By Michelle Collins, Ph.D, CNM, FACNM, FAAN
Vanderbilt University School of Nursing
Call the Midwife is back for its eighth season and so are the faculty of the Vanderbilt University School of Nursing with a weekly guest blog. Watch the show Sundays at 7 p.m. through May 19, then read our blog each Monday morning for historical and contemporary context about the previous night’s episode. SPOILER ALERT: Some posts may contain spoilers.
In my post about Episode 8.3, I talked about watching Call the Midwife and thinking about how it seems impossible that things could have been the way they’re portrayed, even if history tells me otherwise. That rang true again in this week’s episode. A young engaged woman had what was then called “testicular feminization syndrome,” now referred to as complete androgen insensitivity syndrome.
Males have an XY chromosomal makeup and females an XX. With complete androgen insensitivity syndrome, XY fetuses (which are genetically “male”) do not respond to male hormones and are born looking female on the outside as a result. On the inside, though, they have a shortened vagina that is more like a pouch and that does not have a cervix (or uterus) at the end of it. These individuals have neither ovaries nor fallopian tubes. They do have testes, which remain undescended, usually in the abdomen. Unfortunately, many times this condition goes undetected until the individual does not begin to menstruate when menarche would be expected.
This brings me back to my opening comments about how things have changed. I was mortified by the way the young woman in this episode was examined by the specialist to whom Dr. Turner referred her. In teaching practices in the past, it was customary for the “sage” (teaching physician) to lead an entourage of medical students on rounds or in office visits particularly to “see” the most unusual of conditions. The teaching physician would then ask questions of the students, in front of the patient, interacting with them in a manner that totally excluded the patient. Patients were treated more as medical specimens than as people deserving empathy. I would like to say that this never happens now; unfortunately, the issue of vaginal examinations being performed on women in surgery and under anesthesia in the name of “education” still pops up in the news today.
Not until the late 1960s did the practice of unauthorized pelvic examinations come under fire. It was then some time before medical organizations began issuing formal statements condemning the practice. Today there are few states that classify these unauthorized procedures as a misdemeanor. (Why not every state?)
In teaching this most delicate of examinations to nurse-midwifery students, we spend as much time on the nuances of how to best perform this delicate exam as we do on the mechanics of the procedure. Those nuances include what the clinician says during the exam. To hear the specialist telling the young woman to “just relax” as he forcibly opened her legs produced in me a visceral response of anger and disgust. “Just relax” ‒ the same words spoken to women when they are being assaulted ‒ are NOT the words that should be used by a professional performing the most intimate of exams.
I wish I could say that women no longer endure exams like this, but I frequently see women in my own practice who have been traumatized by past gynecologic exams. If that woman is you, know that you do not have to tolerate this type of abuse ‒ I cannot even label it as “care.” There are so many options for empathetic gynecologic care; if you currently are not receiving such, I would even highly recommend that you call the midwife!
Michelle Collins Ph.D., CNM, FACNM, FAAN is a Professor of Nursing and Director of the Nurse-Midwifery Program, at Vanderbilt University School of Nursing.