Tuesday, 5 December 2017

Speculums for the Terrified: a guide for medical staff

Speculums for the Terrified:  a guide for medical staff

The medical profession often describes procedures using speculums as “uncomfortable but not painful”; however many women find speculum examinations painful and traumatising.  The use of a speculum is sexual penetration by a professional using a rigid object, and yet women who have a problem with it are frequently told they are having an abnormal reaction.  Vaginas are not designed for this kind of penetration, and the body’s natural reaction of trying to expel the speculum needs to be consciously over-ridden.  Although the woman may have consented, this might be out of fear of cervical cancer or the wish to conceive a child, and doesn’t mean she won’t struggle with the procedure or that her body/psyche won’t experience it as an attack.  As speculums and gynaecological exams are an accepted part of our culture and are described in medical language, women may feel guilty about their own pain and may sometimes blame themselves for being weak if what they actually experienced was extremely upsetting.

However, if a speculum examination is necessary, there needs to be a way of handling this in the most gentle manner possible for people who are particularly sensitive. This guide is for medical professionals, to help them understand specific issues some of their patients may be facing, and to provide a suggested method for making this easier on such patients.

Medical language regarding pain/discomfort
There is a particular bias in the medical profession against describing speculum examinations as painful, in order not to deter people from potentially life-saving procedures.  For example, for one widely-accepted-as-painful-gynaecological procedure, any patients who manage to stay conscious and not pass out get reported as having experienced “mild discomfort”, even though what they experienced was certainly not mild. 

Some patients may indeed prefer NOT to know in advance if something is going to be painful.  However, for others, there are various negative effects of this minimizing-pain language:
a)    it isn’t honest in that it doesn’t accurately reflect reality for many people;
b)    medical professionals who haven’t been through the procedures themselves might believe the procedures are much less painful than they actually are, and blame the patients for not coping.
c)    the patients are confused by why what they are experiencing is not what was described, experience a lack of empathy from the person performing the procedure, feel lied to, and blame themselves for being weak.

Why might some people find speculums harder to cope with than others?
Every woman is an individual and will experience and process sensory stimuli and pain differently.  The following groups of people might find speculums particularly painful/hard to deal with:
·         Some women have unusual anatomy.  For example, the cervix may be tilted (behind the pubic bone or very far back in the vagina). This makes it much more difficult for the practitioner to get the speculum into the right place.  This can mean extra insertion attempts and additional pain.
·         People who have anxiety issues/post-traumatic stress disorder (PTSD).  For a speculum to be the least painful, you need to relax your vaginal muscles to allow the speculum to enter with the least resistance.  If you’re anxious or have been traumatised, all your muscles tense up and relaxing them is very difficult. 
E.g.  Survivors of rape and sexual violence – very likely to have anxiety and PTSD issues. The gynaecological procedure may trigger bad memories and/or flashbacks.
·         People who haven’t ever had sexual intercourse.  The vaginal canal might be particularly tight as it hasn’t ever experienced the entry of anything as large as a speculum, and all the sensations are particularly new.  Also, the hymen might be partially intact and broken by the speculum, which is painful and can cause bleeding.
·         Highly sensitive people.  We all have different pain thresholds.  Many people are highly sensitive, which means that sensory input is experienced more intensely than the rest of the population.
·         Anyone who has a slow processing speed for sensory input.  If you process slowly, there isn’t typically time to work out what you are feeling, to deal with it, and to relax your body, because it’s all happening too fast.
E.g. Autistic women – are amongst the group of highly sensitive people and also have a slow processing speed.  Most autistic adults do not have a diagnosis of autism, and may not be aware of their issues. 

Some people might have more than one of these reasons which apply.  If they are struggling, it’s not because they are weak or neurotic, and it doesn’t mean they can’t cope with a speculum, just that it’s harder for them.

Adapted method for the Terrified
Refer the patient to the guide: Speculums for the Terrified:  a guide for patients
This guide is for patients who might be extremely anxious about having a speculum examination and it contains strategies to help them cope with this issue.
By the patient doing this for herself, it also helps the practitioner as it will actually make the procedure easier and faster to perform.
The guide examines
·         a woman’s perception of her nakedness,
·         the issues surrounding inserting a foreign body into her vagina and having a stranger do it.
·         stress-relieving strategies which in turn minimises the anxiety and hence vaginal muscle spasm which makes performing a speculum examination much more difficult for the practitioner.

At the appointment – steps for medical professionals
Good communication and continual explanation of what you are doing and rapport is vital.
1.       Offer a supportive, empathic chaperone to hold the patient’s hand and be encouraging. The chaperone should be encouraging and supportive, telling the patient they are doing well, distracting the patient by talking to them and helping them to remember to breathe and relax.  It is not helpful if the chaperone stands back and declares to the practitioner that the patient cannot cope.
2.       Show the patient the speculum and explain to them all of the movements that you are going to make with the speculum inside her body. 
3.       Tell the patient that it’s normal to be anxious and that it might be painful but not to worry because it will be over quickly. 
4.       Tell the patient that the more they relax, the easier and less uncomfortable it will be.
5.       Tell them they will be in control of the process. They can tell you when they are ready for each step of the process.  Tell them that you will stop when they ask you to.
6.       Once the patient’s lower half is undressed and she is on the couch, ask them to relax and breathe.
7.       Encouraging the patient to drop the small of her back onto the couch helps relax the perineal muscles, thus making the procedure easier.
8.       Tell them the first step is for you to touch their vulva and get them to tell you when they are ready for this. 
9.       Just touch but don’t use the speculum yet.  Then wait and give them a chance to cope with that.  Remind them to relax all muscles and breathe. 
10.   Tell the patient the next step is to insert the speculum 1cm, and that it may feel cold.  When they give you the go-ahead, insert the speculum by 1cm, and then stop. 
11.   Wait for your patient to cope with this.  Remind them to relax and breathe.   If your patient is panicking, crying or hyperventilating, they aren’t ready yet – just wait and calm them down before going any further. 
12.   Tell your patient about the next step (e.g. insert speculum another centimetre).
13.   Repeat these very small insertion steps punctuated by pauses, always giving the patient time to process the last sensation and to relax and cope with it, and never continuing until they confirm they are ready for more. 
14.   When you are ready to turn the speculum through 90 degrees, tell the patient about this step.  Wait for them to be calm and ready and for them to say so. 
15.   Do it and then stop.  Remind the patient to relax and breathe.  Tell them they are doing well.
16.   Continue in the same way for the rest of the procedure, with all movement in small increments.  The most painful part is the opening the jaws of the speculum. The slower it is done, the easier and less painful it will be and explain this to the patient. 
17.   Your patient might particularly express pain at this stage, e.g. by clenching up or crying.  Just reassure them they are doing great and it’s nearly over.

Not using the above strategies can mean the process is too fast, terrifying and overwhelming, and feels like something imposed from the outside, which makes them tense up, producing even more pain and anxiety.  This can be very traumatising.

Following the above strategies makes the process bite-sized and gives the patient a sense of being in control. It gives the patient lots of time to fully experience what they are feeling, minimizes the physical sensations as much as possible, and provides time and the head-space to calm down and relax and to undo any panic reactions.  

How you can help
If your patient is struggling with speculums, it’s almost certainly not their fault and doesn’t mean they are weak or neurotic or that they can’t get through the process.  Speculums are much harder for some than for others.
You can help by:
·         explaining every step as you go along;
·         being encouraging and affirming them;
·         being positive in your language;
·         being extra-gentle in all your movements;
·         not judging or shaming them – you can’t know what they are feeling inside or what it’s like to be them;
·         by viewing any crying or yelling as “honest communication of pain” and not as bad behaviour;
·         by allowing them to be in control of your movements and the pace at which things progress (and by not perceiving this as rude/bossy/telling you how to do your job);
·         by allowing extra time for their appointment;
·         being honest, by saying that some people do find this painful (thereby validating their reality if this turns out to be the case);
·         by accepting the patient’s experience as their experience without judging them as inadequate (some people do get PTSD from smear tests, some people do feel like they are being raped).

Also, there is an unwritten social rule that when undergoing such a procedure, if the patient experiences pain, they are supposed to try to hide/suppress this as much as possible in order to avoid hurting the feelings of the practitioner performing the procedure.  However, not everyone knows unwritten social rules that haven’t been made explicit, so not everyone realises they are supposed to hide their own natural, emotional reactions to pain.  Please remember that if you haven’t explained something, the patient might simply not know it and they are not necessarily either badly-behaved or overly-dramatic.  It is also not always possible to hide a very intense reaction. 

·         Speculums can be experienced by some as very painful, even though they are not generally described as such by the medical profession.
·         There are many valid reasons why some people will struggle much more than others, and this doesn’t necessarily mean these people are weak, neurotic or cannot cope.
·         You can greatly help your sensitive patients by adapting your usual method, in particular by explaining it in detail beforehand, slowing it down, allowing the patient to be in control of the pace, by being gentle and encouraging and by reminding them to relax and breathe at each stage.
·         You can help by validating the patient’s own reality, being supportive rather than judgmental and being honest in confirming that some people do find speculums painful.

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