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Political Gynecology: Gynecological Imperialism and the Politics of Self-Help
by Susan Bell
How do health activists institute change in the medical system? A problem commonly faced by them is whether to work to improve a basically sexist and oppressive medical care system or to create their own structures. Does it make sense to institute short range reforms or to struggle for long term radical change? By “improving” the health care system it may be possible to generate more humane health care but at the cost of strengthening an already oppressive system.
Change in the medical system can be instituted in a number of spheres: at the level of federal or state policy making: in private and public funding: in the area of services or scientific research: and in education. In this article is a discussion of these issues in light of the experiences of a group of feminists involved in a program to teach pelvic examinations to medical students in 1975-76 in Boston. Hence, the focus of this article is on change in the medical system at the level of physician education.
There have been numerous analyses of medicine as an institution of social control and of the particular ways in which medicine oppresses women1: Women consume the largest proportion of health services (for themselves and their children), take more prescription drugs than men, and are admitted to hospitals more often than men. Most physicians are white men. Whether women seek private gynecological care, clinical or hospital services, most of them encounter practitioners who have learned how to perform pelvic examinations in the organized medical structure which is part and parcel of the larger racist and sexist society.2
Medical students traditionally learn incorrect and/or distorted information about women in textbooks and lectures.3 They are taught to act as if the pelvic examination is as matter-of-fact as any routine examination, while at the same time learning to use unnecessary and uncomfortable examining techniques.4 They are told to use stirrups and drapes routinely; both of these techniques are usually unnecessary and often uncomfortable for routine examinations. Traditionally they have practiced pelvic examinations on prostitutes, plastic “gynny” models, clinic “patients”5, and anesthesized women. The women are often not asked for consent to furnish their bodies for teaching material.
It has been acknowledged by some educators, critics of medical education, and dissatisfied students that this way of teaching is unsatisfactory. To remedy the situation, some educators have altered the information taught to students and the way in which they learn practical skills. One such improvement, introduced in the 1960s, has been the use of “Simulated Patients” (also called “Programmed Patients”) instead of real “patients.”6 “Simulated Patients” are people who have been taught to exhibit historical, physical, and psychological manifestations of an illness when examined by students. They have been employed in a variety of settings to teach cognitive, interpersonal, and technical skills.7 Prostitutes, friends of medical students, and community women have been recruited to serve as “Simulated Patients” to teach pelvic examinations and patient management skills to medical students. Depending on the emphasis of a program, women might be chosen because they are healthy or because they have specific ailments.
Students, physician-instructors, and “patients” benefit by the use of “Simulated Patients.” Students try out practical techniques on them, thereby decreasing their own anxiety and embarrassment about examining people, and increasing their ability to discuss the examination openly in front of the “Simulated Patients.” They learned to perform examinations in a realistic way and physician-instructors are able to evaluate students’ performances in a standardized way. Hospital and clinic “patients” are saved from repetitive, inept examinations, and ultimately receive care from better-trained physicians.
The Pelvic Teaching Program
In mid-1975, women medical students at Harvard Medical School approached a member of the Boston Women’s Health Book Collective to discuss the possibility of finding women to serve as paid “pelvic models.” The women medical students were displeased with current teaching practices. They specifically wanted feminists since they thought that the use of feminists as “pelvic models” would greatly improve the learning process and would provide a counterbalance to institutionalized attitudes toward women as passive recipients of medical care. The book collective contacted women at Women’s Community Health Center (WCHC) in Cambridge who agreed to a limited number of “modelling” sessions for second year Harvard medical students at local hospitals.8
The members of WCHC, a self-help women’s health center, saw themselves as part of the movement for radical social change, committed to the eradication of sexism, racism, capitalism, and imperialism. In practical terms, this means basic changes in the medical system as part of changing the overall structure of society: for instance, a breakdown of hierarchical relations among provider and consumer in which the provider has a monopoly over skills and information, women providing health care for women, and an end to “for profit” medical services.9
Implementing a program to teach medical students was a focus of controversy in the WCHC from its inception. Some health center women saw it as a low priority issue in the sense that it would entail putting energy into professional medical education and detract from other health center programs which were directed towards implementing long-term changes. In addition, some women expressed concern that the program would serve to strengthen the medical system by teaching physicians how to “manage” their “patients” (by changing their behaviors without changing their power in doctor/patient encounters). Other members of the collective thought that teaching medical students would be a way to improve existing services for women and therefore that it would be a useful interim reform. They also thought that it would be a way to direct money from the medical schools to part of the women’s health movement and a way of gaining access to the medical educational system. This controversy influenced the process of setting up the Pelvic Teaching Program (PTP) and of evaluating and changing it over time and was never completely resolved at the Women’s Community Health Center.
In late 1975, the WCHC expanded this program by recruiting women who were not members of the collective. They also formalized the program by creating an ongoing group called the Pelvic Teaching Program. The PTP was a semi-autonomous program of the Women’s Community Health Center. It was also the first attempt in which collective members worked along with women who were not members of the collective. This led in part to difficulties in communication and questions about power and decision-making among group members and also between the group and WCHC. For instance. to what extent could the Pelvic Teaching Program devise and implement its own structure and to what extent was it accountable to WCHC? Were WCHC members in the PTP more powerful than the others in the group? Could WCHC direct the PTP? The course of the PTP can be traced in stages, each marked by a new protocol.
The First Protocol
In the first sessions changes in standard teaching methods were relatively superficial: “pelvic models” were each paid $25 for each teaching session. In each teaching session, four or five medical students did a bimanual pelvic examination 2 on a consenting, knowledgeable woman, while taught by a physician-instructor. Sessions focused on attitudes and the manner in which students learned to perform a pelvic examination. They left intact the role of physician-instructor. Meanwhile, the feminists did research to find out what had been taught at Harvard and what the professors and students were interested in implementing. The feminists met to evaluate this limited program and then met with the professors and medical students to draw up a protocol. The physician-instructors and medical students were pleased by this limited program. It facilitated more efficient, comfortable teaching sessions. The feminists were dissatisfied. In a retrospective analysis they wrote that “although we gave active feedback as the exam was being performed, the physicians were the major instructors and the students looked to them to handle the tough problems and to field questions regarding pathology. We had very little control over the teaching sessions.”10 The success of these limited sessions was disquieting; the women realized that while they were ensuring more humane and better exams for women, they were also solidifying physicians’ power over women by participating in training sessions in which students learned how to instill trust in themselves by making women more comfortable and informed about pelvic examinations. They saw that this accommodation to the current medical system was a way to strengthen the medical system rather than to change it. They thus proposed a new protocol, which was accepted and implemented.11
A Second Protocol
The second protocol included changes both in the teaching group and in the teaching sessions. The feminists created a formal group, called the Pelvic Teaching Program, and recruited community women to become members. Community women were selected using the following criteria: prior enrollment in a self-help group (this would ensure their familiarity with the concepts and practice of the self-help movement and WCHC familiarity with them); a willingness to share skills with medical students; a commitment to delineate and to critique the underlying goals of the current medical system in their teaching sessions; and a commitment to interrupt sexist, professionalistic, or otherwise offensive behaviors during the sessions. WCHC members were included on the basis of their willingness to put energy into teaching medical students and to participate in a controversial new program.
In teaching sessions, they implemented the following: two feminist instructors from the PTP met with four or five students, at least one of whom had to be a woman. Members of the PTP instructed students; and physicians, if present at all, assumed the role of silent observers. The feminists required a written contract and were paid $50 for each session instead of $25 for each “model” to emphasize their altered status. Each session was focused on a well-woman approach to medical care, describing the wide range of normal conditions. They demonstrated how women can examine their own genitals using a plastic speculum, light, and mirror. Each teaching institution agreed to reproduce and distribute to the medical students “How to Do A Pelvic Examination,” written by the feminists from WCHC. Part of their proposal was not accepted by Harvard. This included purchase of an information packet written by feminists for each student as well as a separate second session to give information about women’s health concerns in more detail to the students. The Pelvic Teaching Program, now consisting of five WCHC members and six affiliated women, began to meet in an ongoing self-help group amongst themselves, to share criticisms, and perspectives about the program, as well as to devote energy to practical training, information, and skill sharing on a personal and political level. They used the group as a way to cope with embarrassing or offensive encounters and to devise strategies to avoid them in future sessions. They also used the group as a way to share their feelings about their dual roles as “models” and instructors.
They shared information about their program through meetings with other women, in reports to WCHC, and through the health center newsletters. At times, women in the PTP felt misunderstood or unsupported by WCHC. One of the ways in which the PTP and WCHC addressed this issue was by requesting that WCHC members who were not in the PTP observe teaching sessions to understand through first-hand observation what the instructors experienced. Within WCHC and the PTP individually, as well as in dialogues between the two, they addressed the controversial questions about the usefulness of an interim reform in physician education compared with other long term changes; they looked at power relations and communications between the PTP and WCHC.
The PTP wrote to HealthRight, a newsletter published by women’s health activists, outlining their new protocol, and pointing out why specific changes were made. They requested that any women thinking of teaching pelvic examinations to medical students contact them. They thought that this would be a way of empowering themselves and other women, realizing how isolated they had been when their own program began. As a result of their own experiences they strongly suggested that any women who were going to teach pelvic examinations be involved in a group, so that they could share skills and support for each other.
The report in HealthRight generated criticism as well as excitement within the women’s health community. Although some thought it was a victory to find members of the women’s health movement being asked to teach medical professionals, others felt that training doctors was simply a cooptation of long-term strategies.
Up to this point, the PTP was similar to parts of other “Simulated Patient” programs. Responses to the PTP by students and physicians were similar to those enumerated in accounts of “Simulated Patient” programs that I surveyed: student response was favorable, with a few exceptions. Physicians who observed sessions reported that the teaching was excellent. Generally students felt more at ease, learned technical skills more thoroughly, and were better equipped to perform examinations on patients. Some of the negative responses of the students reflect the difference in the PTP from the “Simulated Patient” programs: some were distressed by the “women’s libbers” stance of the feminists.
In the Spring of 1976, the members of the PTP analyzed the program and began to assert their unique political perspective. It happened in three ways:
(1) Through the political development of the group itself.
(2) By means of the issues that the feminists, as part of the women’s health movement, wanted to address through the PTP.
(3) In the institutional response of the medical schools to the Third Protocol.
The second protocol left basic contradictions unresolved. As nonprofessionals, they taught professionals techniques that only professionals could use legally; men learned how to practice medical care for women; fragmented medical care was encouraged by the program since the feminists met only once with students, thereby offering limited and isolated information; hierarchical power relationships between provider and receiver and amongst providers were not confronted.
After their analysis of the second protocol and its implementation, the members of the PTP met as a group to write the Position Paper to evaluate their experiences as a group and as individuals, and to devise a new protocol that would meet their needs and serve their political purposes. The Position Paper outlined their self-criticism and their suggestions for questions to be raised by other women before beginning to teach pelvic examinations. They circulated this in Boston women’s publications, in HealthRight, and in Women and Health, and sent out copies of it to any people who had inquired about the PTP over the past year. By this time, members of the medical profession had heard about the PTP as well, and wanted information about the program and copies of the manual written by the feminists as a sourcebook for their own programs.12
In discussions leading up to the formulation of the third protocol, the women in both the PTP and the WCHC addressed the ongoing issue of reform versus radical change. In their analysis of events, they concluded that as a reform within the medical system the PTP had been successful, but that it had failed to Institute long term change.
In order to emphasize their self-help politics, a third protocol was devised which would make explicit the differences between their point of view and the point of view exhibited by creators of the “Simulated Patient” programs. They devised a program which would be acceptable to them and thereby, they expected, not acceptable to the medical schools. Rather than presenting a critique. they proposed a new program, thereby requiring that the medical school officials respond.
The Third Protocol
The third protocol included the following changes: first, teaching would be limited to women. The PTP as part of the self-help/women’s health movement was committed to reciprocal sharing, and learning through reciprocity is not only different from, but more meaningful than, one-way learning. The PTP could only have integrity as a self-help experience if there was reciprocal sharing. This would entail being examined as well as examining. By definition, then, the teaching of pelvic examinations would be limited to women. By limiting the teaching to women, they wanted to force all the medical students to address the question: should men be providing gynecological care for women?
The feminists had also found that despite their efforts to the contrary, they had felt embarrassed and exploited by some of the male students — and they wished to avoid focusing attention on this part of the training. By teaching only women, they thought that it would be a more positive experience for themselves and rid them of sexual exploitation during the sessions.
Second, each teaching group of four or five women would include not only medical students, but also other hospital personnel and consumers, taught by two women from the PTP. By doing this, the feminists would address the issues of hierarchy and elitism among medical care providers and between providers and consumers, which encourage physicians to maintain a monopoly of skills and information. Instructors would exchange roles with others in the teaching group, emphasizing the need for a breakdown of the rigid hierarchy among physicians, nurses and other health workers as well as that between powerful physicians and passive “patients.” They would also promote identification and recognition of similarities between provider and consumer rather than objectification and distance. This would help to demystify and defuse the physician’s power and be a way of stimulating discussion about these issues.
Third, the new protocol called for three or four sessions with the same individuals to allow time for analysis of the politics of medical care, to share health information of special relevance to women, to discuss what a good examination should include, and to perform self-examination. This would challenge the teaching of medical care as fragmented and episodic. By placing the technical skills and information within the general context of the politics of medical care, they would stimulate discussion about commonly held assumptions about what students are learning and why.
Fourth, the PTP raised their fees, in recognition of their value as instructors, and of the ability and common practice of the medical schools to pay higher consultant fees. Fees were raised to $750 for the four sessions.
The issues addressed in the third protocol were hierarchy, sexism, fragmentation of learning skills, profit, and division between provider and consumer. By this time, the PTP had been approached by the other area medical schools, Tufts and Boston University. As had been predicted by the PTP, no medical schools wanted to implement this program. Reasons varied: it was too expensive; it discriminated against men. As long as the PTP fell within the acceptable range of innovations, exemplified by the “Simulated Patient” programs, it remained an acceptable program. When it confronted basic power relations and current assumptions about the goals of medical education, the PTP became unacceptable to current teaching programs. At this stage, in the summer of 1976, the PTP ended: women received inquiries and sent out the third protocol after that date, but have no longer taught sessions.
What can we learn from the experience of the PTP? One way to evaluate it is to see in what respects the women successfully implemented a reform in physician education. The PTP demonstrated that a group of nonprofessionals could devise and implement a program. By example, then, the women demonstrated within the medical community that “consumers” can educate themselves and become active members in the medical community. The PTP established themselves as credible teachers to both medical students and physicians. By identifying themselves as feminists, the PTP openly brought political awareness and political issues into a teaching situation and confronted sexist attitudes and practices as they emerged in the teaching sessions. In addition, by emphasizing use of common language to describe medical procedures, and by demonstrating how a woman can participate in the examination, they focused on the distinction between provider and consumer and suggested ways that the consumer could gain more power in the encounter through knowledge and skills. They self-consciously went about channeling money into the women’s health movement; and got a good first-hand look at medical education. They created a need for feminists to teach pelvic examinations to medical students. They accomplished this both by their success in the first two phases, and also by their visibility in the women’s health movement by doing this: medical students and health activists read about their success and the way that they went about teaching and meeting as an ongoing group, and saw by their example that it was possible.
The feminists wrote and circulated a manual for teaching pelvic examinations which is still in demand. The PTP gained considerable attention not only in the local medical and women’s communities, but also nationally, through publications and networks. They continue to receive requests for protocols, for copies of their manual, and in general for information about how to implement pelvic teaching programs.13
However, in their own analysis, the PTP concluded that these successes were insufficient to outweigh the time and energy necessitated by the program. Their decision can be better understood if we turn to three issues: first, the PTP lacked a complete understanding of the history of “Simulated Patients” programs; second, the PTP evolved as a semi-autonomous group out of the WCHC, raising the issues of power and communication within a group of collective members and affiliated women, and between the PTP and the WCHC; and third, they carried on an ongoing dialogue about the advisability of instituting an interim reform.
In some respects, the task of the PTP had been made more arduous by their lack of complete knowledge and analysis of other programs. As we have seen, the development of the PTP occurred through its own experiences rather than being shaped by a vision of the eventual outcome.
When the feminists designed the protocols, it was without a historical analysis of the use of “Simulated Patients” and without a complete overview of contemporaneous programs (having only looked at what had been taught at Harvard previously and screened one videotape of a program in which a physician performed a pelvic examination14 on a “Simulated Patient”). If they had begun with a complete overview of precedents already set by other innovative “Simulated Patient” programs, they might have chosen other strategies with which to confront Harvard with an educated overview. The first two protocols followed essentially the same lines as “Simulated Patient” programs. What seemed to the feminists, at times, as risky and dangerous at Harvard, had already become institutionalized in other medical schools.
It was with the third protocol that the women were not only devising a better program, but were also explicitly challenging commonly held assumptions about medical care and explicitly stating some of their own political goals: to eradicate hierarchy and professionalism; to have women provide women’s health care; to redefine the distinction between provider and consumer and to empower the consumer vis-a-vis the provider; and finally to challenge the monopoly over money and resources that medical schools have.
As a new program of the WCHC, the PTP was the focus of an evolving mechanism for implementing similar WCHC programs in the future. This process entailed working out problems and concerns raised during the course of the group about ways to facilitate communication and decisionmaking in a semi-autonomous program; at times this process was frustrating and stressful.
In addition, the PTP was never wholeheartedly supported by members of WCHC. Not only were the women in the PTP constantly re-examining their goals and strategies, but they were shaped by the ongoing controversy in WCHC about whether to teach medical students. This contributed to a sense of frustration and exhaustion when the PTP evaluated the first and second protocols and drew up the third.
Finally, the task of initiating reforms in physician-training necessitates constant confrontation of the educational structures and individuals serving to oppress women. On the one hand, the struggle faced by the women to implement even the first protocol at Harvard demonstrates the threat they posed as feminist nonprofessionals entering the confines of medical providers. On the other hand, the ability of educational institutions to absorb· and co-opt innovations is striking: teaching medical students ways to improve the pelvic examination for women was taken by them as a technique of managing their “patients” in sessions taught according to the first and second protocols. This ability was taken seriously by the feminists in their evaluations of the success or failure of the PTP, and must be recognized by others considering similar programs. What might appear to be positive reforms in theory might prove to be cooptations in practice, and hence not positive in the long run. Because the feminists paid close attention to the impact of their program during the process of setting it up and implementing it, they were able to evaluate it realistically.
In retrospect, we can see that the PTP was successful in some important ways and provides a thoughtful and politically responsible example of the ways in which health activists might institute change in the medical system. The experiences of the PTP also underline the necessity of an ongoing reassessment of the long range implications of short term reforms, not only in theory but in their practical application.
This article is a revised version of a presentation given at the fall conference of the Massachusetts Sociological Association on November 4, 1978. I would like to thank members of the Pelvic Teaching Program, the Women’s Community Health Center, and the Science for the People Editorial Collective for their help and support in writing this article. Charlotte Weissberg provided sisterly criticisms.
Susan Bell is a founding member of the Pelvic Teaching Program and worked at the Women’s Community Health Center in Cambridge, Mass. for two and one-half years. She is currently completing her doctoral dissertation, which is a critical history of diethylstilbestrol (DES), a synthetic estrogen.
- For example, see the following: Kotelchuck, David, ed., Prognosis Negative, New York, Vintage Books, 1976; Dreifus, Claudia, ed., Seizing Our Bodies. New York, Vintage Books, 1978; Boston Women’s Health Book Collective, Our Bodies, Ourselves, 14 New York, Simon and Shuster, 1976.
- Nurses, nurse practitioners and physician assistants also perform pelvic examinations. It is beyond the scope of this article to look at the differences among these professionals and between them and physicians.
- Bart, P., Scully, D., “A Funny Thing Happened on the Way to the Orifice: Women in Gynecology Textbooks,” Am. J. Soc. 78:1045- 1050, 1973; Howell, M., “What Medical Schools Teach About Women,” N Engl.J. Med. 291-304-307, 1974.
- Emerson, J., “Behavior in Private Places,” in H.P. Dreitzel, ed., Recent Sociology No. 2: Patterns of Communicative Behavior, New York, The MacMillan Company, 1970, pp. 74-95; Shaw, N.S., Forced Labor, New York, Pergamon Press, Inc., 1974.
- The term “patient” will be used in quotes to remind the reader of the debates over the definition of health and illness in society and over the power relations between provider and consumer of medical care.
- Teaching hospitals and clinics associated with medical schools provide services and are also training institutions. Hence “patients” receive care and provide teaching material.
- See the following for discussions of these programs: “Announcement: Using Nonphysicians to Teach Pelvic Examinations,” Contemporary Ob/Gyn, 11:173, 1978; Billings, J.A., Stoeckle, J.D., “Pelvic Examination Instruction and the Doctor-Patient Relationship,” J. Med. Educ. 52:834-839, 1977; Godkins, T.R., Duffy, D., Greenwood, J., Stanhope, W.D., “Utilization of Simulated Patients to Teach the ‘Routine’ Pelvic Examination,” J. Med. Educ. 49:1174- 1178, 1974; Holzman, G.B., Singleton, D., Holmes, T.F., Maatsch, J .L., “Initial Pelvic Examination Instruction: The Effectiveness of Three Contemporary Approaches,” Am. J. Obstet. Gyn. 129:2, 124- 129, 1977; Johnson, G.H., Brown, T.C., Stenchever, M.A., Gabert, H.A., Poulson, A.M., Warenski, J.C., “Teaching Pelvic Examination to Second-Year Medical Students Using Programmed Patients,” Am. J. Obstet. Gyn. 121:5,714-717, 1975; Kretzschmar, R.M., “Evolution of the Gynecology Teaching Associate: An Education Specialist,” Am. J. Obstet. Gyn. 131:4, 367-373, 1978; Schneidman, B., “An Approach to Obtaining Patients to Participate in Pelvic Examination Instruction,” J. Med. Educ. 52:70-71, 1977.
- Information about the Women’s Community Health Center (WCHC) and the Pelvic Teaching Program have been gathered from the following sources: Women’s Community Health Center, Inc. “Experiences of a Pelvic Teaching Group,” Women and Health 1:4, 19-20, 1976 (this is a reprint of the Position Paper, June, 1976, available from WCHC, 639 Massachusetts Avenue, room 210, Cambridge, Massachusetts 02139); WCHC, Third Annual Report, Cambridge, Mass., 1977; WCHC, “Letter to the Editor,” HealthRight, 2:3, 2, 1976 (The address for HealthRight is 41 Union Square, Room 206-9, New York, NY 10003); WCHC, “Announcement,” Women and Health. 1:1, 17, 1976; WCHC, “How to Do a Pelvic Examination,” 1976; WCHC, “Proposals to Teach Pelvic Examinations to Medical Students,” 1975 and 1976; Norsigian, J. “Training the Docs,” HealthRight, 2:2, 6, 1975-76; Other sources have been informal and formal discussions with the PTP and the WCHC. As a member of both the PTP and the WCHC, I have drawn from my own experiences as well as from the above sources.
- The development of the PTP could be analyzed from the point of view of the medical institutions as well as from its self-concept. This article will concentrate on the PTP from the feminist perspective.
- The quote is from the Position Paper.
- Through various networks, other women’s health groups and publications heard about these sessions. Health Right, Women and Health, and Liberation News Service published information about the program.
- The PTP has refused to supply copies of their manual to any members of the medical profession out of context.
- For discussions of the PTP written by members of the medical profession, see the Billings and Stoeckle article and the Announcement, listed in Note #6 above.
- A person conducts a bimanual pelvic examination by inserting two fingers into a woman’s vagina and feeling her cervix (tip of the womb or uterus, which extends into the vagina), and with the other hand presses down on her abdomen. In this way, the person doing the bimanual pelvic examination can feel the size, shape and position of a woman’s uterus and cervix. A bimanual pelvic examination also includes checking a woman’s external genitals.
A speculum is an instrument that is used to separate the walls of a woman’s vagina to be able to visualize her vagina and cervix. By use of a mirror and light a woman can see her own vagina and cervix.