body without asking, how will you respond?
- Have the other person show signs of being irritated or upset, how will you handle their reaction?
(4) Be upfront during the first appointment regarding your needs and wants.
Make sure your needs and wants are given to both the nurse/medical assistant when you are taken back to the exam room and again when the doctor enters the room.
It’s especially important to communicate them to the nurse/medical assistant because it is their responsibility to set-up the room for the doctor. If you want lubricant, a smaller speculum, chaperone, etc. they will need to prepare those items before the doctor enters the room.
Key takeaway: You cannot over communicate – make sure everyone knows what you need and when.
(5) Give regular feedback to your Healthcare Professional.
During your exam, you should absolutely feel safe to share your experience you’re your doctor. Telling them – that hurts, that’s too much pressure, I’m uncomfortable, stop now should always be communicated and your doctor should immediately stop what they are doing and engage in a conversation with you regarding next steps.
Need help feeling more comfortable during your next pelvic exam? Meet with a Board Certified Patient Advocate and let’s develop a plan that leaves you feeling confident and ready to get the care you need.
