Book Review

Public Privates: Performing gynecology from both ends of the speculum

N Engl J Med 1997; 337:796September 11, 1997

Article

Public Privates: Performing gynecology from both ends of the speculum
By Terri Kapsalis. 216 pp., illustrated. Durham, N.C., Duke University Press, 1997. $16.95. ISBN: 0-8223-1921-7

In this book, Terri Kapsalis attempts to make sense of the complex task of performing a pelvic examination. Her knowledge of this topic derives from her work as a gynecology teaching associate who taught medical students how to do a pelvic examination. Kapsalis participated in a program that enlists women who volunteer to undergo pelvic examinations by medical students, during which the women share their observations as patients with the students. The author brings to this book a broad range of life experiences and exceptional credentials. Her experience as a gynecology teaching associate and her training as an actress have given her the ability to perceive interactions between people in more than one dimension. A pelvic examination is a very intimate interaction.

The way in which the pelvic examination — and indeed other gynecologic examinations and treatments — is taught has changed. Social movements, including the feminist movement, have had a dramatic impact on attitudes toward the pelvic examination and even the way it is performed.

The gynecologic examination has been the focus of many debates and experiments with teaching methods. Ms. Kapsalis discusses the evolution of approaches to teaching the pelvic examination. She notes that the examination has been taught under different circumstances, with some patients carefully informed about what to expect and others not informed. There is no question that students have learned to do pelvic examinations on anesthetized patients, women who were clinic (not private) patients, and patients who could not refuse the examination without risking their access to care. These circumstances have changed. The pelvic examination was one of the first interactions between women and doctors that the women's health movement addressed. A major change occurred with the introduction of gynecology teaching associates. These women guide medical students through a pelvic examination by teaching them and giving them informed feedback. In some cases, the gynecology teaching associate has to deal with a student's fear of performing an examination. These women have helped humanize physicians.

Many of Kapsalis's comments are insightful:

Implicit in the role of the [gynecology teaching associate] is a fundamental contradiction. On the one hand, she is an educator, more knowledgeable than medical students about pelvic and breast exams although she holds no medical degree. . . . On the other hand, the [gynecology teaching associate] is bound to a traditionally vulnerable and powerless lithotomy position: lying on her back, heels in footrests.

Despite the value of her observations, Kapsalis has had difficulty organizing her messages. She cannot resist jumping among her own observations, historical facts, medical practice, teaching methods, symbolism, the treatment of women, and pornography. Reading the book was difficult, because I could never determine where to focus my attention and thoughts. It was as though the author worried that important areas would be ignored if she did not constantly remind the reader how complicated the issues are. She mixes the history of the examination with terrible examples from slavery and reflections on pornography.

Those of us who are obstetrician–gynecologists know that shameful things have been done in our field. One of its founders, Dr. James Marion Sims, advanced techniques of pelvic surgery by performing repeated operations on slaves. This practice may have helped improve surgery in some women, but it injured others. Kapsalis discusses many of these problems, which I think are so extensive that her ideas could be expanded into another book. Many of us in obstetrics and gynecology owe a great deal to women like Kapsalis for their dedication, commitment, and insights. Because of the work of gynecology teaching associates, we are better physicians, and women receive more humane care. Although I am critical of some aspects of the book, it is nevertheless valuable, and I commend the author.

Florence P. Haseltine, M.D., Ph.D.
Bethesda, MD 20892