EBB 185 – The History of Narrative Medicine and Childbirth with Tyler Jean Dukes

Learn more about Tyler by following her on Instagram (https://www.instagram.com/birthandbooks).

Learn more about DFW Narrative Medicine here (https://dfwnarrativemedicine.com/). 

Learn more about American College of Obstetricians and Gynecologists (ACOG) here (https://www.acog.org/womens-health/faqs/ultrasound-exams).

Learn more about Listening to Mother’s (LTM) here (https://www.nationalpartnership.org/our-work/health/maternity/listening-to-mothers.html).

Learn more about World Health Organization (WHO) here (https://apps.who.int/iris/bitstream/handle/10665/259946/WHO-RHR-18.01-eng.pdf;jsessionid=6D347E8AC8A769FE8E922B68675407BA?sequence=1).

Learn more about Ultrasound Industry Reports here (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001451.pub4/full).

Learn more about Value Penguin here (https://www.valuepenguin.com/cost-sonogram-ultrasound-pregnancy).

Learn more about Fortune Business Insights here (https://www.fortunebusinessinsights.com/industry-reports/ultrasound-equipment-market-100515).

Read about Benson & Doubilet, “The History of Imaging in Obstetrics” (2014) here (https://pubmed.ncbi.nlm.nih.gov/25340440/.)

Read about  Bucher & Schmidt, “Does Routine Ultrasound Scanning Improve Outcome in Pregnancy? Meta-Analysis Of Various Outcome Measures” (1993) here (https://pubmed.ncbi.nlm.nih.gov/8343659/).

Read about Howarth & Brown, “Obstetric Ultrasound — Its Risks and the Cost of Addressing Them” (2013) here (https://www.ajol.info/index.php/sajr/article/view/92501).

Read about Torloni et al, “Safety of Ultrasonography in Pregnancy: WHO Systematic Review of the Literature and Meta-Analysis” (2009) here (https://pubmed.ncbi.nlm.nih.gov/19291813/).

 Learn more about Pelvic Exam Surveys from Cleveland Clinic (CC) here (https://www.ccjm.org/content/ccjom/82/10/661.full.pdf).

Learn more about American College of Obstetricians and Gynecologists (ACOG) guide to routine pelvic examination here (https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/10/the-utility-of-and-indications-for-routine-pelvic-examination).

Learn about The Embryo Project Encyclopedia (EPE) here (https://embryo.asu.edu/pages/vaginal-speculum-after-1800).

Learn more about Medical Bondage: Race, Gender, and the Origins of American Gynecology (2017) here (https://ugapress.org/book/9780820354750/medical-bondage/).

Learn more about Feeling Medicine: How the Pelvic Exam Shapes Medical Training (2020) here (https://nyupress.org/9781479897780/feeling-medicine/).

Bates et al, “The Challenging Pelvic Examination” (2011): https://pubmed.ncbi.nlm.nih.gov/21225474/

Friesen, “Educational Pelvic Exams on Anesthetized Women: Why Consent Matters” (2018): https://pubmed.ncbi.nlm.nih.gov/29687469/

Lewis, “Waking Sleeping Beauty: The Premarital Pelvic Exam and Heterosexuality During the Cold War” (2005): https://muse.jhu.edu/article/190427

Learn more about Narrative Medicine here (https://dfwnarrativemedicine.com/resources).

Rebecca Dekker: Hi everyone. On today’s podcast, we’re going to talk with Tyler Jean Dukes about the history of prenatal ultrasound and pelvic exams.

Welcome to the Evidence Based Birth® podcast. My name is Rebecca Dekker, and I’m a nurse with my Ph.D.  and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.

Today, I’m so excited to welcome Tyler Jean Dukes to the Evidence Based Birth® podcast. Tyler pronouns she/her is a doctoral candidate and graduate instructor at Texas Christian University. Over the past year, she has been working with myself as part of a graduate fellowship program. Tyler specializes in the medical humanities and early British literature. She’s also a trained childbirth doula, which informs her scholarly and personal interests. Tyler teaches many classes at TCU, including “Introduction to Literature, Fiction, and Narrative Medicine,” and she is one year away from graduating with her Ph.D. . Welcome Tyler to the Evidence Based Birth® podcast.

Tyler Jean Dukes: Nice to be here. 

Rebecca Dekker: It’s been so great working with you over the past year as part of your fellowship. And just so everybody knows, I don’t take doctoral students at EBB. I used to work with doctoral students at university, but Tyler is the first and only doctoral student I’ve worked with at Evidence Based Birth® as part of a student project. But Tyler just happened to reach out to me at the right time when I needed help with a project, and she had the right skills to help. And I was really fascinated to dig deeper into the literature in history and some of these childbirth topics to kind of go as far back as we could and learn more about the history. So I’m super excited that we got to spend the last year working together and meeting every other week. So would you tell our audience Tyler a little bit about how you got interested in birth work?

Tyler Jean Dukes: Yeah. So I’ve always been interested in stories and storytelling about women. Even whenever I was a little girl, I would write all kinds of stories in my diary about my sisters, and my mom, and my friends. And I was just fascinated with the complexity and intimacy of women’s lives. And that carried into my education. As I went into higher education, I ended up writing my master’s thesis in literature about the character of Sleeping Beauty and about all of the ways she found herself ill represented in books and films throughout time. And there were many components of my graduate education that I enjoyed, like research and writing. And they were very fulfilling, but unfortunately I also experienced academic gatekeeping during my master’s as a few key people in the department had a kind of spirit of maintaining this academic, elitist status quo. And keeping me as a young, inexperienced scholar out of important conversations in the field.

So through that experience, I was kind of off-put with academia in general to say the least. And I should note that that’s not a unique experience in the academy, right? I mean, I have privilege as a white woman. So the gatekeeping I experienced is amplified even more so for Black, Latinx, and Indigenous women. But just because it’s commonplace in academia, doesn’t mean it’s right or acceptable. 

So I felt really discouraged after experiencing this. And as a stroke of faith, right before I graduated, I ended up attending one of my friend’s home birth. And I was not there in any kind of official capacity. I was there to keep an eye on her children and to just help out with whatever she needed. 

And it was the first birth that I had ever witnessed. And the only correct word to use, to describe it is just magical. And I had never witnessed a person with so much nerve and courage just dig down to the absolute depths of their being and then have to claw themselves back out again in order to birth this thing into the world. And it was an honor to be there and to support my friend.

So shortly after attending that birth, I decided to sign up for a doula certification program. And I didn’t really know what I was getting myself into, I’ll be honest.

Rebecca Dekker: Didn’t know there was a whole world?

Tyler Jean Dukes: No, I didn’t. And I didn’t know what I was getting myself into. But I did know I wanted to keep being a part of what I had witnessed at that birth. And it was surprisingly refreshing because as I began the doula training, unlike academic work, which Dr. Dekker, it can just feel like it exists in a vacuum sometimes. Which is why I feel like part of the reason why you established Evidence Based Birth® is because you’re translating this vacuous knowledge to lay people so we can actually do something with it. But birth work is so immediate. So you have to give your full attention to your client in front of you, because they’re going through this life-changing experience, and they deserve your energy and support. 

And I think that’s something that maybe we gloss over about birth work. But it is the best mindfulness practice in the entire world because you have to be present. And you have to support them physically and educationally. So I loved being present with my client.

But I still wanted to get a Ph.D. and I couldn’t really get that thought out of my head, no matter how much I tried. So I decided to apply to doctoral programs, but I made kind of a vow with myself. It sounds dramatic, but I did. If I ever got accepted to a program, the department would have to be willing to let me incorporate both birth work and literature into my research. That was my ultimatum for myself. 

And eventually, I was accepted into an excellent program that allows me to do that. I get to research medical history and reproductive health during the Renaissance specifically. And I get to teach courses on narrative medicine. And I really fully believe that my training as a doula makes me a more compassionate and informed teacher and researcher.

Rebecca Dekker: Yeah. Can you tell us what narrative medicine is? What does that mean?

Tyler Jean Dukes: Sure. So narrative medicine started in the early 2000s and at Columbia University as a way for doctors to provide more patient-centered care through the medium of storytelling. So rather than a doctor seeing a patient as symptoms, and listening to the symptoms, and pathologizing about the patient in regards to how they felt about X, Y symptom is really about listening to the entire story of the patient and asking themselves, “Why does the patient feel this way? What kind of systematic barriers have prevented them from getting the care that they need? How could these symptoms be part of a larger picture about their personal life or their health?” So really, narrative medicine began as a clinical practice in order to help patients through their illnesses through storytelling. 

But since then, it’s kind of blossomed into this section of the medical humanities that all sorts of people are interested in. Literature people, historians, obviously practitioners, and nurses, and all sorts of people are now interested in it because it’s really just about humanizing patients in front of you and listening to their stories. That’s it. 

So I think that is something that as time goes on, we’re realizing that maybe we deleted out of medicine as it became overspecialized. And we’ve kind of forgotten, a lot of people have forgotten their “bedside manner,” or their investment in their patients. And that’s what narrative medicine is trying to restore.

Rebecca Dekker: It sounds like it almost is a return to Indigenous practices of storytelling in Indigenous medicine and traditional healing. So perhaps it’s more of a return to what used to be rather than something brand new. Does that sound-

Tyler Jean Dukes: Yes. Yeah, there’s even a concept in that they call … well cultural humility is a term obviously that people know. But it has even been co-opted by this movement to say narrative humility. And that is just the awareness that these kinds of stories have existed for a long time. And that we should, either if you are a doctor, or a nurse, or a doula, whoever. That whenever you hear these stories, it’s coming from a place of trying to understand and not rewrite, or not erase, or not-

Rebecca Dekker: Put it into a box.

Tyler Jean Dukes: Put into a box. Yeah. So that is something that I think that they are aware of as they’re continuing to develop this into a discipline.

Rebecca Dekker: So you found an amazing program that was willing to work with you. How did you end up integrating childbirth and birth work into your Ph.D.  studies in literature?

Tyler Jean Dukes: To be honest, since my master’s program, there was one instance of Sleeping Beauty where she gives birth and breastfeeds while asleep. So its a really old story called, “Perceforest.,” which is a chivalric romance with knights and stuff.

But she gave birth and breastfed while she was asleep, this version of Sleeping Beauty. So since then, anytime I’m reading or watching something, I’m just like, “Is there a birth in here?” Which I’m sure is really annoying to people in my life that I’m just always looking for those things. But I knew that I wanted to continue looking at birth in literature as I did my Ph.D. . 

So for my dissertation, I am exploring the importance of childbirth on the Renaissance stage. So without getting too jargony, basically I’m investigating how playwrights like William Shakespeare dramatized birth.

So my hypothesis in my dissertation is that the everyday nitty-gritty realities of Renaissance childbirth, and it was really nitty-gritty because they had no sewage, no running water, no life-saving pharmaceuticals. Not to mention the maternal and infant rate was so high compared to today. But my hypothesis is that the everyday realities of Renaissance childbirth were in some ways represented onstage. 

But playwrights were also re-imagining birth into this version that was theatrically constructed. So that is to say that Renaissance drama presents a version of birth that has remanence of realism, but it also has a real constructed quality to it. And

I think the best example without going too in-depth, but if you were a theatergoer during the Renaissance, so if you were going to see one of Shakespeare’s or Marlowe’s plays, they had props and there was kind of lighting because they used fire, non-electrical means. But the stage setting was relatively limited and the casting was relatively limited. So the majority of female characters were played by male actors. 

So to put it more clearly, in instances of childbirth on stage in the Renaissance, what you have is male actors constructing through their artistic choices their tone, their body language, etc., what they thought childbirth was like for Renaissance women. 

And then to add another layer, most plays were written by men. So you have a man writing a Renaissance experience into a script. And then you have male actors performing maternity. So it’s just this bizarre, fascinating moment in time that I could go on for forever. So I will stop. But basically in my research. I am interested in how birth is re-imagined or reconstructed through dramatic storytelling.

Rebecca Dekker: Okay. So the storytelling you’re looking at specifically and you’re researching is from what time period? I know that you said Renaissance, but what were the approximate years or centuries?

Tyler Jean Dukes: Loosely 15 and 1600s. Sometimes, it goes a little bit after that, depending if you’re using the term Renaissance or early modern. Early moderns tends to extend a bit more.

Rebecca Dekker: So you’re looking at European depictions of childbirth from the 1500s and 1600s?

Tyler Jean Dukes: Yeah. And really, because of the specificity needed for my dissertation, it’s really I’m looking at plays in London in this timeframe. So it’s not even-

Rebecca Dekker: They make you really narrow down when you’re doing your dissertation.

Tyler Jean Dukes: Because you end up with things like … they had these things called city plays. So there’s this really funny one. It’s actually really funny, called “A Chaste Maid in Cheapside.” If you’re ever bored, just go read the play. But it’s written by Thomas Middleton, and there are male actors who are playing Renaissance midwives. And what they would call gossip or the birth attendance during that time period. So it’s just a rabbit hole of circumstances of these male actors performing comedy about midwives and about bosses. There’s so much going on there. And it’s really hard sometimes as a researcher because you are reading what would have been performed. So I guess that’s something that I’m always trying to keep in mind is that this was meant to be performed. So there would have been so many layers to that, that we don’t get to experience because we’re reading it on a piece of paper.

Rebecca Dekker: Sounds like it could also be a topic for a Ph.D.  in theater.

Tyler Jean Dukes: It could. It could. It could.

Rebecca Dekker: So tell us about your fellowship project that you did with me. What were your goals for the academic year that you and I spent working together?

Tyler Jean Dukes: Well, I found out last spring that I was awarded the Albert Schweitzer Fellowship, which is a year-long program. It’s obviously separate from my dissertation work. This program is service-based, and it’s a national program. And it’s intentionally interdisciplinary, which is really what drew me to it. The goal for each Schweitzer fellow is for them to help fulfill unmet health and wellbeing needs. And usually in local communities. But because of the pandemic, the Schweitzer program kind of had to adapt. And what ended up happening for many people in my cohort was an expansion out from a face-to-face and person volunteering, which was almost impossible at the beginning of the pandemic. That was not happening at all, obviously. To virtual online-based programming and activism. 

So I knew I wanted to work within the realm of childbirth education. And as a doula, I had always used Evidence Based Birth® for the resources. And so I reached out to you Dr. Dekker, and I proposed the fellowship. Like you said, this is not something that you guys have in place or will probably have in place. But I just was like, “Hey, I have this year-long fellowship. Can we research a handful of topics and then write corresponding social media posts?” And you were gracious enough to allow me to do that. 

And I think as far as what our goals were for the project, some of them have extended beyond what I thought was going to happen. I had to write the final reports this week. But total, the posts reach over 100,000 people. Which for me, that is beyond what I thought was going to happen. We of covered more general topics like cognitive biases in medicine, to first trimester screenings, and Rh incompatibility, and all sorts of stuff.

But early on, I think another goal of Dr. Dekker and of our goal was that many of the posts would focus on racial disparities and reproductive health. And I know that Dr. Bervell and Dr. Morgan mentioned in a previous podcast that this year has been special in that conversations about racism are front and center in white America’s cultural consciousness. So for myself and for other white people, this was an important time of self-education.

So one of our goals for this fellowship was to engage with the current and ongoing conversations about racial disparities and reproductive health in a responsible and evidence-based way.

Rebecca Dekker: Yeah. So you worked on some of the black tiles that we posted on social media. So you can look for the ones that, just scroll through our Instagram feed and look for the black tiles. And some of them were done by Tyler Jean. You can see her name at the bottom, the ones she helped write. And then we also, I would just kind of say as well, “Tyler, can you look into this? I just want to know the history of this.”

So like you said, we looked at things like the history of nursing, all the way to current issues related to maternity leave and paternity leave. So we covered a wide range of topics. So I would love though, I think for our audience, it would be really helpful to hear about two of the things that we looked at in detail. One of them prenatal ultrasounds, and the other pelvic exams. 

So let’s talk about what you discovered about the history of prenatal ultrasounds. Walk us through what you found as you dove into old texts and literature about the history of this subject.

Tyler Jean Dukes: Sure. So I should say before we dive into the history of ultrasounds that I am not a medical provider, and I’m not an ultrasonographer. So I am a researcher with an interest in medical history like you said. So my findings are within that scope, right? 

So when we began looking at ultrasounds, I feel like I knew just about as much as anyone else. I knew that there’s on average two ultrasounds per pregnancy. One scan at 8 to 13 weeks to estimate gestational age and screen for genetic disorders. And then one around 18, 20 weeks to check the anatomy and for abnormalities. But as a birth worker, I also knew from observation that there’s a whole spectrum of ultrasound use in pregnancy. I had some clients get up to four or six screenings, and some clients opt for no screenings at all.

But through our research, we reread the “Listening to Mothers” survey. And we do know that 98% of pregnant people get at least one ultrasound in their pregnancy. So that is an extremely high number, especially compared to what it was even 50 or 100 years ago. 

So that was the basis of what I knew. What I didn’t know we were going to find is the density of historical and economic information in regards to ultrasounds. So a brief history, ultrasound technology as we know really took off in the 1940s. However, there were a few key historical precursors to modern ultrasonography.

So the first was in 1974, or not 1974. 1794. So the first was in 1794 when Dr. Lazzaro Spallanzani, I wrote that out so I wouldn’t mispronounce it. Who was a physiologist, discovered that bats use ultrasound to navigate through echolocation. So as early as the 1700s, we have a doctor recording how sound waves are used in bat echolocation.

And then there were some experiments about bells underwater to see when people found out that sound travels faster underwater. But then the final precursor was in 1914, we had, his name was Paul Langevin. And he saw the results of the Titanic crash and he thought, “Hey, what if we use this technology, this sonar technology to detect icebergs?” So this was the first instance in 1914 of ultrasound technology being put to work for military uses. So his transducers ended up being used during World War I to detect enemy submarines. So I guess we can think about that the next time you’re at an ultrasound appointment. At one point in time, they were looking for submarines with this technology.

So by the 1940s and ’50s though, this is when we get to the first soft tissue ultrasounds on humans. So Dr. Ian Donald was originally pioneering the technique of A-mode ultrasounds to examine abdominal tumors. But actually by accident, he ended up finding out that the ultrasound technology could be used for obstetric applications. So the 1940s is when this first started becoming, when it was first kind of established. And then it’s become more and more common practice over time. 

So it is important to keep in mind though in the ’40s that the machines were massive, and clunky. Extremely strong, and quite frankly a little scary. So if you ever just go to Google image and type in ultrasound machine 1940, it’s fascinating to look at all the black and white images of how big these things were, and how intimidating it might’ve been to use them on pregnant women.

But in the 1960s, the American Institute of Ultrasound in Medicine was founded. So that’s how you know you kind of made it is whenever there’s official organization to say that you’ve made it. 

And then by the 1980s, this is kind of where real-time sonography starts to replace static scans. So if you think about the 1940s as the first we’re using this on human beings, now the 1980s is when the real-time sonography, so the moving sonography replaced just a static image. And this a lot of people have thought has revolutionized the field of minimally invasive obstetric procedures. So instead of using x-rays and possibly exposing a pregnant woman to radiation, ultrasounds have come to produce real-time images at relatively low cost and with minimal risks compared to x-ray.

So in the 1990s, we got our first 3D ultrasound imaging. But it was kind of slow actually with the growth of technology until recently, whenever what they call souvenir ultrasound. The souvenir ultrasound industry was born. And what I mean by that was people who are electing to get 3D and even 4D ultrasounds in clinics outside of their usual provider’s office to get keepsake photos and videos for their babies. So this has really turned into a commercial industry now where people will go and get 3D and 4D ultrasounds in addition to their usual scans that they would have at their doctor’s office. 

So one of the parts that was just fascinating besides the history of it was the global equipment market for ultrasounds. So it’s about $7.7 billion a year, which is just an insane amount of money. And as we dug further into it, we learned it’s a pretty savvy business venture. Because the startup for an ultrasound business, the machines, education, rent, etc., is only about 25,000 to $75,000. Which sounds like a lot. But, most ultrasound clinics can make up to $1,000 dollars a day. So in just 25 to 75 days, you can cover your startup fees for an ultrasound clinic, which is one of the reasons why it’s become a really popular business investment. There’s even clinics that, what’s the word I’m looking for? They’re in vans.

Rebecca Dekker: Mobile.

Tyler Jean Dukes: Mobile. Yes. Mobile ultrasound clinic. So the last thing I should say is that we did find that the average cost for ultrasounds for most people in the U.S. is about $280 per screening. But that can vary widely based off of your location and your provider. And because ultrasounds are not explicitly named in the Affordable Care Act, some insurance companies use that loophole to not cover the cost of the technology for pregnant women or for pregnant individuals.

Rebecca Dekker: So one of the things I asked you to look into is just … and we didn’t go into in-depth looking at safety, but I did ask you to look into like the strength of the ultrasound waves. Because obviously, it’s changed since they first introduced it with those giant massive machines. Can you talk a little bit about what you discovered?

Tyler Jean Dukes: Sure. So they definitely have learned over time what waves are the best therapeutic dosage, and how strong the waves need to be in order to get the image that they need. So there have been some very limited studies on animals where the ultrasound waves can disrupt some of their bodily functions. But, these studies were done on very small animals like mice, etc., using extremely strong ultrasound pulsations like you would for humans. So there still needs to be more research into that realm. And on the pulsations of ultrasounds if you think about it as a wavelength, a slow wave is seemingly doing less damage than a fast-paced wave that is going up and down through all spectrums.

So over time, they have really had to rethink the machines. So the machines have preset ranges on that, that the ultrasound tech can select from. Previously I think before, I want to say before the 1980s, the machines had the ability to go very high past therapeutic levels. And that has really been reined in within the last 50 years or so. 

Rebecca Dekker: And then you also found something interesting about the professionalization of the field. And I know you just talked a little bit about the amount of money in the industry, but can you talk a little bit about the professionalization of it?

Tyler Jean Dukes: Sure. So the professionalization is something that has necessarily had to develop because of the industry demand. So obviously, there are all sorts of sub-specialties now such as cardiology, gastroenterology, urology, that use these machines. So because that demand so high, again, because this is one of the least invasive things that you can do to diagnose a patient. So I think that ultrasounds are used as the first line of defense before more invasive procedures. 

But because of that, there has been a steady growth in ultrasonography as a profession because of the demand for it. They have found that it is really useful. And many of these subspecialties, they need more ultrasonographers, they need more machines, they need more abilities to process the data that doctors are often asking for when they send their patients to get screenings. 

Rebecca Dekker: And I had never really thought about it, but it would be interesting to read more about how ultrasonography contributes to the bottom line of obstetric clinics, and hospitals, and that sort of thing.

Tyler Jean Dukes: Yeah, absolutely. Because like all things, something that is minimally invasive but still costs a little bit of money, it’s very easy for it to become exploited. Right? So for every doctor to just request an ultrasound as a baseline, it’s like you know if you’ve ever been admitted to the ER or something like that. A lot of times they’ll give you an EKG, this, and this, and this, and this, even if you’re not necessarily having cardiac symptoms. So I think sometimes, ultrasounds can be used in that way by doctors. We’d like to believe that that’s not how it’s being used, but of course it is.

Rebecca Dekker: All right. So moving on, let’s talk about the history of pelvic exams. What did you find on this that surprised you?

Tyler Jean Dukes: Well, honestly the pelvic exams was one of the more memorable research reports that I remember discussing with Dr. Dekker this year, just because of how utterly absurd it gets in the 1950s and ’60s. So there are many precursors, historical examples that I could talk about with the pelvic exams. But for sake of time, and I don’t need to re-summarize because Dr. Bervell and Dr. Morgan actually discussed James Marion Sims in a previous podcast. But Sims and later, the state-mandated pelvic exams are representative of how a procedure that used to be performed by women was co-opted oftentimes by men in the profession. 

So in 1845, James Marion Sims began these terrible experiments on enslaved women who had fistulas. And what he called was the Sims speculum. This is the tool that he started to develop. It really actually just started as a bent spoon, which is kind of terrifying to imagine. And then it was further developed into an obstetric tool. So this tool, this speculum, although ubiquitous to us now was crucial to the medicalization of childbirth. And if you think about it before the 18th and 19th centuries, midwives were primarily filling most of the roles related to pregnancy and childbirth.

So for example, as early as 1671, the famous Renaissance midwife Jane Sharp wrote a whole section in her book about pelvic exam, and about how to use butter or duck grease on your hands in order to perform a pelvic exam that was more comfortable for the patient. But the Sims speculum, and in the 1800s in particular, it enabled physicians to gain control over women’s bodies and position themselves as sole experts on obstetrics and gynecology. 

So by the turn of the 19th century after years of using the sims speculum, physicians and their use of tools such as the speculum and then the forceps were the new normal when it came to pelvic exams.

So the second example I want to just hone in on is from the 1950s and 1960s, where pelvic exams started to get bizarre. There were at this time, state-mandated free marital pelvic exams. Yeah. State-mandated pelvic exams before you got married. And states such as Oregon, Texas, and Wisconsin required a signed certificate verifying that you had a physical pelvic exam before you were married. And these were not like the pelvic exams that we get today. In contrast, these exams were intended to prepare the woman for marital sex. So in plainest words, physicians thought that monitoring a woman’s sexual response during a premarital pelvic exam was one way to tell if a woman’s marriage would be “sexually fulfilling.” And therefore, it was thought her marriage would be fulfilling.

And anyone who has ever gotten a pelvic exam is tragically laughing right now, because it is usually very far from sexually arousing experience. And in fact, many women report pain and fear during their pelvic exams. So during the ’50s, we can thank Freud for this intense interest in psychosexual development. And I should note that issues of race, class, and sexuality were incredibly salient during this time as well. So patients were expected to be white, heterosexual, and middle-class. And anything that deviated from those norms such as working-class women, queer and trans women, and women of color were often thought of as “abnormal cases” that exhibited pathologic behaviors, that would disrupt the pelvic examinations. Right?

So the physicians at this time hoped to preempt any emotional or physical trauma. This is what their thought process was. I’m not saying this is correct. Physicians at this time hoped to preempt any emotional or physical trauma that might be inflicted on the bride during her wedding night. So the physicians literally saw themselves as these sexual instructors who were performing premarital pelvic exams that were meant to quell patients’ fears about penetration, which is just wild when we think about it today. And it’s just completely inappropriate and not acceptable. And this kind of subsumptions of women’s bodily behavior, we’d like to think that it’s disappeared today. But the truth is that exploitative behavior during medical exams continues.

When we were researching, we found that in 2003, medicals students were surveyed. And 90% of them said that they had performed a pelvic exam on an anesthetized woman. So a person under anesthesia. And in fact, many scholars estimate that about a quarter to 75% of women who got a pelvic exam under anesthesia did not give consent beforehand. They are simply just not being asked. 

And I think it’s essential to understand here that patient education and consent are essential components to pelvic examinations, right? And we found that many medical practice reformers have called to fix this by having doctors only perform pelvic exams when absolutely medically necessary. When they are performed, to get clear consent. To only perform the parts of the exam, I already said the exams that are necessary. But to make patient comfortability paramount. So if the patient needs a chaperone or there needs to be further attention paid to the speculum size or lubricant. So making the patient’s comfort the number one priority.

And then finally, to be aware and attentional with groups of people who may find pelvic examinations more challenging. For example, victims of sexual or physical abuse. People who have experienced female genital circumcision, people with disabilities, or people who have gynecological conditions that are uncomfortable.

So if anything, what I would want people to take away from this discussion is that routine procedures like ultrasounds and pelvic exams of course have benefited us, right? In multiple types of ways, as they’ve gone through history. And as we experience them today. But we’re also still mitigating many of these histories long-term and trying to reframe the way that these procedures are performed, who they’re performed by, and what kind of considerations we give for the patients that they are performed on. 

Rebecca Dekker: Yeah. And I’d encourage those of you who are listening to go and listen to EBB episode 180 with Stephanie Tillman, who is an expert on trauma informed pelvic care. And Stephanie actually makes the case that we should treat everybody as if they’re special, not just special cases if that makes sense. Because you never know who’s a victim of assault or who’s a survivor. We never know people who are experiencing trauma in other ways, or people who do not engage in penetrative sex. So pelvic exams can be extremely traumatizing for them. 

And I also want to say when you found that one article just talking all about the, the research article all about premarital pelvic exams, I was shocked. But at the same time, it didn’t surprise me. Because I’m like, “So this is where this comes from.” This mandating, legislating over our bodies. And this whole concept of, “Well, this is my job. I have to do this to you,” with the pelvic exam. And then when you read the article and you see how they literally thought that they were basically trying to take care of the virginity part before you went to your husband on your wedding night. Which it’s so sickening that that’s what physicians thought that they were allowed and able to do. It’s so gross.

Tyler Jean Dukes: Anyone who’s ever had a pelvic exam even today knows it’s an incredibly vulnerable experience. Because you’re laying out there, and this is like you really have no control over how the exam is performed, unless you have discussed it with your provider beforehand. But I think that especially for those women in the 1950s and ’60s, it would have been something that they could not have gotten away from in many ways if they wanted to get married. Especially if you lived in one of these states in which it was legislated that you had to have an exam. If you wanted to get married, this was something that you had to do. 

Rebecca Dekker: And I verified it. I went and I asked my family members. I asked them, “You got married in the ’60s. Did this happen to you?” “Rebecca, let me tell you how horrific it was.” And they had kept these stories to themselves all this time, had never talked about it. And I never knew that my own family members had had state-mandated pelvic exams where the doctors literally were trying to get them prepared for sexual intercourse. It was really sickening and really traumatic for them. Yeah. So it was interesting. But like you said, we’re still mitigating some of the effects of that in terms of the attitudes that we see towards people with pelvic exams. The attitudes that have been down through the generations of medical schools, and academia, and clinicians. And obviously, we have people who are trying to work away from that. But there was never one point where physician stopped and we’re like, “You know what? We’re doing this wrong. Let’s start over from scratch.” And instead, it’s just been this kind of gradual progression to where we are today. 

Tyler Jean Dukes: Yeah. And if you look on a timeline, right? If this is the 1950s to now, and it’s less than 100 years. And there are hundreds and hundreds of years before that in which pelvic exams were handled by midwives and by all sorts of different women in cultures that were specifically intended to take care of women’s health. So in some ways, maybe our informed approaches to pelvic exams is a return to some of the things that existed before the medicalization of childbirth. But then also an expansion as obviously we live in a different world today than they did then.

Rebecca Dekker: All right. So we’ve covered the prenatal ultrasounds, which is interesting and intriguing. And then the pelvic exams, the premarital, and during pregnancy pelvic exams, which that information was shocking and horrifying. But is there anything else you want to share before we go?

Tyler Jean Dukes: I don’t think so. I think that this has been a really great opportunity over the year to work with you on I would say a critical part of my professionalization as a Ph.D. . Because a lot of the times when you’re in a literature Ph.D.  program, there aren’t very many people who are interested in medical history. So this was an opportunity to further educate myself and to hopefully help other people learn something new about these procedures and these situations that we find ourselves in relation to childbirth.

And I also just want to say if people want to connect with me, they can find me on Instagram. I’m @birthandbooks. I’m open for continuing any of these discussions. I also, I post a lot of dog pictures there, but that’s not related. Or if you’re interested in me facilitating an in-person or virtual narrative medicine workshop, we have a website now. It is dfwnarrativemedicine.com. And like I said, we can facilitate an in-person or a virtual workshop for individuals who are interested. 

Rebecca Dekker: Thank you so much Tyler for all your work over the past year, and for what you’re doing to help with storytelling to help encourage healing. And we wish you the best of luck as you wrap up your dissertation over the next year.

Tyler Jean Dukes: Thank you, Dr. Dekker. I’m going to need it. It’s been a pleasure to chat with you.

Rebecca Dekker: Today’s podcast episode was brought to you by the online workshops for birth professionals taught by Evidence Based Birth® instructors. We have an amazing group of EBB instructors from around the world who can provide you with live, interactive, continuing education workshops that are fully online. We designed Savvy Birth Pro Workshops to help birth professionals who are feeling stressed by the limitations of the healthcare system. Our instructors also teach the popular comfort measures for birth professionals and Labor and Delivery Nurses Workshop. If you are a nurse or birth professional who wants instruction in massage, upright birthing positions, acupressure for pain relief, and more, you will love the Comfort Measures Workshop. Visit ebbirth.com/events to find a list of upcoming online workshops.