[Crossposted from my blog]
I attended an interesting talk today at the CRT at 20 conference on the topic of medical education and cultural competency, focusing especially on women of color's experiences with gynecology. I started thinking about a tangential topic that I think is sometimes overlooked in LGBT studies: lesbians' experience with sexual and reproductive health care services.
Later I will probably post some comments on how lesbians experience sexual and reproductive health care generally and differently from heterosexual women. Just now, though, I had a thought about the construction of the female body and how badly this jives with feminism and with lesbianism.
There has been a lot of talk among feminists about how the female sexual organs are reduced to their reproductive function, and how women's sexual pleasure can be effectively erased from a discussion about women's anatomy. My thought is that the woman's body is sexualized, but it is sexualized only with reference to the man/the male body.
When you think about this part of the body, it's likely that one of your first thoughts concerns the vagina. My guess is that gynecologists and other health care professionals see the vagina in two ways: as a receptacle for the penis (focusing on sexual health, contraception, disease, etc.) or as a passageway for a child (focusing on pregnancy, fertility, etc.) I think this is also true of the culture in general.
One problem is that the vagina is, for many women, not the site of sexual pleasure (or not the sole site), and so there is a separation between health and pleasure. I would posit that it is difficult to celebrate and enjoy the experience of health and health care when it is separated in this way from sexual pleasure. I think most of us experience our body in vastly different ways in the bedroom and in the doctor's office. Another problem is that it makes the healthcare experience irrelevant for lesbian women, especially lesbian women not interested in giving birth. Our concerns may be difficult to express because society and our health care experiences have not given us a language to express them. I know that I find the gynecologist fairly irrelevant to me - I get an annual pap smear and I get birth control for migraines, but that's it. My doctor is not necessarily someone I trust, nor do I associate him with my overall health.
I think that this disconnect may also have something to do with why lesbian women often do not go in for services such as pap smears, mammograms, and STI tests. STIs are often conceived of as a penis-in-vagina consequence. Even if we know that STIs can be transferred through any fluid contact, the lesbian community tends to see barrier methods as weird. If not weird, they're just a pain. I'd guess that many of us haven't asked our health care provider for advice concerning sexual health. I've had experiences with a female gynecologist who told me I only needed pap smears if I were having sex with a man, and a female resident whom I asked about sexual health and she said she didn't know anything about STI risks. I've also had a lot of frustrating experiences when I'm talking with a health care professional about PCOS and he or she tells me repeatedly about my fertility options and forces literature on me, even though I say that I am not interested in having children, ever. I was even once told "oh, you'll change your mind." I find this condescending, and the lack of agency makes me fearful of healthcare.
I'm not sure exactly how this could be fixed, but I do think that in anatomy courses and wherever else medical students learn about the female body, the woman should be construed as a whole person, and her experiences of her body considered fully. I want health care professionals to think of women's sexuality in terms of her own body, and all of it - not in terms of a penis and a vagina, plus possible "alternatives." I also think that healthcare professionals need to learn how to have effective dialogues that do not make assumptions about sexual practices or reproductive choices. I don't know how we get there, but I hope it's where we're going.
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"I've also had a lot of frustrating experiences when I'm talking with a health care professional about PCOS and he or she tells me repeatedly about my fertility options and forces literature on me, even though I say that I am not interested in having children, ever. I was even once told "oh, you'll change your mind." I find this condescending, and the lack of agency makes me fearful of healthcare. "
I know exactly what you mean--I was treated like PCOS is only a legitimate concern for women who want children, and since I don't, my doctor seemed to have trouble figuring out why I was even there to see him.
Heaven forbid I try to take care of myself for reasons other than preparing to have a child!
Definitely! PCOS was presented for me as something that I should only think about in the context of children or health concerns if I'm overweight. Because my weight is under control, the doctor didn't really go over the risks, etc. I have a lot of questions about the syndrome that bother me: for example, is the excess testosterone related to my sexuality and gender identity? I also found it quite insensitive for the doctor to say to the resident by way of explanation, as I'm lying there for a pap smear, "see how her clitoris is a bit enlarged? See all that excess pubic hair?" I didn't even know I had excess pubic hair, and I felt very insecure and worried as I'm lying there, thinking oh God, have my past partners been horrified? Was I supposed to do something about it? Very frustrating.
Last time I went to the campus gyn I was relieved to see that under "sexual partners" on their medical history form they had added "both" and "transgender" next to "men" and "women." Now, I don't have female or transgender partners so I don't know if that acknowledgment on the form translates into meaningful health care information. But it was refreshing to see and a huge improvement over a private gyn office I once visited that had the question "Ever raped?" on their medical history form. Seriously-- I am not paraphrasing. I should have known from the get go they were insensitive and not worth dealing with.
Your point about STIs is interesting-- people often say lesbians are at the least risk for STIs, but "less" risk doesn't translate to "no risk."
Was having that question on the medical history form insensitive because of the way it was worded? Just wondering because the medical history forms at my gynecologist ask the same thing (but in much more respectful terms), and I found it comforting that they even considered it relevant.
The insensitivity and cruelty of the medical form question "Ever raped?" is beyond question. The reason for the question, however, should relate to how the gynecologist approaches the physical examination. This topic came up during my most recent annual exam. My wonderful gynecologist trains future gynecologists. She told me, however, that she does not let her students perform an examination of a patient she knows was raped. They simply haven't yet developed the skills needed to conduct the examination without potentially traumatizing the patient.
I know all too well the horrors of visiting a bad gynecologist. My first visit to a gynecologist at 16 was so traumatic that I didn't go back until an older coworker strong armed me into do so at 24 because I was having abdominal pain strong enough to cause me to double over. Fortunately, I have found good gynecologists since then.
Yikes! I agree that the wording was extremely insensitive... and such a simple thing it would be to get right.
As for STIs, I've often been told that they really just don't know. Less risk, okay, perhaps, but lesbians don't exist in a vacuum - after all, there are lots of STIs that can pass through bodily fluid contact, and if a lesbian has ever had sex with a man with an STI, that might pass to her female partners. Perhaps the transmission risk is lower, but I would appreciate a frank discussion of the possible means of transmission. For example, I think most of us don't think about how likely it is that we have a small cut on our finger that we don't notice. One source I read suggested a very simple test - pour alcohol on your hands to see if it stings - and if doctors would suggest this to their WSW clients, at least a few STIs would be prevented. If there is a cut, gloves are fairly easy to do.
This was really interesting -- thank you for posting it.
I now identify with the asexual community, but did not the last time I visited the gyno. (A lot has changed in the last year!) It will be interesting to see the visit from a newer perspective.
Great post, thank you. I completely agree that in the medical world, women are often reduced to their reproductive system, which is seen solely as for use by men and for giving birth. There is a very long history of this; in the 18th and 19th centuries especially, during the decline of midwives, who weren't allowed to join medical guilds, male doctors attributed anything a female patient complained of to her uterus. This is where we get the word "hysterical." The root of the word comes from the Greek word for uterus: "hystera." It's the same as the root of the word "hysterectomy."
(Sorry for the info-babble-- I majored in Women's Studies.)
However, I disagree with your claim that lesbian women are not interested in giving birth. I don't think sexual orientation is necessarily connected to whether or not one wants to have children/become a parent. Also, I'm heterosexual and not interested in giving birth, and when doctors assume that I am, I also find it condescending. Why should I be interested in giving birth just because I'm interested in having sexual and romantic relationships with men?
Anyway, still, great post. :-)
She didn't say that no lesbians want to give birth- I'm assuming it's fairly common knowledge that some lesbian women use sperm donors and IVF and do have biological children. And she didn't say that all hetero women want to give birth either. So I think you're reading something into her post that wasn't there.
I haven't seen statistics on it, but I would definitely be willing to believe that a lower percentage of lesbian women give birth (i.e. either are childless or adopt children) as compared to hetero women. Obviously it is not 0% of lesbians vs. 100% of straight women, but she didn't say it was.
Actually, I did misread it. She wrote, "(...)lesbian women not interested in giving birth." I accidentally read, "lesbian women are not interested in giving birth."
Sorry bout that!
No worries!
The historical point is really interesting - I got my B.A. in history and am considering a PhD in women's studies, so I certainly don't mind a little history lesson!
The professor who gave the talk I mentioned at the beginning of the post made some really interesting points about how cultural competency training can improve the health care experience of women of color. I can see an application for this training generally with women as well - I think if all doctors were educated in the history you mentioned, they might spend more time thinking about how they conceive of the woman's body and how the woman experiences her own body. I can even see this training contributing to a diminishing of the fear many women feel when going to the gynecologist.
I'm very lucky to have had good experiences with the gyno. I was having pain issues during sex (with my then-fiancee, a woman, and hands only) and my doctor gave me considerate and useful advice that worked. But I can see how, faced with the same concern, other doctors may dismiss it--why would you have pain during sex without a penis?--or just be completely baffled or condescending. Fortunately, my gyno was considerate and knowledgeable (and the nurses/assistants who questioned me beforehand were unfazed and kind as well).
Not that I don't feel trepidation when I go to a new one. I never know if they're going to be professional about it or not.
Your experience does give me hope, though! In general, I think it would be great if we could all move in a direction of understanding that "real sex" is not just PIV. I'm thinking of the Chasing Amy scene where she proves to the guy that lesbian sex can be real because of fisting - why should we assume that only sex that simulates PIV sex is real? I certainly can think of a number of ways that lesbian sex might hurt, heck, I've even hurt myself masturbating, haha.
It is incredibly problematic that the author uses the word "woman" when describing users of health services for female bodies. This implicitly assumes that all those persons possessing a vagina|uterus|breasts are women. It is an erasure of intersexed and transexed bodies, some of whom have a few "female" organs, but not all of whom are women. The conflation of sex (female) and gender (woman) makes it impossible to discuss sexed issues (health care for bodies with female subsystems) in an inclusive, exhaustive manner.
As a man who uses ob/gyn services on occasion, I find it completely reasonable that my remaining female reproductive organs are reductively treated as independent systems. It is logical that my health care providers DON'T construct me as a whole woman because of some remaining tissue I've yet to excise.
Thank you for pointing out my mistake.
I was unaware that "female" applies to sex and "woman" to gender generally, but I will keep those terms in mind. I should have been specific that I am referring to the cis-gendered female body, because I think these concerns would apply most directly to that situation. I can imagine that the healthcare experience of transwomen and intersex individuals involve plenty of assumptions, as well, but likely different ones. I don't have anything exhaustive to say about the experience of those with female bodies or female organs, or about all women-identified-women, because my only experience is as a cisgendered, outwardly semi-androgynous lesbian woman. I would certainly be interested to hear how intersex and transpeople experience healthcare, including gynelogical care.
Thank you again. I'll try to be more conscious of what I'm saying when I use the words "female" and "woman," and be more specific when referring to cisgendered women.
I am a heterosexual, sexually active female and I have problems with the state of women's health services. I decided when I was 18 years old that I didn't want children. Everytime I visit a doctor I am bombarded with information on reproduction and how to prepare my body for a child. Whenever I say that I do not want children I am told, "I will change my mind". This is infuriating. Why am I reduced to my reproductive organs and my overall sexual health ignored? I once had a doctor give me literature on the dangers of not having children. I didn't even know they printed anything like this. It listed the benefits of bearing children v the dangers. Another, not so subetly, asked why I was having sex if I didn't intend to have children.
Ugh. I've had the same deal (also complicated by PCOS). A young woman who is certain that she would not like to use her reproductive capability is always seen as naive little girl who will snap out of it when she gets older, wiser and more in line with conventional thinking. When she decides to focus on her own health instead of her fertility, she's ignored and condescended to. Even medical professionals don't seem to recognize women's bodily autonomy.
When I said that I would prefer to consider some different options to control the PCOS rather than take BCP for the rest of my life, and made it clear that I'd rather be infertile than in constant pain, I was laughed at. By 5 separate doctors. One of them even asked me "But what happens when you meet a nice man and he wants to make you pregnant?" I can't begin to explain all the things wrong with that sentence, and from my doctor no less.
Thankfully, I finally did find an OB/GYN I felt like I could trust. She was the one who performed the emergency surgery to remove half of the organs the other doctors thought were more important than my life.
Another [doctor], not so subtly, asked why I was having sex if I didn't intend to have children.
A response for the next time you run into such a clueless doc: "Well, doc, I've found that sex with a partner is more fun than masturbating."
I mean really, how stupid are these doctors? Have they not figured out yet that (*gasp*) women can actually enjoy sex? {grin}
I had a tubal ligation at 29 and I've never regretted it (I'm 48). I probably would have done it even earlier if there had not been so much pressure that I would change my mind.
I do understand the concept that a teenager, male or female, might change his/her mind about having children. But whatever guidelines the doctors put in place for counseling young adults about permanent sterilization should be the same for men and women. So, if they would perform a vasectomy without blinking on a 23 year old man (don't know whether they do or not) then they had better perform a tubal ligation on a 23 year old woman without any hesitation, either. (I know that the two medical procedures have different risks I'm just saying that the "you might change your mind" argument is the same in both cases)
In fact, it is very difficult for a man under 30 or so to get a vasectomy. If you already have a bunch of kids, or you spend a lot of time convincing your doctor you really will never change your mind, it can happen.
But a 23 year old man off the street would be turned down. At least, that is the experience of everyone I have known who has tried.
Ugh, that's awful! I can't believe they actually print literature on the dangers of not having children.
As for the permanent sterility question, I used to suggest that when I was 13 or 14, but I decided as I got older that it's not the solution for me, at least at the moment. I do pretty well with the birth control, which keeps my migraines under control (unless I miss a day, eep, did that yesterday and not looking forward to the coming migraine!) I used to be concerned about taking the birth control every day for the rest of my life without a placebo pill, but my endocrinologist assures me that the dangers are just a myth. I hope he's right. I respect the choice of those who went for the surgery, but I just don't know about it. I've never had surgery before, aside from my appendectomy.
seriously. when i had my first pap smear (at a VERY GAY women's college for chrissake) the woman told me that i didn't need to have one unless i was having sex with men. LIES!
When I went for my first pap smear at my university health clinic, I not only had the doctor tell me I didn't need a pap smear if I wasn't having sex with men, she flat out refused.
She asked me if I had ever had sex. I, being someone who has sex on a regular basis, just not with anyone with a penis attached to their body, asked her what she meant by sex. She defined it as "intercourse with a penis." Since I had not had intercourse in that way, she told me she "was not allowed" to give me a pap smear (though I know there is no such rule). I had to spell it out for her that if all she was worried about was my discomfort and her not wanting to be the one to break my hymen or something, she was sorely mistaken because even not having ever had "intercourse," I had had plenty of penetrative sex.
She gave me the pap smear out of sheer embarrassment.
No one should ever have to out themselves to their doctor in that way, nor should anyone ever have to beg or educate their doctor in order to get something as important as a pap smear.
I won't even get into the two doctors who tried to convince me I was pregnant when I had mono, but wouldn't actually ask me if I was having sex with someone that could get me pregnant (apparently asking "are you really sure?" ten times covers that).
Maybe my outlook is still a little juvenile because I didn't start seeing a gyno regularly til about a year ago (I'm 24. btw). I've always felt that women's health, in a way, further serves to teach us to objectify ourselves or pay more attention to our bodies than what's necessary. It's difficult to explain why I feel that it's a negative thing. I guess because I don't see the same kind of push for medical attention in the male direction. It just seems unfair and uncomfortable. I know that health is important but I don't see why we need to go no matter what condition we're in. Breast health. what's that? They're there. What could be wrong with them? I just don't get it. I only go now because I am in love with my birth control.
I dunno, there's quite a push for men to get prostate exams, which they don't enjoy.
I don't think they're expected to go yearly, though. Also, it's unnecessary for women to have pap smears yearly, but most women still think you need to, and their care providers don't bother to tell them differently, since it's easy money.
I think with both the yearly pap smears and the breast health issue, the problem is cancer. I would encourage regular gyn visits simply because you want them to catch cancer early if it happens. With the boobies, I think you could do your own monthly self-exams if you're good at that and be ok, but regular pap smears will catch cervical cancer (or so I've been told).
Yes, but according to the industry's own standards, you only need them every two or three years, depending on your age, for the purposes of cancer screening. I have a friend who works at the women's reproductive care clinic (our local version of Planned Parenthood), and she told me this. When I called my doctor to get a refill on my BC prescription, the receptionist was going to schedule me for a pap smear. I told her I had had one last year so I probably didn't need one. There was this awkward pause, and she said she'd have the nurse call me back. When the nurse called me back she said I was right that I didn't need one, but asked me how I knew that. It seems to me like they were irritated that I threw a wrench in their little system, because they routinely schedule you for a pap smear every year even though it's not required or recommended. I assume it's because they want the $$ from my insurance company.
This really makes me upset because I've had doctors refuse to prescribe me BC unless I have a pap every year. Why is my method of contraception constrained by my agreeing to a medical test??
...follow the money...
So, I've been seeing a gynecologist for seven years now (i'm 22), and i've had, all in all, a pretty good experience, especially compared to some. they don't ask about men, they ask "how many partners?" or "what kinds of intercourse?" which i really appreciate. but as a petite woman it is a physically traumatic experience for me, even with the kiddy speculum, and not something i exactly look forward to.
The really unfortunate thing about a lot of women's health issues is that they're silent. they can really sneak up on you, because a lot of things like STIs, PID, and various cancers can grow and grow without any symptoms for a very long time. you may think there's nothing wrong, when really it's only a matter of time. one of my friends didn't go to her gyno regularly, then came down with crippling pain in her abdomen. turns out it was pre-cancerous tumors on her cervix, portions of which had to be removed. had she gone to the doctor as scheduled, they could have found them earlier, greatly lessening her pain and physical trauma. as for why men don't have the same push to go to their GPs... well frankly, their problems tend to be more obvious (burns when you pee, lump in the scrotum), fewer in number, and start later in life. and if -IF - a woman does ever want children, an infection is far more likely to affect fertility in her than in a man.
i have a touch of hypochondria perhaps, but i see thinking about the physical health of the body as crucial to being able to accept it and enjoy it. i think what we need is not less of an emphasis on gynecology, but more of an emphasis on treating female patients with respect, and better connecting genital health to overall health, perhaps partly through encouraging women to see a GP in the same way most men do (in addition to regular sexual/genital health specialist checkups, because like it or not the female anatomy is complicated) in order to encourage better overall well-being.
I definitely agree with you - my rationale is that frankly, I have no idea what's going on "down there." Maybe if I had a speculum and a mirror and a flashlight, I wouldn't feel a need to go each year, but since I don't, and since I've seen so many women fall victim to cancer, I get my regular checkups and feel reassured because of it.
First let me say that I love this topic.
Most of my issue with the western medical industry actually has to do with the way childbirth is so horribly mismanaged. However, I think many of the motives and the view of women that drives obstetrics are also relevant to gynecology. Since the medical establishment is an industry whose main goal is to be profitable, it's in their best interest to have patients (or "revenue streams") who are docile and easily handled. That means mainstreaming everyone into one big group and bullying them into cooperating. Taking time to answer questions, to adapt treatment to the needs of the individual patient, and to have a more nuanced and inclusive presentation of information don't make sense in this model because it all requires additional labor and materials that would not bring a corresponding revenue increase. Add to that the fact that western medicine is so deeply pharmaceutical-driven, and I wouldn't expect many changes.
I think this applies disproportionately to women because women tend to seek medical treatment more often than men, because they're more likely to be asking questions, and because they're potentially very lucrative revenue streams due to their reproductive role. When you add these motivations into the pre-existing tendency to construct female bodies as passive and docile, you get the kind of contruction you see in the gyn/ob industry.
It really does seem that gynos are confused by any one who isn't having PIV sex and isn't planning on having kids. I'm a straight cis-woman, but I almost never have sex and don't want kids (and I'm almost 40, so at least I don't get the "You'll change your mind speech.") This last visit, the doctor and the nurse both tried to encourage me to use condoms. Neither asked if I was sexually active. Since I am not, haven't been in a very, very long time, and have no prospects of being so in the forseeable future, just what do they want me to do with condoms? Next time, I'll say "Yes, I make them into lovely party balloons." Doctors really do need to make fewer assumptions and ask more questions in order to serve their patients better.
i beg to differ. i've taken a&p and specific anat. courses. i also work in the "medical profession". it seems you went out of your way to avoid the mention of the nervous system. any modern (this century)anatomy book details the many receptor sites as it relates to pleasure. most modern anatomy books i've read, do not solely isolate vaginal nueral receptors and delineate the clitoris (a clearly discernable anatomical structure) as having the main concentration of nueral receptors. you also fail to mention the largest pleasure organ: the brain.
your kung-fu (science) is weak. could you be playing to your audience?
Your condescending tone really does identify you as a "medical professional." It's exactly what we generally get, so exactly what we've come to expect. Women's actual lived experiences in their bodies, as well as their knowledge and concerns, are considered to be far less important and valid than the currently dominant view of their bodies and their issues. This is a patriarchal approach, and until that changes, I think you can expect feminists to continue to object to it.
umm, a more widely used acronym is STD,if by STI you intend that to stand for sexually transmitted infection(s).
perhaps you reference it elsewhere, but i saw no mention of the nervous system. in modern anatomy books, there are citations of nueral receptors associated with pleasure. it would be inaccurate to claim that current anatomy books only mention the nueral receptors that are vaginal. it is common knowledge in the "medical prefession" that, in the female, there are a far greater number of nueral receptors in the clitoral area. and, the grafenburg spot does indeed exist. i've taken a&p and specific anatomy courses and believe it or not, the books i've read go into explicit detail on that very subject. the largest pleasure related area, in the human body is the brain itself - an anatomical and medical point of fact.
it's unfortunate and regretable that your experiences have been so negative. perhaps you should move on to a health care provider that you like better, instead of settling for inept ones. just think what would happen if the individuals you speak of lost revenue.
So are you blaming women for choosing the wrong "medical professionals"? Are you assuming that every single person is in a position to have access to the best doctors? If you plan on becoming a doctor, I would move on from you, with a tone like that.
Additionally, explaining what you have learned in anatomy books in no way negates what the article says about reducing women to their body parts. Knowing the clitoris is full of nerves, which are for pleasure, still does not take into account a person's emotional experience when confronted with a "medical professional" who is supposed to be caring for your health but is insensitive to your needs or questions or, worse, makes assumptions about you simply because you have a vagina.
It must be nice to have the choice to freely go wherever you want for your healthcare. I have a crappy student HMO myself. I can only see who my HMO allows me to, and I can't afford to pay out of pocket.
Well, one solution is the gynecological teaching associate. I am own and I study them. These are people who teach healthcare providers to be how to do the exam on their own bodies. These are people who work with future providers on wording and understanding the patient as not a docile body but as a whole person with needs and agency. It's fascinating stuff. It's unfortunate that programs vary so widely and not all practitioners get enough time with GTAs.