Wednesday, May 28, 2008

Rant: Gynecology, choice, "annual exams", and the medical establishment

For those readers of this blog who are made squeamish by feminism, medicine, or vajayjay talk, I suggest you look away now. Consider yourselves warned.

Recently, I read a post on feministing asking how women felt about getting their "annual exams". I didn't weigh in on the topic, because where I live now, and where I lived before, "annual exams" aren't annual, and include only a pap smear, rather than the breast exam and everything else that seems to happen in the States. Also unlike the U.S., here these exams are usually done by your family doctor, rather than a gynae specialist. what this discussion reminded me of, though, was a pro-feminist framing of gynae care I'm not sure I am comfortable with. I'm not sure I can agree that gynae care is entirely feminist--while being healthy is certainly pro-woman, I'm not sure viewing the female reproductive system as something that needs to be checked once a year to remain healthy, or the pap smear as a pre-requisite to a birth control prescription is feminist. The first reminds me enormously of the medicalization of birth, with all the patriarchal control of female reproductive organs and disconnect between a woman and her own body and health (after all, what other body system needs so much checking out once a year?). Requiring a pap before prescribing birth control smacks of medical paternalism to me--even in the highly legalized medical environment in the U.S., surely a woman ought to be able to sign a waiver and get her birth control anyway (there are some places that offer this option, but from what I have heard they are in the minority). I think it is likely, too, that this insistence on intimate exams may actually prevent some women from getting hormonal birth control--this insistence will not force unwilling women to get gynecological exams, it will cause them to use other (potentially inferior) methods of birth control.

Combine this climate of control and medical paternalism (of which there is a long history with regard to women's bodies) with the fact that often women are not in charge of their gynae exams--take this and this as examples from the medical blogosphere and the feminist blogoshpere respectively that make my toes curl in their shoes--and you have a pretty ugly scenario.

In Australia, around 61% of women go for their pap smears every two years as recommended. That means 39% don't. To try to raise this number the government is paying doctors extra for treating women who have not been tested for a while (but you can guarantee that that extra money is not being passed on to patients). In a country the size of Australia, you can guarantee some of the problem is access and choice--when you're dependent on a rural health service that covers a wide area, well, it might take a bit longer to get to a doctor. Like anywhere, though, some women's reluctance will have to do with what doctors call "anxiety or embarrassment", which I believe is meant to cover everything from anxiety and embarrassment right up to fear and trauma. While the medical approach is that these women should "get over it for their own sake", I am a little disappointed to note the actual level of care being offered--I'm going to talk about the Australian model, because I've done some research about it.

In Australia, around 2% of the ordinary non-liquid paps are inconclusive (usually because they contain blood or mucus), requiring the woman to come back for another test 6-12 weeks later. While there is a more effective test, the cost of this test is not covered by the Australian government (unlike most other medical testing), and even where it is performed an ordinary pap must be performed anyway. In a traumatised woman, the additional testing, expense, and discomfort may be the barrier between getting successful health care, and not getting it, but it is much easier to trot out the line about how "women with cervical cancer should have come in for a smear" than actually address this problem.

HPV testing could be offered as an alternative to traditional pap smears, meaning women did not have to get tested so frequently, but again, this is not covered by the Australian government, and therefore does not actually help many women.

And then there is collection method. Blind sweeps, and self sampling (either with the traditional method, as this midwife offered, or with the newer mechanisms) can offer women an non-traumatic way to collect the necessary samples. The Australian cancer screening program., however sees 'no evidence' to support the use of this approach. I guess the women in this study who would use this approach but did not get regular pap smears are not enough evidence. As this paper says, self sampling could bring the participation rate in cervical screening to near 100%, but cynically I have to wonder if it is easier and cheaper to blame women for getting cervical cancer.

My point is this (and yes, I have one): I do believe that being healthy, and having a healthy reproductive system are feminist objectives. I also believe that choice, knowing one's own body, and questioning the patriarchy are feminist objectives, and given the above it is clear that (at least in Australia) choice is being restricted (and may pose a barrier to the health of up to 39% of women). I am all for taking care of our bodies, and I am grateful that (largely thanks to the feminists who went before us) gynecological care has advanced enough that women are allowed to get pap smears these days. Having said that, the fact that the medical patriarchy is denying birth control without a pap smear, or constricting womens choices about what kind of pap smear they have (financially, practically or informationally) quite frankly makes me think that too much gynecological care isn't feminist. Until women everywhere can get care in the way that works best for them, until the blaming of cancer victims for "not coming in for a pap" stops, until women are seen as intelligent beings and allowed to decide for themselves about the risks associated with birth control, I can't quite see the "annual exam" as feminist.


Angelia Sparrow said...

I get a pap every 6 months. I have some cells that haven't decided whether to be cancerous or get better.

I've had hideous annuals, including one male doc who flashed my entire vulva to the nurse's station by answering the door in mid speculum-opening.

I've had very pleasant ones, almost always with female doctors who KNOW what their actions feel like.

It's definitely a feminist thing. Blog on!

Placebogirl said...

Angelia, Thank you for your comment. I've just had an ah-ha moment about what I was trying to say. Access to gynecological care is feminist, but the practice of it often isn't. I hope your cells get better, BTW, it's annoying to even have to find time for a biannual doctor's visit, much less money or anything else.

Lyndsay said...

Women can be denied birth control if they don't get a pap smear done? What? That is news.

Placebogirl said...

Hi Lyndsay. I don;t know whether this occurs in practice, but in the US there are certainly health practices that claim they will not dispense birth control without a pap smear, for example this one: