E81: The Emotional Domain of Pap Smears

Kirtly: Years ago, I went to a fundraiser with my husband and my 16-year-old son. It was a local production of "The Vagina Monologues." I sat next to my son. I didn't hold his hand. My husband sat next to a friend, and they were 2 of maybe 10 men in an audience of 200 women, including the president of the university. I was so emotionally uncomfortable as I listened to women on stage talk about their Pap smears.

I'm Dr. Kirtly Jones from obstetrics and gynecology at the University of Utah, and today we're continuing our deep dive . . . can I even say that in this context? Oh, dear . . . into the emotional domain of Pap smears.

With me in the Virtual Scope Studio is my partner in discomfort, Katie Ward. Katie has a doctorate in nursing practice and is a specialist in women's health. She's an educator, a curious investigator, and has performed thousands of Pap smears.

So, Katie, did you ever see "The Vagina Monologues"?

Katie: I did, and I didn't actually go with any of the young males in my life. They would've crawled right under the seat. "The Vagina Monologues" was such an important work, I think, mostly because it challenged the taboos really at the time about talking about women's bodies and their experiences at the gynecologist.

I mean, now everybody's got a TikTok about it, but in the day, just the title asked people to confront their discomfort even with the word vagina. So I think it was groundbreaking.

Kirtly: It was. Well, it certainly broke my ground, for sure. But there I was in the audience, as a gynecologist and the mother of a 16-year-old young man, intensely uncomfortable as I listened to women on stage talk about fear, and anger, and humor, and many other emotions surrounding their experiences with pelvic exams and Pap smears.

I mean, there were a lot of other topics, but to hear women talk about their pain, their out-of-body experiences when examined so personally, I felt that I was part of that other side, the person who was the examiner, the person who did the pelvic exam, the person who did the Pap smear.

And of course, in this play, there were many other topics around women's lady parts. See, even I . . . Their vaginas, their vulvas, their lady bits. Guys all have names for their parts. I was talking to my husband about junk. They call their parts their junk. I was like, "Oh, really?" But women say their "lady bits" or "down there."

But anyway, the pelvic exam and Paps discussion left me the most uncomfortable. Had I really taken the emotional temperature of my patient in the clinic room, on the exam table before I did the Pap smear? Had I inflicted pain and fear in a patient?

And as I reflect on the thousands of encounters with women and trans men who still need a Pap smear back when we did them, the old-fashioned in the vagina sort of way, I think of the world of emotions that colored my exam room — fear, curiosity, anger, shame, sadness, anxiety, relief. It's a whole . . .

Katie: I was thinking that we could do a whole film of "Inside Out" the Pap smear version. We have every emotion here in the room.

Kirtly: We do.

Katie: I was thinking about this, training to be a nurse practitioner. And I was thinking maybe it's just the timing of when that role came into being. Nurse practitioners weren't a field that we had really until after the women's rights movement and a lot of work done by people like the Boston Women's Health Collective.

Kirtly: Right. "Our Bodies, Ourselves."

Katie: Yeah. I mean, that was my textbook for training to do this work in a lot of ways.

And the other thing that happened in my training program was that we practiced on each other. Now, we don't do that anymore, and I'm not recommending that. But at the time that I was going to school, that was what we did. So I'm really baked into the idea of both being a patient and the clinician at the same time, because that was my experience learning. I was having to also be a pretend patient.

So I don't know if that made a difference, but at least it really put that idea of "I could be in either role in this environment." And so I'm conscious of that, I think, with every exam that I do.

Kirtly: This takes me back to . . . We didn't have what we call the models where people volunteer or are paid.

Katie: Yeah, the gynecologic teaching assistants.

Kirtly: Right. So we divided up in our medical school class with a partner, and we did our physical diagnosis, including the pelvic exam. And I wanted to be a pathfinder and a road builder with a friend, a guy friend, so he was going to be doing my Pap smear, and I was going to be doing his genital exam. We wanted to know how it felt to be examined by someone of an opposite gender.

We were at Fitzsimmons Army Hospital, and the colonel who was the doctor was horrified that I was allowing a medical student who was a good friend . . . I trusted him to do my pelvic exam.

So back in those days, and even now, how we train people to do Pap smears is changing.

Anyway, I would say my own state of mind when performing a Pap smear was one of tenderness. This is as a clinician in taking care of a sister in womanhood. The first part is the clothes that women leave on or take off.

In American exam rooms, women coming in for an annual exam would take off all their clothes without me in the room. I really am uncomfortable being in the room when women disrobe because it's such a vulnerable moment. I'm not going to be there watching them trying to bend over and take off their socks, or whatever, unless that person is disabled and they need help.

But I would leave them with a gown. Put it on open in the back, and many women put it open in the front. It doesn't matter, but convention dictated that women had more coverage and privacy if they put it on open in the back. And a sheet across their laps.

These were the days when we were still doing clinical breast exams once a year. So the gynecologist was the only doctor who actually looked at all of a woman's skin.

I would see a pile of women's clothes, usually with the blouse or the sweater on top. And you'd think that the last things off, which would be bra and panties would be on the top of the pile, but they were almost always tucked underneath so you couldn't see them. It's such a lovely modest gesture.

And some women in denial or discomfort left on their undies. I mean, they knew they were going to have a Pap smear, but they left their undies on, and that required a last-minute removal with a little embarrassment.

Anyway, women were embarrassed that they hadn't shaved their legs, and they would mention it. I always felt tender in the face of women's modesty.

Of course, there were those women from Scandinavia who were totally confused about the gown and the sheet, like, "What am I supposed to do with this?" and just hopped up on the table with no clothes or drapes. They were just naked, and they were so comfortable in their no clothes-ness. And I was kind of uncomfortable with their confidence.

Katie: I think a lot of it is how we're socialized. We're such a weird, modest culture. And maybe that's going to have to be a whole other series on 7 Domains of Modesty.

Kirtly: Modesty. Right.

Katie: But it extends into our language as well. We were just talking about that, that women, we don't even have weird names like males do for their junk. Is that what you called it? But women use euphemisms all the time. "Down there," "lady parts," I think, "private area," anything to avoid saying vagina, vulva, clitoris. And I think that this linguistic modesty is not a coincidence. Women are actually have been discouraged from knowing, or naming, or discussing their genital anatomy.

I have patients now in the menopause care that I do, and they've never even looked at their own vulvas or learned the correct anatomical terms.

And I think that that taboo . . . we were talking about that with "The Vagina Monologues" . . . it creates a form of disconnection with your own body. And so I think that it's important to get a little more Scandinavian and be more comfortable with your naked self.

We've gotten more comfortable with the word vagina since the "Monologues." But people still use vagina now to describe absolutely their entire genital space. So I always like to sort of specify that the vagina is the interior space, the tube. And you can't really see that without a speculum exam.

And the outside part, the part that you could see and inspect yourself, is the vulva, but people don't seem quite as comfortable with the word vulva or even then the specific parts of the vulva. I mean, it's all better than the old medical term, which was pudendum. That's a Latin word, and it actually means "to be ashamed."

Kirtly: Oh, no. Oh, God. I'm never going to use that word again. Never.

Katie: No, don't. And it's not a word that most people would know, but I bring it up just because I think that emotion of shame is really baked into our language going back thousands of years of how people have felt about their genitals. And so unpacking some of that shame is really important.

Kirtly: Yeah. I would usually ask if my patient had any difficulty with pelvic exams or Pap smears, and had they had pain before, or was there anything I could do to make them more comfortable, and would they like a mirror so they could watch what I was doing. And most women were horrified by that suggestion.

I had a pretty conservative patient base, but some wanted to, and we always had a mirror available, and some women have genuine curiosity as a major emotion around a pelvic exam.

Katie, do you remember the scene in "Fried Green Tomatoes," the movie "Fried Green Tomatoes"?

Katie: Yes. "Fried Green Tomatoes at the Whistle Stop Cafe." I do. "It looks like a flower, Rosa." It was a great scene where a group of women all got speculums and looked at their own vaginas with a trusted friend.

Kirtly: It was so funny. This was a modest group of women, and they were having their consciousness reined about their lady bits.

Anyway, anxiety about the unknown, this is common, especially in women having their first pelvic exam or Pap smear. How do you deal with that with your patients?

Katie: I definitely see this a lot. I've done a lot of people's first Pap smear. So there are a lot of things that I do. One is to acknowledge that their feelings are valid and they're rooted in some real historical and maybe some personal contexts.

Medical anxiety doesn't exist in a vacuum. It reflects generations of women being dismissed or mistreated in a healthcare setting. And there have been some real terrible abuses of what should be a safe space in your gynecologist's office. There's some news going on right now about that. And so I think people's anxiety is entirely justified.

I have a similar reaction to dental work. So I think a little about how I get treated at the dentist when I'm in an anxiety-provoking situation. They are very kind to me and do everything they can to give me the control that I need. And so that's my magic touch there, is to give people as much control over this as I can.

And so that might be discussing the procedure, and showing them the speculum to hold and examine and see how it works. Most importantly, I explain that they can tell me to stop at any point. And I mean it. I will stop. So they're in charge, and I say it exactly like that.

For people with really severe anxiety, I might even provide them medication if that's what they need, and the exam is important. For some people, it means deferring the exam until a time when they feel like they can handle that. So anything that gives control back to my patient, I think, is an important thing to do.

But I think that that's been a real paradigm shift, not just gynecology but healthcare across the board. And it really has kind of come out of the women's movement and some of those things that we were referencing, the "Our Bodies, Ourselves" and works like "The Vagina Monologues," that have kind of moved people away from what used to be a very paternalistic model of care where people were just told what was going to happen to them to an environment where there's much more meaningful consent. I think we're talking about consent a lot more.

Kirtly: Yeah, and I think the drapes, the way we drape women so they can't even see you. Women who are listening know this. You've got a drape that's between your . . .

Katie: It's like those old-fashioned photographers, right?

Kirtly: Right. So I usually would push down the drape a little bit so I could . . .

Dr Ward: I do, too.

Kirtly: . . . actually see their face and talk to them, so they could see that I wasn't doing anything weird. I mean, they have no idea what's going on down there, and I want them to have an idea. So at least they can see my face.

Katie: I do the same thing. I have a very specific technique of kind of making sure the sheet clings to people's knees so that they've got some coverage still, but that it's pushed down in the center. And I'll bring the patient's head up a bit.

Kirtly: That reminds me. Some women deal with this in their own way, and some women are quite matter of fact, and they're not going to have their pelvic exam interfere with their daily experiences.

And so I had a patient who was on the phone doing business or doing something. I wasn't listening because I was too busy doing what I was doing, and she was fine. She was in another space completely.

Katie: Since the pandemic, it's gotten worse. Now, people are actually on Zoom calls with their camera off, for sure, and very careful about that. But it's not just a phone anymore. Now it's you're in an actual Zoom meeting.

Kirtly: The other emotion that really tears my heart is fear. And it's usually fear of pain, but it can be fear of the test showing a significant problem with a cancerous or precancerous condition that we're looking for.

If it's fear, often in the setting of a previous bad experience or a history of physical or sexual trauma, the good news is that it's just a Pap smear, and it doesn't have to be done. We can do it later, as you already mentioned, Katie.

And now there are wonderful alternatives that include just a swab or a patient-administered swab. So a woman can do it herself if she's really fearful.

Our understanding of the nature of cervical cancer and the association of the HPV virus means we can use other techniques that don't require that speculum or the duck-billed thing that we put in the vagina to look at the cervix.

And then there's shame. Shame is a complex emotion, really, and it's a complex conversation to have with women. Our current understanding is that most all cervical cancers and precancerous are caused by a virus, the human papillomavirus, and it's transmitted by intimate sexual contact. This conversation didn't usually arise when we did the old-fashioned Pap smear, and we put the speculum in the vagina, and we put the little spatula that collected cells by wiping the spatula across the cervix and putting a little swab or a tiny brush inside the cervix to collect some cells.

The HPV discussion didn't come up because we didn't know about it then, so we just did the Pap smear. We didn't know about this. We knew that there were risk factors that women with sexual partners . . . Having had sexual partners was a risk factor. But now we have to talk about it. And because the test we're doing isn't a cell test, it's a virus test. If the woman tests positive for the virus, they ask, "How did I get this?"

Katie: That can be a difficult conversation to have, right? I always start by explaining that this is an incredibly common skin virus and that most people come in contact with it at some point in their lives.

And the good news about HPV infections is they can go away on their own. Our body knows what to do. HPV has been living on humans forever. And we have an immune system that builds antibodies against HPV, and that eradicates it eventually.

So we're going to talk more about the HPV vaccine in our next episode, but the brilliance of the vaccine is that it gives you immunity before you ever encounter it. Your immune system is already primed to recognize that. But the vaccine only protects against 9 strains of HPV, and there are another 40 more or more out there.

So when patients do test positive for HPV, we've got to talk about what that means in practical terms. It is sexually transmitted, and so I usually start by asking people if that makes sense in their current life situation.

Obviously, if you're dating or you're intimate with a new partner, the presence of HPV makes immediate sense, and I can reassure them that it's going to go away most of the time, usually within a couple of years. And all that's probably going to be needed is that we'll monitor them closely and make sure that the HPV does indeed go away.

What's challenging is when that result doesn't align with their expectations. So particularly when someone's in a monogamous relationship, then it's bringing up, "Does this mean someone's been unfaithful?"

And in those situations, I try to present it as possibilities. It could mean yes, that someone's had close, intimate contact with someone else, but it doesn't necessarily require intercourse to transmit the virus. So that's one possibility, is that there's been intimate contact but not intercourse.

And another possibility is that the virus has actually been there for a long time in very low amounts and went undetected in previous exams.

We don't always test for HPV when women are very young. So you may have had a normal Pap in your 20s, but the HPV was there, and we wouldn't know. Now you're in your 30s, and you're getting co-tested, and the HPV is just showing up, but it's been sort of hanging around there for a long time.

Or it might be that something has changed and a virus that was there in low doses is now replicating a little bit more actively. Or the immune system is temporarily suppressed for some reason, like maybe pregnancy, and the HPV is showing up, even though the infection itself was further back in time.

And every once in a while, I've seen what I think is probably a false positive test. I usually don't emphasize that because that's really uncommon. But after a lot of years of practice, I've seen it happen in circumstances where it's just like, "Oh, that really didn't make sense," and the repeat test was negative.

Bottom line is if somebody tests positive for HPV, I do recommend they get screened for all the other sexually transmitted infections as well, just in case.

Unfortunately, I have had patients whose partners are placing my patient unknowingly at risk for various infections. I think testing to know everything else is negative gives people a lot of peace of mind, and it's just important to do.

Kirtly: Yeah, it does, but sometimes it makes people angry. I mean, I've had women who felt that they had only one partner in their life, and they knew that they had only one partner in their life, and now they come up some years after they were married or whatever with a positive HPV test or a precancerous condition or cancer.

That anger that someone gave this to them or caused the cancer, it can make people very angry. And I think there's a lot of appropriate emotional stuff around the Pap smear.

Katie: And that is sort of the worst-case scenario, when that positive HPV test opens up a conversation in which you discover that there has been some infidelity. That's the tip of the iceberg for a whole other conversation and rightful anger.

So there's a challenge for males in this situation, though. It's that we don't currently have an HPV test for males. I hope one is coming in the future, but right now, they simply can't get tested for HPV. And that means, at least for women who have sex with men, their partners aren't necessarily being irresponsible or dishonest. They just have no way of knowing that they carry the virus.

Now, they might know that a previous partner also had problems with Pap smears, and that should give them a bit of a hint. But it's a challenging situation because when that woman gets a positive HPV test and feels angry or betrayed, our partner may say that he's been tested for everything, but this particular virus wouldn't have been included in that screening.

Males can get vaccinated against HPV, and we encourage them to. We're going to talk about that more in the next episode. But right now, they can't get tested and know their current status. And so that's a little bit of an asymmetry in relationships.

I've seen that happen, too, that males are angry because they don't know for sure that they were the person that brought it into the relationship.

Kirtly: One of the most common emotions when there's a test that suggests there's a problem is anxiety. It's so common that it takes a minute for a woman to hear what actually comes next.

As soon as you hear the word cancer . . . So we say, "Your Pap smear has some suggestion," or, "You have this virus, which is a screening test for cervical cancer," when you say the word cancer, for some women, their whole computer and processing goes down. All they can hear is cancer in the phrase. The Pap smear is a screening test for cervical cancer.

And the conversation about this precancerous condition and how treatable these conditions are is so complicated. You have to explain to the patient that we do this so that cancer doesn't develop, and all that conversation gets lost behind the word cancer.

And sure enough, if people go home, all they remember is cancer. And so it's often a situation where anxiety just blocks out everything else, and you may have to go back. This may take a couple conversations before people calm down enough to actually talk about it.

Katie: Yeah, for sure. A lot of my practice is following up on abnormal Paps. So in the group of providers that I work with, I'm one of two people who does the follow-up procedure. It's called a colposcopy.

So when a patient does have an abnormal Pap and we tell them that, that's a tricky thing, at least I find, as a healthcare provider. I want to give them the message that their Pap was abnormal and coming back in for this next test is really important. And so we do use the word pre-cancer, or the potential to progress to cancer, and that does evoke all of that anxiety.

On the other hand, if I try to just gloss it over and not explain how important it is, I've had the experience where people think, "Oh, well, that didn't sound important. I just didn't follow up on it."

So I think know from your provider's office that we're walking a fine line of saying, "We want you to understand that the follow-up and these next steps are really important. If we don't do them, we might miss something that could progress to cancer. We're not saying you have cancer, but we do want you to come back in." So that's the needle we're trying to thread there.

When people come back for that follow-up test, the colposcopy . . . One, it's a big scary word that sounds like colonoscopy, but it's something totally different. And what I try to explain to people is that this is a test to make sure the Pap didn't miss anything worse.

And usually, almost always, if the Pap and the biopsy that we obtain during the colposcopy show low-grade cell changes, then we feel very comfortable that this is something where we can do kind of watchful waiting for the next few years and just close follow-up. We don't need to do any treatment, and we're just going to give the body a chance to get rid of this on its own. And it almost always, 90% of the time, does that.

So, again, I'm trying to give my patients all the education I can, but make sure that they understand that there is this risk, and we want them to continue to come in regularly.

But colposcopy is definitely another anxiety-provoking procedure. It's similar to getting a Pap smear, but it takes longer. So you spend more time in that uncomfortable position with your feet in stirrups and a speculum inserted.

The biopsies that we collect usually aren't particularly painful, but just the word biopsy triggers a lot of anxiety for patients. And so we talk about how little skin we actually take with that.

As we discussed, we do everything we can to make people comfortable, and that includes careful explanation of the procedure and breaks if somebody needs that, having someone else in the room with them, medication if they need that, whatever it takes to get them through it.

One of the things I've learned after 20 years of doing colposcopies is almost everybody says to me when they're done, "That wasn't nearly as bad as I thought it was going to be." And I tell them, "Those are really my favorite words to hear." Those are my words of love and affection. "That was not bad as I thought it was going to be."

Kirtly: That's another emotion, which is relief. The best emotion about Pap smears and screening for cervical cancer is relief, and whatever the road up to the Pap smear or HPV test, hearing that there isn't a problem brings relief and reassures confidence in your body. Or after a colposcopy and the possible treatment, knowing that you're probably cured, what a wonderful message to receive.

So wherever you are as a listener or someone you love is in your Pap smear cervical cancer screening road, or whatever you've been through in the past, please tell your clinician what your fears and hopes are.

If you've had a difficult experience in the past with exams or procedures, please let them know, and let them know what it will take to make you the most comfortable.

And if you are receiving information or results that give you the forgetfulness of anxiety, please ask someone to tell you again, or tell you in a different way, or give you a handout so you can read at home when you're a little more comfortable.

Seeking out information on the internet can be useful if it comes from a reputable source. The National Library of Medicine does a good job, and the Mayo Clinic, and the Cleveland Clinic. Those are all good sources. Your girlfriends, unless they're clinicians specializing in women's health, are not always good sources.

The Pap smear, and the test for HPV, and follow-up colposcopies, and treatments are very good at eliminating precancerous cells, dramatically lowering your risk for cervical cancer.

So if this podcast has stirred up emotions about your own screening tests for cervical cancer or your past experiences, talk to your clinician. We're doing the 7 Domains of Pap Smears to help think about the powerfully effective screening test that's been so helpful in lowering the rate of cervical cancer.

We'll talk more about this in other domains. The intellectual domain will help you understand the science and the procedures behind new recommendations for screening and ways that screening can be done.

And I think, armed with information, you can be your best advocate and advocate for others. You can never be too informed or too protected.

Thanks for listening. Check out our other 7 Domains of Pap Smears and all of our other "7 Domains of Women's Health" wherever you get your podcasts, or at womens7.com. Thanks for joining us.