The speculum is a misogynistic device. Women dread pap smears, forced into a position of ultimate vulnerability as a hard piece of metal or plastic is placed deep inside their most feminine of caves; how could they not? Samantha feels nausea at the thought of a pap smear, her legs clamping together, she is desperate to escape the horrific sensations of her childhood that it is bringing back. How could I, a midwife, do that to a woman?
The speculum was invented by James Sims and was based on his initial use of a gravy spoon in 1840. As this instructively awful article describes, it was first used as he experimented on slave women suffering from recto-vaginal fistula in Alabama. Its history is unsurprisingly nasty.
In the1970s radical feminists co-opted the speculum in an effort to reinvent it as a tool for women’s self-knowledge. People have tried to design a less awful speculum too, without much success. Just as obstetrics must escape from the stirrups and the delivery bed in order to be women centered, so the speculum must get rid of its handle in order to free women from the required position of submission and vulnerability.
I try to help Samantha to be OK. She keeps her clothes on the upper part of her body. She is draped in a colorful cloth. The lights are dimmed. If she is very anxious, we can move to the edge of the bed in the birth room, low music playing. I can introduce her to the plastic duck. She can handle it, understand visually and physically what it does; but I have not escaped the speculum.
I persist because pap smears are simple tests that save lives. That is true.
But since I started doing pap smears in the 1990s, things have become murkier. Now a pap smear is no longer a few cervical cells smeared onto a slide and assessed for cancerous or precancerous cells. The sample collected is used to look also for human papilloma virus (HPV) which is a precursor to most, although not all, cervical cancer. It is a more nuanced test for a more nuanced understanding of the causes of cervical cancer. The frequency of recommended pap smears has been reduced so women suffer less speculum exams. And there is now an HPV vaccine. These advances together must surely be positive. But as with most things, it’s complicated.
Cervical cancer is the third most common female cancer worldwide but the burden of cervical cancer is many times greater in poor countries than in rich countries. This is because of inadequate medical infrastructure in poorer countries. Reduction of the disease in rich countries is because of the pap smear. Cervical cancer is a disease that when discovered in a precancerous state can be treated easily and successfully. The pap smear and its nasty partner, the speculum, have made that true. People in richer countries still get cervical cancer. But it is not common and they very rarely die from it.
If this is so, why develop a vaccine? Was this medicine looking for an answer to a problem that wasn’t really there? If women have regular pap smears, cervical cancer can mostly be prevented. So why develop an HPV vaccine to prevent cervical cancer when we already have a cheap and effective way to do the same thing?
The HPV vaccine has attracted a lot of negative attention and its manufacturer, Merck, has pushed back. Much of the focus of debate is on the merits of injecting a vaccine for the prevention of a sexually transmitted disease (HPV) to children as young as 8 years old. This criticism detracts from the question of the real efficacy of this approach to women’s health and Merck’s motivation. For “full protection” 3 doses on 3 different occasions are required for a total cost of about $500. Both the cost and the number of injections required make this a potentially very ineffective tool particularly in poor countries where the problem is the greatest. Additionally, it is as yet unknown how many years it remains effective.
Unless there is a cheap, safe, effective alternative, the nasty old pap and speculum are the way to go.
I am sorry Samantha and all those women who share her feelings. I will continue to offer speculum exams and to be as gentle with my plastic duck technique as I can, offering up curses to Dr Sims for his awful and useful invention as I do so.