E86: The Spiritual Domain of Pap Smears

Katie: Well, hi, and welcome back to the "7 Domains of Women's Health." Today, we're wrapping up our series on Pap smears. I'm Katie Ward. I'm a professor in the College of Nursing and a women's health nurse practitioner with a clinical practice. And as always, I'm joined by my co-host and the spiritual mother of this podcast . . .

Kirtly: Thank you.

Katie: . . . Dr. Kirtly Jones from Obstetrics and Gynecology.

Today, we're talking about the spiritual domain of Pap smears. And you might be thinking, "I didn't know there was anything spiritual about a Pap smear, except maybe praying it'll be over soon."

But actually, we wanted to explore something that's unique to Utah, and Utah is where our podcast originates. And this is also maybe a little bit unique to members of the Church of Jesus Christ of Latter-day Saints. So this is a practice called the premarital exam, which is probably better called a sexual health exam, but it is a thing that comes up on my schedule from time to time in clinical practice.

Both Kirtly and I have been providing healthcare in Utah for our whole careers, and while the premarital exam is maybe less common now than when we first started practicing, it is still something that patients come in asking for.

And in fact, as I was kind of looking around at different practices available throughout the Wasatch Front, I see a lot of practices that advertise that they offer premarital exams. So it's still a thing and a thing that people talk about.

And certainly, from time to time, it surfaces on social media. So even a little reluctant sometimes to bring up the phrase, because it usually also sparks a little bit of response from other advocates in the social media space. But I think it is worth talking about because people have strong feelings about it.

Now, I have to say, I never received any specific training about a premarital exam, or what should that entail. Historically, there was a blood test that was required before marriage to screen for syphilis. So maybe that's where the phrase came from.

And there was a time when pretty much every state required it. But these were just blood tests, and they were aimed to prevent disease transmission both between one party and the other in the marriage, and also between mothers and babies.

But laws requiring those tests started being repealed in the '70s, and now no state requires that. And it was just a blood test, not an exam.

So I had to just kind of figure out on my own what someone was asking for when they scheduled for a premarital exam.

Kirtly, what do you include in a premarital exam, or what's been your experience?

Kirtly: Well, before I launch into that, I'll remind people that also there were people who got tested for rubella immunity as part of their requirement for their marriage license in some states because they wanted to make sure that women, before they got pregnant, had been immune or got the measles vaccine. And once again, those things have been dropped.

I'll say that I did premarital exams when I was a resident in Boston, although it wasn't common, and I think it was common in cultures where virginity among the married couple was of high value, and if you had access to a doctor who would do some kind of exam.

I know that my grandmother took her future daughter-in-law, my mother . . . So it was my father's mother who took my mother down to the Margaret Sanger Clinic in New York City from Boston to get fit for a diaphragm. And I believe at the time, she said she was a virgin. So she got fit for a diaphragm when she actually hadn't had anything in her vagina yet. And I'm sure that wasn't always pleasant, but that served as her method of contraception.

Anyway, Katie, as you said, there's no guidebook or educational experience in our training in OB/GYN for this encounter, and I would guess we all make it up as we go along.

I mentioned my own "premarital exam," and I'm putting that in quotes, which was my 17-year-old going-off-to-college exam by our family doc. I mentioned that, I think, in one of our first 7 Domains of Paps podcasts. It included a Pap and a pelvic exam, and, for me, some not very helpful guidance about birth control, which was "just be careful."

So there's some kind of equivalent encounter when mothers bring their daughters in for their first pelvic exam sometime in their late teens, unless they were having problems with their periods and came earlier, and it's taking a gentle history of their period. So this is what I do in terms of a premarital exam.

It's taking a history of their periods, and then it's getting the mother out of the room so the daughter can have her "privacy" as she changes her clothes. And so that's an excuse to get the mom out of the room.

And then I say, "I'm going to bring you back in when she's ready." So I walk in, and then I take a sexual history and ask her if she wants her mother, or occasionally it was her father because the mother wasn't in the picture. So occasionally her father brought her in.

And occasionally, it was a couple who came together. They were going to be married. They came together. And that's, I think, ideal, personally. But then I get the husband to be out of the room so I can talk to her privately.

Then if she doesn't want a pelvic exam, I don't do one. Most women in the world have their first sexual encounter without the "benefit" of a clinician assessing their hymen, the small membrane at the entrance of the vagina.

But for some women, the vaginal opening is very small, and rarely there are women who have no opening. So I talk about the vaginal opening. It's easy to talk for women who use tampons or have already had sex.

Then I ask them what they want to know about intercourse. And I get the feeling that some mothers never had the talk with their daughters here in Utah, and they were expecting me to do that. So I say, "What do you know about intercourse and your first encounter?" And they look at me kind of blank. Although I can't see how anybody with a phone could be blank about that, but anyway.

And in the case of the premarital exam, in couples that are both virgins and have not had any intimate contact, I ask them, "Well, what have you already done with your honey? Have you held hands?" "Oh, sure." "Have you kissed?" "Oh, sure." "Have you touched anything? Has he touched you or touched your breast?" "Oh, no, that's not allowed."

So if there's not really much intimate contact between the two, then maybe the wedding night isn't the best time to start their sexual life with the act that might be uncomfortable for them both.

So I say, "You might start with the night after the chaos of the wedding and the wedding reception and everything else with just getting to know each other's bodies and not do the one thing you think you're supposed to do on the wedding night, but you're scared about." For moderately good reasons. It's not always wonderful. It can be wonderful.

But anyway, I have no idea whether anyone took that advice. And I think without having the groom-to-be in the room, telling it to the bride-to-be who's then going to transmit that to the groom that, "My doctor told me we're just supposed to touch each other everywhere, but we're not supposed to have sex yet," I'm not sure that would go over great.

Anyway, there's talk about whether their period will come on their wedding or their honeymoon and options to try to avoid that. And then there's the contraception if they're not planning on getting pregnant right away.

There was a somewhat common practice among gynecologists here in Utah, all male at the time, 40 years ago, of performing a hymenotomy or hymenectomy under anesthesia before a woman married. If she had a small vaginal opening in the hymen, they would put women to sleep and they would make a little cut on the hymen or remove the hymen so that their first sexual encounter would be more comfortable.

And I was a little appalled when I got here that this was not uncommon. But that isn't common anymore. And mostly, we teach young women to do their own stretching of the opening, but they may not want to do it. For some women, that personal intimacy is somewhat embarrassing, or it is taboo for them.

So after many, many years as a clinician, I kind of had a thing, and I kind of taught my thing to other residents, and they probably made their thing up, and there you go.

Katie: Yeah. I've actually grown to enjoy those interactions. Usually, I take it as an opportunity to provide all the advice I wish I'd been given before becoming sexually active. And I talk about things like how important it is to make sure you empty your bladder after intercourse to prevent bladder infections, and that lubrication and communication are key to a good sex life. And of course, sorting out what people's contraceptive needs are and all of that.

But I also recognize I'm probably way more comfortable talking about this than my patients are. And the other thing that I have to do is calibrate my language to meet where my patient is coming from. Again, I think, in this podcast as well.

So today, we're going to discuss a little bit more about this. What happens when your faith intersects with your women's healthcare, and if you're advised to seek an exam with a healthcare provider before engaging in a religious sacrament like marriage?

It ties into Paps not because the Pap is required. As we've discussed, that is a test for cervical cancer. And unless there's been intimate physical contact, a Pap smear might not be the thing you need at this premarital visit. But a Pap smear is still sort of synonymous with getting a GYN exam. So we thought it tied in nicely with this 7 Domains segment.

So today, we're really excited to welcome a special guest with us in this domain. We've invited a colleague, Rosemary Card. Rosemary brings a really fascinating perspective to our conversation about premarital exams, and within the LDS community in particular.

Rosie graduated from Brigham Young University. She served an LDS mission and worked at the church creating documentary films. Today, she's a multifaceted individual. She's an entrepreneur, an author, a thought leader. And what makes Rosie particularly valuable in our conversation today is her experience as an advocate for women, and I think her cultural understanding of the dynamics within the LDS tradition.

She has developed a significant following on social media, where she creates space for important conversations about faith, identity, and womanhood. And so I think her background brings some unique insights into the cultural pressures that young women face as they approach marriage in religious communities, and the religious community that predominates here in Utah especially.

Katie: So, Rosie, thank you for joining us today and helping us unpack this intersection of faith and women's healthcare.

Kirtly: Rosie, it's an honor to have you, because here are two women without any particular strong secular or religious anchors to tell us what we should have been doing during the premarital exam. So please, after 40 years of practice for both of us, please tell us what we should have been doing.

Rosemary: I'm here to set you both straight, let me tell you.

Kirtly: Thank you, thank you, thank you.

Rosemary: No, I'm grateful to be here, and it's such a fascinating conversation to have. I didn't get married until I was in my 30s, and so I didn't have kind of the classic premarital exam. But it was definitely a common topic of conversation while most of my peers were getting married in our early 20s, mid-20s, and something that came up a lot when marriage was happening for a lot of my friends at that time of life.

Katie: Do you think, among young women, are they more worried about the exam? Are they more worried about the wedding night?

Rosemary: I think a lot of women, at least at that time 15 years ago, there was a lot of concern about the wedding night. And the premarital exam was just seen as . . . It just was something that I didn't ever question and it was part of the standard to-do list, I thought, for everyone. I didn't even consider that it was just a Utah or Mormon thing. It was just something you did. And at some point, just like you got a wedding dress or you tried out different cake flavors, you got your premarital exam.

Katie: Yeah. I mean, sometimes as a provider, I end up wondering how it is people know that they're supposed to do this. How is it typically discussed among LDS women? Is it presented as part of your checklist, or do you hear it from your spiritual leaders or the women in your life? Who tells you? Who's on the list?

Rosemary: I wouldn't say from spiritual leaders. In the LDS Church, when you are a young woman in your teens, you're a part of a young women's organization. And I could see the conversation coming up with your leader, which is typically a woman in her 20s or 30s, sometimes older, just someone who's a little bit further down the path, if you will. It could come up there. But I think it's just probably passed down from moms and sisters and friends.

I think they're probably becoming less common now because, just like you said, anyone who has a phone has the ability to gain certain education. But I think a lot of it is attached to the lack of sexual health training and education in our community and Utah in general. If a mom is not comfortable talking to her daughter or her child about sex, that is the fallback, I guess, that, "Well, she can have that conversation at her premarital exam."

Katie: That is a piece of what I certainly try to do. Kirtly, it sounds like you do that as well, to try and sort of figure out what people know and what they're thinking about.

Kirtly: Right. What are their expectations? I ask the mom, or whoever's bringing them, "What would you like to make sure that we talk about to the young woman? What do you think we should talk about?" But it's variable. It's really quite variable.

Katie: Yeah, and I don't know how much the LDS teachings about chastity and sacredness of bodies influence how women approach this, if it feels like that you need permission to have sex, or if you need permission to use birth control. Maybe that's some of it. I don't know. Rosie, what are your thoughts on that?

Rosemary: That element is so interesting to me because initially, I think, "Well, there's not a lot of overlap between the spiritual element and then the actual element," in the sense that I don't think there's a lot of spiritual teachings that really influenced my feelings about Pap smears.

But then I thought, "Well, that's so unfortunate," because there is so much from the church and church leaders about sex and women's bodies. But for the most part, it's more coming from a do or don't kind of situation. "You're not allowed to do this until you get married." And previously, even after marriage, there were certain constraints that the church had opinions on and that they would teach.

I just think it's unfortunate that it's a missed opportunity to then encourage healthy sex education or healthy personal understanding of your body. So there's a lot as far as the church having opinions as "don't do certain things with your body," but then there's a gap as far as learning the wonderful things about your body.

And so I think a lot of young women, at least young women I know in my life, go to these premarital exams never even really understanding their body at all.

I think there are a lot of great Instagram accounts from therapists and people who focus on this stuff that are trying to change it. But there's less coming from the church encouraging positive sexual health. More is in the frame of, "Don't masturbate. Don't have sex before marriage. Don't do anything even close to that before marriage." But then once it's okay to have sex, there's really not a lot that these young women and young men are given.

Katie: Yeah, I noticed that a lot in my practice, and I see women over years. I may see them for their premarital visit, and then I'm seeing them back later. I feel like people come in with a couple of different narratives, and sometimes they're both wrong.

But one narrative is that sex is sacred and it's a wonderful gift from God, and it's a thing they're really going to enjoy. And another narrative is that it's this unpleasant duty, "think of England," a thing you're going to have to endure.

And I think either one of those narratives influences how you approach that experience. And then if your own experience challenges that or is opposite, it leads to some confusion.

I've seen both of those over the years. Kirtly, do you see that at all?

Kirtly: Yes, but also, as we're ending this premarital exam, I tell them that sex is something that gets better as you . . . It's like any "something." It might be from cooking to sports. You get better at it when you've done it a little bit more and you know each other's bodies and you know your own body.

But if it isn't going well in three months, or if you're still having so much pain, or you have a urinary tract infection, then please come back and see me. It is okay.

And don't be afraid if things aren't the way you want it to be. Come back sooner than later. Don't come back in three years saying, "We've never really actually been able to have sex, and we're not getting pregnant," or something along that line. That's happened. "We've been trying for a year," and they really haven't been having sex.

So I think if things aren't going well, please come back and see me because this is a learning experience for the two of you. Sometimes people get it right away, and sometimes people don't.

Rosemary: I have a loved one who had very little sexual education, but she had heard the idea that in the beginning it hurts without kind of the follow-up of what can help with that, whether it's lubricant or foreplay. And for years, she suffered through.

After, I think, five years, she went back to her doctor, and it turns out she had an extreme case . . . I don't even know if case is the right word, but she was experiencing vaginismus. And it breaks my heart that she didn't know. She just thought this was how it was, and this was normal, and this is just how it would be for the rest of her life because she didn't have the education.

And I think that's what it comes down to on a lot of the issues. People get really riled up when they hear that there's this idea of premarital exams. But I think, for a lot of people, it's their first opportunity to get good education. And so I think it can be a really helpful thing, but I understand why people get kind of squirmy about the idea.

Kirtly: Squirmy.

Katie: Well, I think especially given the history of what Kirtly was talking about before with the hymenectomies or hymenotomies . . . I've never seen that done, but I have heard stories of people who that was their experience. And I think that is the thing that . . . I mean, they're kind of two things. There's that procedure that maybe people don't understand they're going to get. And hopefully those just aren't being done anymore. So I think that's the thing that really gets people kind of riled up about it.

But yeah, I think however you get your education, if it's coming to see a trusted healthcare provider, I love that opportunity to talk to people and meet them where they are.

And I think the most important thing I can give them is not permission to have sex per se, but permission to enjoy themselves and enjoy the experience. And that might be something they haven't been given up until now.

Kirtly: Yeah, I think the concept that "it's wrong, it's wrong, it's so wrong" is totally, really wrong and spiritually wrong. And then after one very long day of posing, being in a dress that's too tight, and going to the temple, and then coming back and doing things and then doing this thing that you've been told is wrong, you're supposed to flip a switch and say, "Now it's wonderful"? And it certainly can be, but that's a big switch to make, to be able to totally relax into that moment.

Rosemary: Yeah. I mean, it's so much pressure. I have so many friends, male and female, who their wedding night was heartbreaking. They don't even like talking about it 10 years later because it was so devastating. Both physically painful, but confusing because they have been told their whole life that this thing is bad until that exact moment. And also, disappointing because you expect that it's just going to work.

I think, unfortunately for some men, and I hope that this is changing, but I think for some young men, they can come into the situation feeling like this is kind of something that is theirs now. This is their experience that they get to have. They have this right where now they get to have sex with a woman. If there's not healthy sex education for the man, then that can be a devastating experience for this new bride.

It's really sad, and I think a lot of people feel a lot of shame, and they don't know who to talk to about it, who to turn to. And if they do turn to their friends, there's a good chance a lot of their friends had the same experience.

And it can just be really isolating and really confusing, especially when there is so much emphasis from the church of having children pretty quickly after getting married. It doesn't leave a lot of space for, like you were saying, that all skills take time to develop. If there's not a lot of emphasis on taking that time and conquering one thing at a time before moving on to the next, it's really difficult.

Katie: Rosie, I want to ask you, just because you have a foot in both of these worlds and you're so much more involved in social media and that space than I am. Do you see competing trends, especially for LDS women who are in the social media realm, that are kind of giving them different messages between the conversations that are happening in social media and the official messages from their church?

Rosemary: I think that there's quite a spectrum. I don't know if movement is the right word, but there is a push amongst certain social media influencers or content creators trying to help LDS women be more knowledgeable and comfortable with their own bodies in general, but introducing things like vibrators to them and lubricant and just that whole spectrum, whether it's tools or toys that can help them have a more positive experience.

And I don't think there's a large movement of people online saying, "Don't do that. That's not necessary." There can be kind of an attitude sometime of, "That's not necessary," that those things aren't necessary, and kind of looking down on it, but then not really giving the education on how you might not need those things, but probably if you're doing X, Y, and Z.

And obviously, there can be a lot of shame in saying publicly, "I don't feel like I'm good at sex," or, "I don't enjoy sex," or, "My partner and I have different desires or expectations when it comes to sex." And this is probably not unique to Mormonism, but there can be sometimes people who project that, "Oh, it's great. I don't know what you're talking about. We have no issues." It's hard to know how to compete with that.

I guess it's just difficult to openly say you are struggling with this thing if it seems like it's coming so naturally to people, and it's just a natural thing between a husband and wife and it shouldn't be so complicated. But it does feel really complicated for a lot of people, and I wish that there was more space for that to be addressed.

Kirtly: Well, especially if there's an understated concept that ecstasy between a husband and wife is spiritually endowed. And if you can't get there, it's maybe because you're not good enough. You're not endowed with this amazing experience that you watch on TV or you read about in romance novels or whatever it is.

And if that is supposed to come to you as part of this spiritual experience of marriage, then why isn't God giving it to you? Why don't you get this magical experience? People are ashamed to say, "I don't really think this is wonderful."

Rosemary: Yeah, there's such a high expectation. While I didn't have a premarital exam with my doctor, when you are getting married in an LDS temple, there's a series of interviews with local leadership that you have to go through.

This is such a crazy story to me. My husband's leader requested that I kind of Skype in or Zoom in to the end of my husband's interview. And this man who I had never met before, I have no idea who he is, what his own sexual background is, what his own education is . . . I mean, I guarantee he's not a sexual health provider in any way.

But he kind of called me in and gave my husband and I, or my soon-to-be husband . . . His idea of a sex talk was, "You should always feel the spirit of God while having sex," and you shouldn't do anything while having sex that would make you uncomfortable, to leave that situation and immediately go perform a very spiritual duty within the church.

Kirtly: That's a mixed message.

Rosemary: I was telling myself . . . I was Zooming in, and I just kept thinking, "Do not look at . . ." Kyle is my husband. "Don't look at Kyle. Don't look at Kyle," because I knew I would just burst out laughing. And I just thought, "This is so crazy."

I'm, at that point, 32 years old and I'm confident in my own education and understanding that I can say what this man is saying is so bizarre to me. But I can only imagine how that would feel to 21-year-old Rosie or 19-year-old Rosie, which a lot of LDS women get married that young. How would I interpret that? What effect would that have on me? What impression would that make?

Kirtly: I can just see us. I'm supposed to have intimacy with my husband and then grace for breakfast or say grace at dinner or . . .

Rosemary: Some couples have the impression that they should have a prayer before and after. And if that's your choice, that's your choice.

But I think one of the difficult elements of the church, and a beautiful element of the church, is that we do have a lay clergy. But that does mean that you could meet with someone who is your spiritual leader and they feel kind of like that it's their place to give sexual advice, potentially, in this premarital spiritual meeting.

This person could be a dentist, a plumber, an accountant. It's just really the luck of the draw here. And you have no idea where they're coming from, what their own sexual experiences are, but their words are taken very seriously and they hold a lot of weight. And so it is one kind of complicated element.

Kirtly: Gosh, it could be your next-door neighbor. In a small community, the person who's doing this work is your next-door neighbor.

Rosemary: Oh, totally.

Kirtly: Or it really is your dentist. Well, I think that putting a sanctity to this magical thing called a marriage that makes children who are blessings, I get that. I really get that there is a spiritual domain over the entire process. But how that leads us to a better understanding of our own bodies and how to love our partners is a tough one, I think.

Katie: But I do want to say, as a healthcare provider, I think your healthcare provider is someone you can trust to go back to with these questions. I think regardless of what community I work in, I do take it on as a responsibility to understand a bit about the religious background that my patients are coming from and what they're bringing to their visit and the context that they're situating their sex life into. And I do try to be very respectful of that while still answering people's questions.

So I understand if I have a patient that's coming out of the Catholic faith and contraception is not going to be acceptable. I'm going to approach my conversations about family planning differently.

I do appreciate that in the LDS church women get to use contraception. I think that's a frequent thing that we talk about in the premarital exam because it might be something like they want to make sure they're not on their period during their honeymoon. And so can we do things to try to move when the next period is going to occur?

And so just while we're wrapping up this domain, I'm going to put this out there, that there are some things we can do. But come in sooner rather than later. If you come in two weeks before your wedding, the chances that we're going to be able to accomplish that are a lot less than if you come in a few months before and we have some time to move things around using hormonal contraception.

And so I think that's one message I want to make sure that I get out there, is that your healthcare provider is a trusted source. Regardless of what spiritual practice I have, I'm going to do my best to be respectful.

Rosie, are there any last bits of advice that you would give us as healthcare providers to better understand the context that our patients are coming into or how they're approaching healthcare that we haven't already discussed maybe?

Rosemary: I think I would just say, and this is not groundbreaking information, but that there's such a wide spectrum of experiences and beliefs that could affect Mormon women, and that every individual is just that, an individual.

They might be carrying an element of shame, and so they might be more prone to lie about their past sexual experience because they don't know if that's going to be shared, which I think is an important element.

If you are in a small community and your doctor is also your bishop or a member of your ward and you are concerned that being honest with your healthcare provider . . . Even though legally that shouldn't be a concern, but if there is an element of, "I'm worried to talk about this thing with my doctor, who is a family friend," there are places that you can get telehealth care, Planned Parenthood being one of them, where you can talk to someone or get help and support with a little bit more privacy that you might be worried about might be compromised in some situations.

Katie: That is awesome. I mean, that's a sacred thing for us as healthcare providers, to hold our patients' situations in strictest confidence. But I certainly get how that doesn't feel safe if people are holding multiple roles in your life. Wow.

Well, we've covered so much stuff in this 7 Domains of Pap Smears. I think we've taken Pap smears broadly, but I think it makes sense because, as we've talked about, that phrase "Pap smear" stands in for so many things about your GYN care.

So as we wrap up, I just want to say if you've been with us on this whole journey through the Pap smear and all that that stands for in the words that we talk about when we talk about going to the gynecologist, thank you. We've covered a lot of things.

If you haven't, please go back and listen to all seven domains. It's been a fun framework for us to use to talk about a lot of things that touch on women's health.

You can get the "7 Domains of Women's Health" on all podcast platforms, or online at womens7.com. Thank you.