The exam table with its stirrups. The cold, metal instruments lying in wait. The drape-sheet hiding the patient from herself. The invasive poking and prodding. A routine trip to the gynecologist can elicit anxiety and dread.
One study attributed “negative affective, behavioral, and cognitive processes” to the pelvic exam, “unlike most other preventative care procedures.” Each year, some 60 million pelvic exams are performed in the United States. Providers use a speculum—the hinged, two-bladed instrument that looks like a duck bill—to inspect the cervix, test for STDs, and obtain pap smears.
For all its beneficial uses, the speculum has a sordid past, one connected to patriarchal authority and institutionalized racism. In the hands of professionalized medicine, the speculum became a tool for (mostly male) doctors to make public decisions about women’s private, reproductive organs. But today, product designers in San Francisco are taking aim at gynecology’s hated device. They’re rethinking the speculum’s jingling screws, materials, and uncomfortable angles to make the pelvic exam less unnerving for patients and providers.
In 1845, James Marion Sims, a 32-year-old surgeon in Montgomery, Alabama, was asked by a local slave owner to treat a young woman suffering from vesicovaginal fistula. This debilitating condition, a source of pain and incontinence, is usually caused by an obstructed labor: when the baby, stuck in the birth canal, crushes the soft tissues between the vagina and bladder. In the antebellum South, where black women had little health care or control over their bodies, rape and chronic infections were also often to blame. Sims, a plantation doctor, lacked relevant experience, but took an interest in finding a cure. Between 1845 and 1849, he performed dozens of surgeries, without anesthesia, on at least 12 enslaved women. In these experiments on human chattel, Sims developed a technique to repair fistula, the first of its kind. In the process, he invented the duckbill speculum so that he could better visualize the cervix.
Sims moved to New York, where he founded the first hospital for gynecological surgery in the country. It served the city’s white, affluent clientele. He moved to Europe in the 1860s, where his female patients included royalty; later, he served as president of the American Medical Association. His accomplishments made Sims a hero; he eventually was immortalized in New York’s Central Park, where a controversial statue of the “surgeon and philanthropist” still stands. Its inscription makes no mention of the enslaved women—Lucy, Anarcha, and Betsey were the only names Sims recorded—on whose bodies he practiced his surgery.
These are the chilling origins of gynecology in America, but the shift had begun in Europe even earlier. Until the early 19th century, women’s health “was a craft for laywomen,” left to midwives who weren’t viewed as real medical providers, says Ornella Moscucci in her book The Science of Woman: Gynecology and Gender in England. But that changed when population concerns and the professionalization of medicine put men in charge of women’s reproductive health.
The speculum offered a solution to a problem that had plagued gynecology from the beginning: How could a man inspect a woman—“a serious sacrifice in delicacy,” as the French doctor Marc Colombat de L’Isère put it—without violating her modesty? The speculum allowed the male doctor to access the cervix while abiding by the strictly separate gender spheres of the day. “There was great anxiety about what it meant to examine a woman and about the propriety of that exam,” says Agnes Arnold-Forster, a historian at the University of Roehampton. “The speculum meant not touching with your hand, but with an object.”
Despite its utility, the device was immediately caught up in intrigue. For critics in the medical community, the speculum compromised a woman’s morality. They worried that it could even lead patients into illicit relationships with their doctors. In 1850, The Lancet reported on a raucous meeting of the Royal Medical and Chirurgical Society of London, where an overflow crowd listened to opponents rail against the “filthy and indecent application” of the device.
Soon, hysteria, the upper-class affliction said to originate in the womb, entered these debates. British and American physicians warned that the speculum could trigger “furor uterinus” (mania of the uterus), the symptoms of which included nervousness, insomnia, loss of appetite and sex drive, irritability, and a “tendency to cause trouble.” As Terri Kapsalis, the author of Public Privates: Performing Gynecology from Both Ends of the Speculum, writes on the matter, white women were diagnosed as hysterics “in a period when rebelliousness, shamelessness, ambition, and ‘overeducation’ were considered to be likely causes.” No wonder suffragettes (Elizabeth Cady Stanton), social reformers (Jane Addams), and other disruptors of the status quo all shared the condition.
Beyond the bedside, the speculum was an instrument of surveillance, deployed by police to detain prostitutes suspected of carrying venereal disease, according to Moscucci. Britain’s Contagious Diseases Acts of the 1860s introduced compulsory exams by speculum-wielding doctors. Similar laws targeted the separation of the “unclean” from the “clean” in France and Germany. This is how the speculum became a symbol of sexual deviancy, linked to syphilis and gonorrhea. Gynecology was a product of the social and political order—one that aimed to control women first. As Moscucci asks, why else would there be a medical science of women when no such equivalent exists for men?
In San Francisco, four women at the design firm Frog hope to revisit the speculum Sims created 170 years ago. Their design, known as Yona, grew out of a conversation between women designers about the flaws of the pelvic exam. From a product standpoint, the exam’s audio cues only ratchet up discomfort and anxiety. The patient, lying with feet in stirrups and unable to see what’s happening, hears the jarring sounds of jingling metal and the tightening of the screw. “You actually have open screws on this instrument,” Hailey Stewart, one of Frog’s industrial designers, told me. “You hear them as they’re opening you up.”
Stewart’s team also explored materials, settling on surgical-grade silicone for a quieter device that doesn’t feel as unnatural in the body as plastic or as cold as metal. It bears no resemblance to a medieval torture device. Fran Wang, a mechanical engineer working on the project, focuses on questions about the speculum’s received shape: “Why is it shaped so flat? Why is it so wide? Why is it angled? Why does the screw pinch when not covered by the provider’s finger?” After addressing exposed screws and pinching, the designers wanted to modify how the mechanism operates, with the goal of allowing providers to carry out the insertion and opening process with one hand, freeing the other to grab swabs. The result, they hope, will be a shorter exam. Stewart noted that even small adjustments to the apparatus magnify improvements in comfort during the exam. By pulling back the handle angle, they say Yona creates more space between the provider’s hand and the table, so that the patient no longer has to “scooch down” until they’re practically hanging off the edge.
Together with the designers Rachel Hobart and Sahana Kumar, Stewart and Wang hypothesized that the older generation of ob-gyns—providers with decades of experience using the hulking, gray instrument—would be less open to change than others who are just starting out. Yet, according to Stewart, interviews with clinicians confirmed the opposite. She says that providers recounted “ hacks” they adopt with the speculum “to put patients at ease” because they “know it’s not the right instrument” for the job. Gynecologists may be as eager for an alternative to the speculum as their patients.
The Frog designers aren’t the first to set their sights on the pelvic exam. It’s impossible to imagine Yona without the women’s-health movement of the 1970s and ’80s, when feminists—mostly white, middle-class women—gathered at speculum parties to inspect their anatomy, equipped with the device, a flashlight, and a mirror. The idea was to reclaim knowledge about the body while challenging “the mystique of the speculum and the fear and anxiety surrounding its use,” as Kapsalis says in her book Public Privates. No longer would the male doctor peer inside the powerless patient who had never seen her own cervix.
When 19th-century doctors clashed over the speculum, Arnold-Foster says, they engaged in debates about a man’s authority over women, but they also made claims about how to gather information. Until the introduction of the microscope into the diagnostic process, even elite, highly trained doctors believed that seeing, which required uncomfortable poking and prodding, was unnecessary. The seasoned physician could simply ask questions and determine what ailed the patient. The speculum was the perfect tool for empiricists who put their faith in observation. It “signified the growing belief in clinical practice that to see was increasingly to know and that this kind of knowing was inextricably linked to power,” writes Margarete Sandelowski.
Women now account for about 85 percent of U.S. gynecologists, a profession once dominated by men. Even so, the speculum hasn’t changed much, even as ultrasounds and fetal monitors have transformed the practice of looking at patients in similar clinical contexts. That might finally be shifting, even if the practical future of a design like Yona is hardly guaranteed. At the very least, it represents a new approach to the design and use of a device that has seemed inevitable, even if not natural. To serve women better, the speculum has to face its history in American slavery and 19th-century gender relations, in order to move beyond it.
This post appears courtesy of Object Lessons.
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