Obsession is perhaps a strong word, but this is how much I talk about paps: I was hanging out on Brooklyn's queer beach last Sunday, and an acquaintance came over to talk with a mutual friend. As I stripped off my shirt and started applying sunscreen on my tattoos, the acquaintance looked me over and observed, "I honestly can't believe you don't have one that says 'Did you have your pap smear yet?'"
I had no snappy response, mostly because I was busy designing that new ink in my head. And it's true: I'm a comic/nurse hybrid and I live and work amongst people who often have a very hard time accessing preventative care. I will bring up pap exams on stage, at weddings, at funerals, at a bar mitzvah, in an elevator, on the subway, at a protest. In a boat, on a moat...
Well, you get the picture.
In fact, in order to demystify this whole genre of health promotion, I once participated in a bar-based event in which myself and another comic and a few community leaders (and a nurse practitioner who was a very good sport) went through the pap exam process on stage. Much to the surprise of the bar manager. Fortunately for everyone involved, in New York anything can be sold as performance art as long as you do it with a microphone in your hand.
While I don't know anyone who does cartwheels of joy when they call their provider to schedule a pap, for some folks this every-other-year (more often if you're in certain high risk categories) very important exam is much more than an annoyance. For survivors of abuse, sexual assault, trauma, gender trauma, etc, getting a pap exam can seem impossible.
What follows are some tips that I've gathered from more than 15 years of working with folks for whom getting this life-saving test is an act of heroism. I've included some direct quotes from some of them, as well as tips from health care providers who specialize in this work. These are just tools and no one tool will work for everyone, but perhaps you can figure out if some of them will work for you:
Tool #1: Remember You Don't Have to Love Your Body to Take Care of It.
I've had just about enough of this "love your body" business. Not because it's not a good goal, because certainly it is, but because it's used as just another shame club to bat women around the head.
If you've been raped, assaulted, shamed for your body and/or having a vagina, or maybe you have what other people consider a vagina but it doesn't match your essential gender identity, or maybe you needed to have your vagina surgically created because you weren't born with one, having a difficult relationship with your body does not make you a bad feminist. It makes you human.
And, this difficult relationship notwithstanding, your body still needs care, and your body is depending on you to provide it.
To use a slightly lighter illustration, I'm a masculine looking chick with absolutely huge boobs; I have the shoulders of a linebacker and the chest of Dolly Parton. So while I don't really love my tits, I still go for regular mammograms. Not because I look at my boobs and say "damn, mmm that looks good on me" but because I don't want to die from anything that could be treatable if caught early.
Tool # 2: Take Control: Use Your Words And Speak Up For What You Need.
Victoria Albina, a family nurse practitioner and health coach who works in primary care in New York City, explains it this way, "Don't be afraid to use your voice. Your provider works for you."
Ask to speak to the provider before the exam begins. Explain that you'd like to keep all your clothes on for the conversation. You might have to be adamant, but where else but in a health care situation are you expected to meet someone for the first time when you're mostly naked? That's just weird.
First, explain why the pap exam is difficult for you (in extremely general terms, no specifics are needed here unless you want to share them) and then present your list of What I Need To Get Through This Dammit.
For example, some people want to be told everything that is going to happen before it happens and have the whole process narrated step by step. For others, this makes the exam harder. S. Bear Bergman, a Canadian writer, explains "My standard spiel to providers is 'Please don't talk if at all possible. Don't ask me anything, don't announce what you're going to do - don't do any of the things that you were taught would make this process more empowering. I am going to quietly disassociate from my body. I would prefer not to have any reason to return to the present until you're all finished rummaging around. Thanks.'"
Eliza Jane Manoff, a 30-something butch dyke from the Pacific Northwest, has an equally clear idea of what she needs: "If you are doing a pelvic exam on, say, me, and I start bawling, please ignore the fact that I am bawling and just get that shit over with."
Other provisions Pap Smear Heroes have asked for include:
- Having the exam while in a less prone position (ie almost sitting up).
- Using a mirror during the exam to see their own cervix. I know, very ’70s, but it helps some people to feel empowered in the exam.
- Determining certain "full stop" words that aren't used in the exam: for example, for some people, the word "vagina" might be triggering. You can work with the provider to pick words that are okay for you and your body.
- Using a pediatric speculum.
- The patient, rather than the provider, completing the actual speculum insertion.
- Not wearing the standard-issue revealing paper gown. For a pap exam, the provider only needs access to one very small area of your body. There is no reason you have to strip off your T-shirt or your lucky hoodie or lace camisole or whatever makes you feel good about life.
Does all this sound like an impossible conversation? Albina suggests, "If it's hard to speak, email your providers or ask the front desk if you can leave a message on your provider's voicemail."
Of course, during the actual exam, if you get stuck in a triggered/traumatic response, language is unfortunately often one of the first things to go. Thus, tool number three:
Tool #3: Take a Friend.
Trina Acocella explains her Theory of Accompaniment for Medical Treatment: "As a person of color who has difficulty getting a pelvic exam because of past sexual trauma and medical trauma, I always bring a knowledgeable and confident white friend (or two)...it is helpful to have a white ally there to help witness and address any microaggressions that may occur during the exam. Also, if a provider is acting up before I even get my clothing off, I ask for someone else to work with me."
Albina is adamant: "I encourage all my patients who need extra care to bring an advocate. If your provider won't let you have an advocate in the room, don't take your pants off. "
Your accompanying friend doesn't have to be your closest pal and certainly doesn't need to be your boyfriend/girlfriend/husband/spouse/partner. Choose someone who knows how to speak up for others in a medical situation and can be a calming force while still being a fierce advocate. Someone who is conflict adverse might not be the best choice. We've all got a bossy friend; that's the person to bring along, if they know how to back off being bossy with you.
Tool #4: Take A Pill: Pre-Medicate or Meditate.
If pap exams are untenable, don't be ashamed to ask for some pharmaceutical help to get through it. Ronni Hayon, a primary care MD in Madison, Wisconsin explains her practice: "For patients for whom the pelvic exam is very overwhelming or triggering I do offer the option of pre-medicating with a short-acting benzodiazepine. I write a prescription for two tablets of 0.5mg of alprazolam with one tablet to be taken 15 minutes before the exam, and the second tablet to be taken if needed."
If you're clean/sober, you'll have to make your own decision about whether benzos are a good choice for you. There are non-pharm calming alternatives as well: Rescue Remedy, music, deep breathing, visualization and meditation.
Tool #5: Take A Moment: Scheduling That Works.
When you make arrangements for your pap, ask to schedule two blocks of the provider's time. This takes the rush off the situation and makes it more relaxed for you and the provider. Albina also suggests scheduling appointments in the beginning of the day when providers are less likely to be running behind.
During the exam, you can use an established safe word with the provider if at any time you need a break. Take a cue from the BDSM world and use "yellow" for "slow down, caution, not sure this is working for me" and "red" for "I'm not kidding, Holy Mother of God everything stops RIGHT NOW."
In case of a total communication breakdown, there are two magical words every patient should know: "I refuse." We were taught in nursing school (and my doc friends say medical school covered this as well) that if the patient says "I refuse" and you continue with the procedure, it's considered assault.
Tool #6: Take A Stand Against Triggers.
If you're a trauma survivor, you may or may not be able to completely avoid being triggered by the pap exam, but you can take steps to help stay grounded.
Sometimes holding your friend's hand helps. Or a solid object. "It's a little woo, but I also bring a stone with me that I keep in my hand, which helps to keep me grounded and from disassociating." Acocella says. "Also bringing a snack to eat after the exam [can be helpful because] eating and drinking are very grounding."
If the smells (such as disinfectant, hand sanitizer, etc) of the exam are part of the difficulty, you can bring in a small bottle of essential oil into the exam room and either dab a tiny bit on your upper lip or sniff it directly as needed. Citrus oils are often a good choice as they overpower most other smells with the possible exception of patchouli.
If you're seeing a therapist or another mental health professional, you can work with them before the exam on specific grounding techniques as well as identifying what stimuli is triggering to you.
And even if it takes you more than one appointment (or more than five appointments) to get all the way through the exam, take heart and celebrate. You're making a huge stride in self-care.
Of course, none of these tools will make getting the pap exam or any other health care easy; that's where the heroism part comes in. But they might make it possible.
So you're going to schedule that exam now, right?
Please. Don't make me show you my new tattoo.