How To Banish Shame And Stigma From Sexual Health Care
By July Westhale
Judgement has no place in the treatment of sexual health.
M y first year of college, my dorm room had a broken door. Located at the end of the second floor hallway, it was an easy 30 steps and one swift kick to the place I slept, studied, stared out the window, and tried to figure out adulthood.
My roommate and I liked that our dorm mates could come and go as they pleased. For my roommate, who had a difficult time sleeping alone, it meant that she always had friends to cuddle with on a regular basis. For me, it meant that people felt comfortable and at home in our space. In fact, our dorm room was so notoriously homey, it was photographed for the university website. And the photos are likely still there, 10 years later. More than comfort, however, I loved the access to our room because we made a point of keeping a large jar of condoms, lube, plan B, spermicide, and dental dams on the middle shelf.
The RA lived four doors down from us, and was well-stocked with all of the same safer-sex options we employed; however, many students chose to kick down our door instead, because of the power dynamics of admitting sexual activity. After all, many of us were still teenagers. In a dorm of women, many of us had internalized shame about pleasure and sexual health, about our bodies and what we did with them.
Every popular college movie, novel, or television show depicts college as a hotbed (pun totally intended) of sex and openness — for men, at least. But on our campus, and I suspect many campuses, everyone walked around not talking about what they were doing — except to me and my roommate.
In a dorm of women, many of us had internalized shame about pleasure and sexual health.
We worked hard to make our room a normalizing space, a validating space. Our room was open 24/7 and entirely confidential. This was back when free clinics and California Planned Parenthoods allowed patients to take up to 50 condoms a visit, ample lube, and all of the safer-sex materials you might need. So I made a habit of dropping by the clinic in town once a week to restock, so no one would come to us in an hour of need and find one more place that had failed them.
Reproductive health and justice has always been supremely important to me. Perhaps it’s because I was raised in a Southern Baptist household; we never talked about sex. It was one of my best friends, Nora, who bought me my first book about bodies. I remember it was a pop-up book, and turning the pages to see genitalia opening and folding like origami cranes seemed lovely to me, more intuitive than any reproductive health class I’d had in school.
And to be clear, I went to a tiny, underfunded, backwater public school. All I remember from my high school health class was:
a) A giant cardboard cutout of Batman, with a speech bubble that said, “Think before you do!”
b) Classic condom-on-banana shit, and,
c) Our teacher explaining menstruation by dipping an unwrapped tampon in a glass of water. It bloated immediately, like a cotton whale who has just swallowed an entire school of fish in one gulp. I remember my uterus recoiling in terror — though I couldn’t have told you that it was my uterus at the time.
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So going away to college felt like a new opportunity to be a person people sought out to help them feel normal about their bodies and their health. And as I got older, and the attacks on reproductive health care worsened (including my beloved Planned Parenthood), I felt even more determined to be involved.
I just wasn’t sure how to begin.
As the story goes, former U.S. poet laureate W.S. Merwin once went to visit Ezra Pound, a literary hero of his. Eager to show the master his poems, he presented Pound with a stack of ambitious work. Pound famously took a short look, before turning to the young poet and saying, “Start with the seeds, not the branches.”
I heard this story when I was interning as a poetry editor at Copper Canyon Press, where my job routinely involved reading W.S. Merwin’s mail before sending it on to his agent, who then sent it on to him. It’s been four years, and I still think about this story often, not only in regards to my own poetry, but also as a mantra for activism and organizing in general.
The opportunity to start with the seeds fortuitously found me at a writing fellowship at UCLA in 2011 (where I met my best friend Francesca, who is found in the queer girl friendships article, among others on this site). My roommate, a big-hearted fiction writer who also lived in Oakland, was married to a woman who was running Project Prepare — an organization that teaches trauma aware, trans-competent reproductive health care to medical students, nurse practitioners, and physician’s assistants all over the Bay Area and in parts of Nevada and Idaho.
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I applied for Project Prepare, but wasn’t brought on as a health educator/teaching associate until the summer of 2014, after extensive training and interviewing. The exams we teach are comprehensive — a few of the exams I’d never known about until I became an educator — and focus on two primary objectives: the physical component (clinical skills), and reducing patient anxiety during the exam and intake interview.
As educators, we represent the every patient. We keep personal experience out of the classroom. We get to be the seeds, or part of the seed packet, where medical students have the opportunity to learn about bedside manner, appropriateness and inappropriateness, body language, how to deliver bad news, compassion, and empathy with boundaries.
Within reproductive health care, practitioners face the specific challenge of navigating clinical language with the task of reducing patient anxiety during an exam. In order to successfully provide care in that gray area, practitioners must work to not bring into the exam room any other context where a patient’s genitalia may be viewed or touched.
So we teach students how to utilize strictly clinical language — insert, separate, remove, palpate — along with how to read body language and diffuse fear/anxiety. Teaching the pelvic exam, for example, begins by talking specifically about language, and how it relates to the intersection between clinical and trust-building medical intake. A good example of a question is, “I offer this to all of my patients: would you like to be tested for Sexually Transmitted Infections today?”
Notice that language? It’s non-assumptive and very normalizing.
Along those lines, we teach a small cliff notes section at the end on how to compassionately deliver bad news (though many of the universities and institutions we service provide additional education about this). We stress kind body language, presence, and eye contact, evening power dynamics, and reducing the feelings of vulnerability the patient may be experiencing.
“Sit at the patient’s level,” I instruct my students. “Don’t tower over them. When listening, keep your palms up on your lap, showing openness and capaciousness. Like you can hold whatever it is they are going through.”
Every educator has a slightly different way of teaching, a different component of the job they love. My favorite? Students come in terrified — they are working with anatomy they’ve been taught to be afraid of, anatomy they’ve learned through covert and overt misogyny is disgusting, or not valuable. So I see them, anxious and scared, and I get to model anxiety-reducing techniques. Just as we’re teaching them to normalize their patients’ fears, I can work to normalize their own fears and anxieties as practitioners. I listen to them with openness, and keep my face and tone free of judgment. And if I’ve done my job correctly, they relax — and then, my favorite part: they begin to show excitement. I get to be witness to what made them love medicine to begin with. And then I feel lucky, to see that transformation.
Students come in terrified.
Even if our students decide not to go into OBGYN (though I always hope my especially skilled and compassionate students do), these skills are highly translatable to whatever field that choose.
I wish that more medical students and practitioners could have access to the kinds of patient advocacy that organizations like Project Prepare teach on the regular. Because the sad fact is that so few programs give their students that opportunity. And the patients are the ones who suffer.
I’d be remiss if I didn’t also say that the experience takes me back to being a kid in a dorm room, listening to the fears of other kids in dorm rooms. Kids at the seed-stage of their lives.