On her busiest days, Molly Callahan has 16 speculums inserted into her vagina. She works full time as a gynecology teaching assistant (GTA) – a layperson who helps medical students practice Pap smears and breast exams before working with real patients.
It’s not as unpleasant as you might think. In fact, the goal is to help students learn how to do it without causing discomfort. Contrary to popular belief, Pap smears – screening tests for cervical cancer – do not have to be painful.
“I never really feel any physical pain, even after a really long work week,” she said. “If (your) reaction to my work is that it feels like torture, I hope you feel scammed,” added Callahan, 30, who is also president of an international association for GTAs and MUTAs (male urogenital teaching associates). “I hope you fire your gynecologist.” (While students practice speculum exams with her throughout the day, she says the Pap test itself — collecting cells from the cervix — is a bit abrasive and she “definitely couldn’t do 16 in a row.”)
Pap tests have reduced cervical cancer deaths by 86%, but many women avoid them because of confusion around guidelines, perceived lack of symptoms and, most often, discomfort and embarrassment of the speculum. A large study of U.S. cancer statistical data found that between 2005 and 2023, 32% of women ages 21 to 29 and 15% of women ages 30 to 65 had never had a Pap test.
The negative association is not surprising. Examining the cervix for indications of cancer became more common in the early 20th century, said Dr. Kirsten Gardner, director of medical humanities at the University of Texas at San Antonio, and methods focused on innovation rather than convenience.
“A lot of this conversation (about Pap tests) has been about the medical possibilities, not the impact on the patient,” Gardner said. “And when it came to impact, it was very much in the language of early detection of cancer. It was never in the language (of), ‘How does a woman feel? Is it painful? What can we do about the pain?'”
RGTs exist in part to answer this question. Pelvic exams and Pap tests were historically performed on anesthetized patients until the 1970s, when GTAs became more common in an effort to improve the ethics and educational quality of these exams. Although GTAs teach medical students the basics, they also provide real-time feedback and feedback.
“They center the patient’s voice,” Gardner said. “Experiencing GTA simply reminds practitioners that they can talk to patients. »
Currently, more than 90 percent of medical schools in the United States and Canada use RGTs – Callahan, who lives in Queens, teaches at 30 universities and hospitals. But despite the flexible schedule and pay rate — nearly $100 an hour — Callahan estimates there are only about 40 RGTs in the tri-state area, where there are more than 15,000 medical students.
GTA trainees learn the anatomy and tactics of breast and pelvic exams: how to sample the cervix, look for abnormalities, find the ovaries. They train on a skilled GTA, then on each other. This requires two months of training and a final test to ensure they are capable of teaching the exam to medical students.
Callahan became an RGT thanks to her mother, an actress, director and producer, who was looking for extra income when a friend suggested it. Eight years ago, Callahan, who also attended acting school, was putting her life together after graduating. “She told me, ‘You would be so good at this,’ which is a weird thing for a mother to say to her daughter,” Callahan said.
One stormy evening, I drove to Teaneck, New Jersey, to observe Callahan teaching two labor and delivery nursing students from Fairleigh Dickinson University. In a fluorescent-lit classroom, Callahan sat upright on an examining table, wearing a patient gown.
“I talk a lot about preserving people’s modesty and privacy as much as possible,” she said. “But for me? No, I don’t care. It’s just parts. It’s just my meat suit.”
Callahan spent a few hours with the students — probably their only lesson on pelvic and breast exams in school, as is often the case for nursing students. First, she told them about breast exams; the students sprayed their hands with disinfectant and sat at the foot of the table. Callahan dropped her coat and explained that because appointment times are often short, they would focus on the areas of the breast where malignancies are most common: the outer tissues and the armpits. They took turns gently pressing their fingers in a circular motion on Callahan’s chest.
“Don’t tell patients they look ‘good’ or ‘perfect,’” Callahan said. “Use positive but clinical language.”
She proceeded to do pelvic exams, holding a small mirror so she could see their movements. The student carefully placed the back of her hand on Callahan’s inner thigh, a gesture Callahan teaches to gain consent and calm the patient before continuing.
Next, Callahan gave instructions: First, place two fingers on the lips and check for redness. Gently expose the clitoral hood to check for adhesions, which can indicate infections or skin diseases, and check the vestibular glands for cysts. Insert fingers, nail side down, to assess the size of the speculum. Explain what you are doing at each step; if the patient grimaces, you are causing them pain.
A proper review is a collaboration that begins before the appointment even begins, Callahan said. For patients, it can be helpful to know the intricacies of a Pap test and what evidence-based care looks like. Patients can read guidelines and recommendations from the American College of Obstetricians and Gynecologists (ACOG) to stay informed on key information such as how often to have a Pap test. There is also knowledge of your own body: what does your vulva look like? Do you feel pain during sex? Is your breast tissue naturally firm?
This is important because you may change providers between exams, or a provider may not remember you, Callahan said. By tracking differences over time, “you can tell when something is changing and not healing, so you have really concrete information.”
One of the best things people can do is reflect on their own experiences with providers, especially negative experiences, and identify what would make the situation better and more comfortable, Callahan said. Then ask what you want at the start of the meeting.
“If you, the patient, know that there is a certain part that you really hate – like speculum exams that are very painful – could you ask for the smallest size possible? she said. (Speculums come in different sizes: small, medium, large and pediatric.) Larger speculums are sometimes used by default simply because “the more tissue you push back, the more you can see,” said Dr. Corey Babb, medical director of the Haven Center in Tulsa, Oklahoma. Additionally, patients can request blind sampling, which omits the speculum, or insert the speculum themselves.
For added comfort, Babb said, specula can be heated and should be well lubricated. Patients may also request to be placed on nitrous oxide or laughing gas, if available.
A provider who makes you feel comfortable and is invested in your well-being is worth keeping, Callahan said. And if the experience is negative, you can give your opinion or file a complaint for more distressing cases.
On one of her days off, I met Callahan at Hex House, a members-only warehouse in East Williamsburg, where she sometimes conducts training in the Greater Toronto Area. In his studio, Callahan gestured to a three-tiered cart filled with medical books.
“I love this one,” she said, pointing to a 1981 publication called How to Stay Out of the Gynecologist’s Office, by the Federation of Feminist Women’s Health Centers.
“Going to the gynecologist was a nightmare (back then). So he walks you through pelvic self-exams, how to treat yeast infections, how to do an assisted abortion,” she said, flipping through the images. “The whole bush, obviously.”
Gynecology emerged in the 20th century as a male-dominated field that replaced midwives, Gardner said. In the 1950s, biologist and sexologist Alfred Kinsey conducted a study known as the Kinsey Report. In his research, he gently stroked patients’ cervixes with a cotton probe, which only 5% of the 878 participants could feel. When trying a larger object, 84% said they felt a sensation. Yet only the first result was included in the final version, and it concluded that the pass was unresponsive. J Marion Sims, “the father of gynecology,” practiced on enslaved women and never used anesthesia. Body parts like the fallopian tubes, Bartholin’s glands, and the G-spot are named after male doctors.
“They think they’ve discovered these things,” said Callahan, who prefers location-based names, such as “fallopian tubes” and “vestibular glands.”
At the end of the teaching session, both nursing students admitted that neither of them had ever experienced a slow, gentle pelvic exam. Callahan put his clothes back on as the students said goodbye.
Once home, Callahan said, she lets a stream of hot water wash away the long evening of contact — her hips and back get stiff from all that sitting, and labor can be…
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