The history of the pelvic exam with Wendy Kline

A Q&A with the author of Exposed: The Hidden History of the Pelvic Exam

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Wendy Kline, Ph.D., Dema G. Seelye Chair in the History of Medicine at Purdue University, is internationally recognized for her scholarship in the history of medicine, history of women's health and the history of childbirth. She is the author of four major books: Exposed: The Hidden History of the Pelvic Exam (Polity, June 2024); Coming Home: How Midwives Changed Birth (Oxford University Press, 2019);  Bodies of Knowledge: Sexuality, Reproduction, and Women’s Health in the Second Wave (U. of Chicago Press 2010); and Building a Better Race: Gender, Sexuality, and Eugenics from the Turn of the Century to the Baby Boom (U. of California Press, 2001).

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Like so many medical procedures in America, the pelvic exam has a dark history, from gynecological research on enslaved women’s bodies to practice on anesthetized patients. Can you explain the origins of this procedure?

The rise of the pelvic exam coincided with the emergence of gynecology as a medical profession in the mid-nineteenth century, and the development of the vaginal speculum. Ever since then, doctors have expressed concern and discomfort over the implications of peering into a woman’s vagina, including the alleged “father of American gynecology,” James Marion Sims, who developed the “Sims speculum” while performing countless surgeries on enslaved women.

Initially, figures like Sims used the speculum—which offered unprecedented medical insights into the female body—with hesitation. Indeed, Sims made it perfectly clear that he was not in any way enthused at the thought of peering into women’s vaginas. This would be scandalous. Significantly, he noted that “if there was anything I hated, it was investigating the organs of the pelvis,” in his memoir. Nonetheless, the speculum triumphed, ultimately giving men more medical power and authority over women patients, who frequently had little or no power to consent along the way. 

In the 19th century, doctors (who were overwhelmingly male) embraced the speculum and other gynecological instruments as tools to help differentiate them from midwives. Those doctors believed patient consent to a pelvic exam was unnecessary. How did that encourage the abuse and exploitation of patients?

Ever since the introduction of the pelvic exam in the late 19th century, consumers and doctors have struggled to understand and define the boundaries between preventive health and sexual impropriety. This blurriness, in turn, resulted in opportunities for male doctors to exploit women and exert power over them under the guise of medical expertise.  

For example, Dr. A.F.A. King, professor of obstetrics at Columbian University, noted in his 1895 obstetrics textbook that a vaginal exam, while rarely needed, was necessary to determine whether a woman was in labor. It was not necessary, he assured the reader, to “obtain verbal consent of the patient before instituting the examination.” Proceed “without hesitation as if consent had already been obtained,” he told them, adding that there was no need for “explaining your actions.” Silence was preferable. “The less said the better,” he emphasized. If women cried or resisted? “Proceed just the same,” he explained.  

This powerful message, which essentially enabled medical men to violate women’s bodies against their will, underscored the extent to which women were completely at the mercy of their doctors. They did not need to be informed of penetration, and they were not allowed to resist. It would take nearly a century to break the silence about the potential for abuse in the examining room.

In the 1970s, women’s health activists began to draw attention to patient abuse and linked it to sexism; 93 percent of all ObGyns were male at the time and dismissive of women’s complaints. Who are some of the heroes who have tried to change a medical system that has harmed many women? 

This is a tough question to answer only because there are so many heroes in this story! Women’s health activism was very much a grassroots movement involving thousands of women, whose experiences at the doctor’s office led to anger and frustration. My second book, Bodies of Knowledge, focused on women’s search for equality through access and information about their own bodies. One way of doing so was to research and write health manuals, such as the bestselling Our Bodies, Ourselves: A Book By and For Women, which became a bestseller shortly after publication in 1970. This book inspired millions of readers to question medical authority and the ways in which their bodies were treated. The original goal of the group who wrote the book (they called themselves the “Boston Women’s Health Book Collective”) was simply to draw up a list of “reasonable” ObGyns in the Boston area (by reasonable, they meant doctors who listened to the patient; respected her opinions, and explained procedures and medications.). They quickly realized, however, that they were unable to come up with a single name to put on the list! So instead, they decided to do their own research on the questions they had about their bodies, which eventually led to the publication of Our Bodies, Ourselves. 

One of their complaints was how poorly they were treated when getting a pelvic exam, which could be anything from painful to traumatic. In Exposed, I show how these women (who typically identified as “health feminists”) played a key role in challenging how the pelvic exam was taught and practiced—and who should do them. Some campaigned to end medical education quotas which had restricted women from going to medical school. Others took matters into their own hands, promoting the idea of self exams and eliminating the gynecologist altogether. In their hands, the speculum became a tool of empowerment rather than an instrument of torture. At the first “women and health” conference in England, held at the University of Sheffield in 1974, conveners composed a conference anthem, called “The Witches are Back.” The final verse spoke to the importance of gynecological self help:

With a speculum in every woman’s hand
We’ll fight for our freedom in every land
We’ve been fucked over for far too long
But with our speculums—WE ARE STRONG!

The revolutionary appeal of the self-exam lost much of its appeal by the 1990s, however. Stripped of its revolutionary potential (and aided by increased access to medical information and images by the 21^st century), self exam appeared as an unsavory form of navel gazing. However, since the overturning of Roe v Wade in 2022, it has increased in popularity as a mechanism for self abortion.

Your book focuses on the importance of patient consent. In the 1990s, nearly 40 percent of pelvic exams were performed on patients without consent, and frequently on women under anesthesia. And even in this century, pelvic exams were being done on anesthetized women without specific consent as a training procedure for medical education and training. Black patients are four times as likely to report having had an “unconsented intimate examination." How has the Department of Health and Human Services worked to change that, and what other changes are needed to evolve the pelvic exam?

On April 1, the Department of Health and Human Services released a letter to the nation’s teaching hospitals and medical schools to “reiterate and provide clarity” about the need for written, informed consent before “sensitive and intimate examinations” such as breast, pelvic, prostate, and rectal examinations, as part of medical training. Any institutions that do not comply with such rules could lose Medicare funding.

Regulation of the pelvic exam is long overdue. How medical trainees learn to perform it is crucial, because of the intimacy of the procedure. In the 1970s, health feminists were among the first to draw attention to the issue of consent, directly linking it to sexism in medicine (because 93 percent of all gynecologists were male in the U.S.). One solution was to bring more women into medicine, as quotas were being eliminated.

And yet, increasing the number of female students did not immediately transform medical education or training nor did professional organizations recommending against the practice without consent. When a 1983 study found that twenty-three percent of US and Canadian schools reported using anesthetized patients to teach the pelvic exam, the following year the Joint Committee on the Accreditation of Hospitals declared that patient participation in clinical training programs “should be voluntary.”

Despite this, the numbers of pelvic exams performed without consent, frequently on women under anesthesia, only increased; by 1990, that percentage was up to thirty-seven percent.

By 2011, Shawn Barnes, a third-year medical student at the University of Hawaii medical school, was shocked after doing his ObGyn rotation, where he was asked to perform pelvic exams on anesthetized women, without specific consent, “solely for the purpose of my education.” His attending physicians told him it was “considered standard procedure,” however.  

Barnes joined a growing number of increasingly vocal medical students who were alarmed by the practice and the message it sent to medical students dismissing the importance of consent. 

Yet the practice, though decreasing, still continues, even though most regulatory institutions either recommend against it or explicitly forbid it. In 2022, the Hastings Center published the first national survey to determine the frequency of the practice in the US; 1.4 percent of respondents answered in the affirmative. This translates to as many as 3.6 million patients in the US potentially receiving such exams; and of course, since the practice is done without patient knowledge or consent, the numbers could be much higher.

What is even more disturbing is the racial bias exposed by the survey; black respondents were four times as likely to report having had an “unconsented intimate examination.” Given that this practice takes place in teaching hospitals, it “disproportionately impacts poor and ‘public’ patients, many of whom are uninsured or minorities.” Just as enslaved women were at James Marion Sims’ disposal in the mid nineteenth century, black women’s bodies today remain more vulnerable to medical exploitation. 

As a result, assumptions about consent as unnecessary have persisted and are at the core of the sexual abuses that continue around the pelvic exam today. Without clear guidelines, such as those just issued by the Department of Health and Human Services, and without a common language to articulate what should be going on during a pelvic exam, it makes it harder to identify what shouldn’t.

When done carefully and respectfully, the pelvic exam remains a valuable, if contested, aspect of reproductive healthcare. The April 1 decision by HHS to require consent for a pelvic exam, particularly on unconscious women, for medical training purposes rather than for the patient’s benefit, makes it abundantly clear that this is not just a problem of the nineteenth century; it’s a problem right now. We need to speak openly and honestly about respectful conduct in the examining room, as well as appropriate medical training that does not rely on patient exploitation.

Today, pelvic exams are considered a routine medical procedure, but for many of us, they're not just often unpleasant, but mysterious. In a 2017 study, for example, only about half of women surveyed about cervical cancer screening felt they knew the purpose of the routine pelvic exam. Can you shed light on the importance of this procedure and how women can feel safe and advocate for themselves? For example, should they ask for a chaperone in the exam room? 

For many women, a pelvic exam, provided in the context of a well-woman visit, can be life-saving. Even if a patient isn’t experiencing any health problems, the exam can allow the provider to help to explain a patient’s anatomy, reassure her of her normalcy, answer specific questions that she may not feel comfortable asking elsewhere, and establish a safe and open communication between her and her provider. 

But unfortunately, this often is not the case. In a 2017 study, half of patients surveyed could not answer the question, “do you know why this examination is performed” directly after receiving one. This only adds to the confusion and misunderstanding when abuse occurs.

And abuse in recent years occurs all too frequently. The past decade has seen a staggering number of sex abuse cases involving physicians, many of whom abused students, athletes, and patients for decades. 

In 2013, for example, Dr. Nikita Levy, a gynecologist a Johns Hopkins East Baltimore Medical Center, was caught secretly photographing his patients’ vaginas while performing pelvic exams, sometimes without wearing gloves, in a case that involved over 8,000 patients. Dr. Larry Nassar, the former doctor for the US women’s gymnastics team, was sentenced to up to 175 years in prison in 2018 after 250 women accused him of sexual assault during alleged medical treatment. And as recently as 2023, 245 patients of Dr. Robert Hadden, a gynecologist employed by Columbia University Medical Center, allege that they were sexually assaulted by him during gynecological exams.

Of course, these cases are not representative of the medical professionals who routinely perform pelvic exams, but their stories serve as a warning of how easy it is for pelvic violence to happen under the façade of medical treatment.

Sometimes, the use of a chaperone can set a patient at ease (although abuse has and can still occur with someone else in the room). But not every patient wants yet another person involved in this procedure, which can equally add to the stress. Any practitioner performing a pelvic exam should approach the patient with respect and care, as well as transparency about what they are doing—and for what purpose.

You talk in your book about how society continues to be uncomfortable knowing about or discussing women's sex organs. Studies show women are uncomfortable using the terms "vagina" and "vulva" and are unable to identify the parts of their vagina on a simple diagram. As a result, many women avoid going to the gynecologist due to shame or embarrassment, and they're missing out on necessary medical tests. What do you attribute this to, and how do we fix it?

I attribute this discomfort to a larger social and political problem about the female body. One gynecologist, Dr. Sherry Ross, writes that “vaginas are everything,” meaning they are “one of the most crucial parts of achieving real wellbeing.” But so many of her patients can’t even say the word vagina or ask her meaningful questions about their bodies. This is a lost opportunity, but it’s even worse outside of the examining room. For example, in 2012, Michigan State Representative Lisa Brown was banned from speaking in the House because she used the term “vagina” in a debate over an anti-abortion bill, a term which her Republican colleague found “offensive.” In response to the gag order, she and other fellow congresswomen uttered the word more than one hundred times on the state capitol steps while performing “The Vagina Monologues.” “If you think there’s something wrong with the word ‘vagina,’ what word would you like me to use instead?” she asked. Such examples serve as reminders that anyone with a vagina has been discouraged to ever talk about their body parts in public, even when their health and wellbeing is at stake. Fear and stigma have literally cost some women their lives. And the first step towards fixing this problem is simply to talk about it! Get comfortable using the word, and if you’re not, ask yourself why. What is the source of that discomfort? Have a conversation about this with friends as well, and start getting angry at the ways in which this type of conversation has been silenced.

You've said that the pelvic exam is more than just a medical procedure; it's a window into a deeper, more meaningful set of questions about gender, medicine, and power. What do you want readers to take away from your book?

I think there’s a tendency in our culture to take medical procedures – such as the pelvic exam – at face value. We don’t think about how the procedure evolved (or didn’t evolve), or what might be problematic about it. After all, if it’s medical, and if it’s practiced by doctors, it must be good for us, right? But as Boston entrepreneur Eloise Davenport recently put it, “how, in a time of untold innovation such as we live in, is this aspect of women’s healthcare—the dreaded pelvic exam—still stuck in the nineteenth century?” It appears to be just as unpleasant as it was over a hundred years ago.

And equally shrouded in mystery. The fact that half of women surveyed don’t know the purpose of the pelvic exam just after receiving one is hugely problematic; how can we advocate for ourselves if we don’t even know what’s being done to us, or why?

The reality is, this is an exam that dangerously blurs the boundary between sex and medicine. 

Historically, it’s been directly linked to getting a prescription for the birth control pill. If you haven’t seen the pilot episode of Mad Men, when Peggy Olson is forced to visit the gynecologist (it’s set in 1960) and subjected to condescension because she’s unmarried, go watch it. It’s remarkably historically accurate, and painful to watch. We’ve been taught to just shut up and take it—and not complain about it.  The stigma surrounding this procedure is really powerful.

The stigma—and the silence—needs to stop. I hope that reading this book leads to conversations among friends, and with healthcare providers, about why it is so stigmatized. I want medical students to think about this as well. Recently I gave a presentation on this research to medical students at Northwestern University. One student remarked that they had initially been terrified at doing a physical exam and the power it wielded, noting that “it meant having to touch someone’s body under the assumption that you’re doing so to further their care.” However, after six months of “desensitization” through rounds of practice in clinical sessions, the “fear and mystique had worn off.” Learning about the pelvic exam’s “fascinating history” made the student realize “how tenuous the physical exam is as a contract between the patient and the physician.” During an exam, the student now realized, “I should be wary of what each action means to the patient, and that my understanding of each action may be different from how they understand it, either from history or personal experience.” Such awareness requires sensitivity; not desensitization. “I feel like there’s something valuable in fully feeling my fear for the physical exam and not getting too comfortable too quickly.” Another student found a solution to today’s pelvic exam problems by linking it to the history I’d provided: “Giving power to patients seems to be at the core of improving physician–patient relationships and patient outcomes in gynecology, as it was founded precisely on patients’ absence of power.” This student embraced the connections between past and present in order to create change—my dream come true. This is what I want readers to get out of the book.