At least one in three women have had a bad experience during a gynecological examination: the examination hurt, the doctor made rude remarks, or sexual trauma was triggered. Despite all of this, little attention is being paid to this problem. Here’s how these examinations could be improved.

Time's up for the gynecological exam

“Are you okay with the resident doing your smear?" my family doctor asked me. “She doesn't get a chance to practice this very often.” "No problem”, I replied with bravado. At that point, somewhere back in 2016, I'd been trying to get pregnant for about five years and I'd regularly been spreading my legs during exams for many months. I felt like a pro and I also felt like being helpful.

Twenty minutes later, the resident had to give up. No matter how much we reassured her, she was too nervous and failed to properly position the speculum around my cervix. How I was doing had faded into the background. I did feel some sort of stabbing pain in my vagina that I'd been experiencing more often lately during these kinds of examinations, but I didn't pay it that much attention. It's all part of the deal, right?

Several more examinations and fertility treatments later, the pain kept getting worse and slowly turned into a chronic, crampy sensation. Inserting tampons felt hellish and intimacy with my partner started to be way less fun. In the fertility clinic, during my examinations, I began to indicate that I was experiencing these painful sensations, but I never really got a response. Only months later would a doctor note that there are four different sizes of speculums and that it would be best to try a smaller one.

I wonder why so little attention was being paid to my experience and my pain, especially given the quite substantial consequences that I was experiencing. Why did I have to discover for myself that there are so many ways to make the examination more bearable? And why is this not the default way of doing them? Especially as it turns out that I am not the only one who’s had a bad time in the gynecological exam room.

How do women experience gynecological examinations? We don't know

The pap smear, fertility testing, vaginal examinations during pregnancy or childbirth, STD examinations: these are just some examples of routine gynecological examinations that every woman and every person with a uterus will likely have to undergo at some point during their life. Yet surprisingly little research has been done on how they experience these examinations.

It was not until June 2021 that the first major study on this question, conducted in Israel, was published. Together with a number of doctors, the Briah Foundation, a foundation dedicated to making women's voices more heard in the medical community, developed a questionnaire on women’s experiences with gynecological examinations.

The Israeli researchers distributed the questionnaire via Facebook, and in two weeks’ time, 6,500 respondents filled out the list. Almost half of those surveyed - 47 percent - were found to experience the gynecological exam as embarrassing, 35 percent experienced it as painful and 19 percent even traumatic.

Would women and people with uteruses in the Netherlands also have such unpleasant experiences, I wondered, and would it be time to start discussing that more publicly?

Being a social researcher, I decided to study this myself. I asked the Israeli researchers if I could copy their questionnaire and distributed it through my own Facebook and Linkedin pages. I got an overwhelming response. Within a week, I received 1,487 completed questionnaires.

My findings are similar to those from Israel: 41 percent of my Dutch respondents experienced the gynecological examination as embarrassing, 44 percent as painful and 23 percent as traumatic. Another 10 percent of respondents said they ever received inappropriate questions or comments during the examination, and 3 percent even experienced sexual harassment (see some quotes below).

Remarks that doctors made during the examinations:

Your vagina still looks like a 16-year-old's

Ooh womb,

come out, come out, wherever you are

Have you ever seen something like this?

So horrible

So ... three kids and still so tight?

Are you also this tense when you’re having sex?

Oh no, I've never seen stretch marks this bad

Does this feel nice?

The gynecologist touched my breasts and told me I could do with losing some weight

Now my own network is probably not representative of all women and people with uteruses in the Netherlands. And people with a negative experience are more likely to take the time to fill out my questionnaire. But still, it’s shocking to me that I can so easily find so many people with bad experiences.

It's part of the deal, right?

The Israeli study caused a stir in Israel. According to lead author Sara Tancman, this is because the study exposed dynamics that normally "are not spoken about, both among medical staff and patients, because of shame, hierarchy and vulnerability.” She also suspects that it was only now that time was ripe to have this discussion. “Ten years ago, this would have been a lot more difficult. But now, with developments such as the 'MeToo' discussion playing out in the background, it's becoming increasingly clear that we need to listen more to women's voices.”

But is there anyone really interested in listening to those voices? Sarah Koppes, lecturer in gynecological research at the VU, tells me that female discomfort is a topic that is not (yet) discussed in her line of work. 'The prevailing view is that it's just part of the deal, so there’s no need to discuss it any further.” Universities are even cutting back on classes that teach doctors how to perform vaginal examinations. For example, students at the VU still practice the manual internal examination, but the use of the speculum is explained via a video nowadays. Koppes: "And then they are supposed to really learn how to do this once they start practicing medicine.”

But when these new doctors start practicing medicine, there are quite a few issues at play that contribute to negative experiences. I speak with at least ten physicians and educators for this piece, and they all mention how their work is affected by the limited amount of time they have available for each patient, busy consultation hours and the routine nature of their work.

'How can you expect doctors to tune in to how something feels in the woman's body,' sighs obstetrician Daphne van der Putten, 'if feeling and setting boundaries is what gets knocked right out of you in training? You can't complain, not even about what all that hard work as a resident does to your body, otherwise we wouldn't have any doctors or midwives left.' In other words, the lack of attention to one's own bodily experience seeps into patient contact.

Yet it is exactly things like taking the time to connect with the patient and work carefully that make the difference between the negative and (also many) positive experiences women share with me (see some examples below).

Negative and positive experiences during the exam:

I wasn't asked anything, I wasn't spoken to. As if I was just a vagina that happened to have a human attached to it

I had my first examination when I was 11. The doctor at the time was very negative, impatient and even got angry with me. Since then I have had pain during gynecological examinations and also during sex. This first experience has (had) a very big impact on my life. I even had EMDR to process this experience.

The doctor first explained everything and reassured me. I had taught myself to do breathing exercises during tense situations. She didn't think that was a problem. Afterwards, there was room for questions.

The male gynecologist let me watch through a mirror and explained everything he was doing. I felt involved and seen as a person, rather than a patient.

The design of the speculum has never been improved

It doesn’t help that the design of the medical instruments that are being used during these examinations, some of which have surprisingly barbaric origins, has never been improved. This is particularly true of the speculum. This instrument was invented in the 1840s by James Marion Sims, an American physician also called the "father of gynecology. Sims’ work involved experimentation on (unanesthetised) enslaved women in the southern United States. Female comfort was obviously of no concern here.

Nearly two hundred years later, hardly anything has changed about Sims' design of the speculum. It would take until 2005 for medical manufacturer Welch Allyn to market an extra-small version of the speculum. The company otherwise innovated mainly with the choice of materials (plastic) and the insertion of lights, not with the basic design.

In 2005, the American company FemSuite attempted to bring a more comfortable and efficient instrument to the market. This FemSpec, a tampon-sized instrument that inflates into the vagina, was developed through extensive user research. However, the company failed to convince doctors of the need to use this new instrument. According to Annie Legomsky, head of marketing for FemSuite, doctors and nurses appreciated the updated design, but were unwilling to put time, money or energy into adopting a new method.

Medical instruments that have not kept up with the times, gynecologists who have no eye and too little time for the patient; in that light, it is not surprising that we often have such unpleasant experiences. Telling is the story of Evelien Bijl, one of the guests in my podcast on women’s fertility journeys.

"I found the internal ultrasounds quite painful," she told me, "but when I pointed that out the doctor just said "oh, this isn't really supposed to hurt." I felt SO unseen.

I came across numerous more such examples in the completed questionnaires (see some examples below).

Examples of pain that wasn't being taken seriously:

I was a virgin and she yelled at me to relax more, otherwise she couldn't examine me properly.

"Have you been abused or something?" - comment from the doctor when I said the internal examination hurt

Is it really that bad? Why are you crying over this?

Why do we accept this?

The blind spot is also perpetuated by the fact that many women are afraid to tell their doctors that they are bothered by the examination. In the Israeli survey, less than half of the women said they would let the doctor know during the examination if something was painful or unpleasant. My own network estimates itself to be a little more articulate: 62 percent of those surveyed think they would speak up. This means that more than one-third of women do not know how they would react, or indicate that they would not dare say anything.

This stands in stark contrast to the way my questionnaire was received. I received dozens of personal messages from women thanking me for "this important survey" and expressing how pleased they were that someone was "finally paying attention to this.” So we do want to talk about our discomfort, just not in the moment when we are lying in a chair with our legs wide apart.

I recognise this all too well myself. I too have to muster up the courage every time I set my boundaries and act as the "difficult patient" who wants to do things her own way. This has everything to do with the subordinate role that patients often feel in relation to their doctor; something that many doctors are often insufficiently aware of.

Sara Tancman therefore advises doctors in Israel to act like a dentist. “Assume that your patient cannot say anything and ask her to raise her hand if something is uncomfortable.” Sarah Koppes, aforementioned educator at VU adds, “We teach students: if the patient indicates that they are experiencing pain, freeze your hand. And then the decision rests with the patient: stop the examination, or does the pain subside, and do we continue?"

But even raising a hand can be a bridge too far. Some women experience so much stress during an examination that they freeze. For example, one woman (name known to the editor) emailed me the following account:

Somewhere in the distance I hear She Who Is Inside Me say something. I think she is explaining what she is going to do, but it doesn't reach me. I keep looking at the screen and all I can think is: I don't want this! ... She Who Is Inside Me asks if I also experience pain during my period. I hear her say it. But I don’t understand what she’s saying. Nor can I answer her question. I don't know anything anymore. I don't know what I think or feel anymore. I feel alienated from everything. And alienated from myself especially.

Victims of sexual and/or physical violence, some 45 percent of women in the Netherlands, are at risk of re-traumatisation if the attending physician does not recognise such a stress reaction. Thirteen percent of respondents also reported being afraid of this. For the physician, however, such a reaction can be difficult to recognize because it can look different in everyone. In addition, only 3 percent of respondents indicated that they had been asked, prior to the survey, whether they had ever experienced sexual violence.

Daphne van der Putten and Mariëtte Frits - obstetricians and pioneers in the Netherlands in the field of pelvic physical and psychological trauma - therefore advocate adopting a 'trauma-sensitive approach.’ Instead of the doctor explaining to the patient what will happen and then starting the examination ('informed consent'), they work with the principle of 'embodied consent': only starting the examination when the patient is physically ready to be touched. This requires the doctor to continuously monitor how the body responds to touch and whether the body is not freezing. But that, of course, takes time.

How to do things differently: creating awareness

Structural solutions are needed to address the fact that doctors’ workloads are too high and that they have too little time for their patients. But there’s more to the problematic gynecological experiences that this article touches upon. They exemplify the structural lack of attention to the medical experience of women and minorities, also known as the medical gender gap. This gap negatively affects the quality of care provided to these groups. Thus, as long as there is too little attention to the patient experience within the profession, outside pressure will be needed to get this issue on the medical agenda.

Sara Tancman showed how this can be done with her work in Israel. She turned the overwhelming interest in her questionnaire into a collaboration with the Israeli Association of Gynecologists and with health insurance companies. As a result, a list of guidelines, based on Tancman's findings, has now been placed in every gynecology clinic in Israel – in plain sight of the doctor and patient.

One example is that both the doctor and the patient are reminded that it is unacceptable for the doctor to make comments about the patient's body, sexuality, weight or religion. Sara's Briah Foundation has also ensured that students in gynecology training are taught by various experts on pain, trauma and dealing with patients who are still virgins.

Even in the Netherlands, outsiders are looking for ways to improve gynecological screenings. Zoë Sluisdom, a designer who wondered why placing her IUD was so painful and why so many people around her appeared to have similar experiences, did research for her final thesis in Communication and Multimedia Design on how women's boundaries could be better respected in gynecological examinations.

Based on her thesis - and on the results of my research - she is now developing and testing a number of interventions: doctors who participate in her project will soon receive a package that includes the Israeli guidelines, relaxation exercises and - very practically - a skirt that the patient can put on during the examination.

And you too can make your voice heard

And you too can make your voice heard. Because it is often difficult to speak up during the examination itself, you can indicate to your doctor or midwife during the preliminary consultation that you’re nervous, that you’re experienced pain in the past, or that you have ever had an unpleasant sexual experience and would therefore like to take your time for the examination. An additional advantage, says Daphne van der Putten, is that by doing so you also take the doctor out of his or her routine and contribute to raising awareness about this topic.

You can mention that research shows that anything that gives you more control over the procedure helps you relax more. Daphne indicates that being able to relax on the table by breathing to your abdomen can make a big difference. You may also ask to control the pace of the procedure yourself. In addition, it is often an option to insert the instruments yourself. This has been scientifically proven to improve women's comfort and, contrary to doctors' fears, need not take more time. You can also work with your doctor to find a position that does not require you to put your legs in the stirrups. Again, this has been scientifically proven to help you feel less vulnerable.

My new GP, Joost Zutt, adds that you can also contact your doctor afterwards if you've had an unpleasant experience. “I assume that most doctors are open to feedback, to learn.” If that is something that scares you, realise that in doing so, you are also helping other women. Because real change will only happen when we make our voices heard en masse.

And, pro tip: if you're wearing a skirt or dress, you don't have to take off all your clothes.

The original version of this article was published in Dutch at De Correspondent