Examiner's unique possibilities to catalyze women's empowerment during a pelvic examination

An article in this journal reports that trust and confirmation were main contributing factors to women's positive experience of a PE (i.e. their aim) (1). Trust arose when the staff made women participate in the examination, created confidence and were supportive. Confirmation meant that women felt confirmed as individuals, when the staff showed respect and engagement. Why are trust and confirmation not always there? Examiners may be unaware that they do not offer necessary requirements. Galtung means that when people cannot realize their aims, according to their full potential, there is something stopping them, i.e. structural violence (2). But, structures that oppress can also empower. If inequality works through structure, it is the structure that should be changed (2). When Galtung's ideas are applied to the PE situation, it could be the structures that surround the PE which stop women from reaching their aims. On the other hand, the same structures could also promote empowering. The examiner thus has a choice. The body part to be examined is loaded with associations to sex. In addition, the examiner's behavior would in all other situations be interpreted by both actors as sexual behavior: the woman exposes her genitals from a position of submission to the examiner who stands between her separated legs, rests one hand on her pubic area while he/she inserts two fingers into her vagina and looks firmly into her eyes. But in this very situation, both actors agree to let go all associations to sex, and together they cognitively restructure and define the situation as “a medical investigation” (3). If something disturbs the woman's cognitive schema, she is prone to interpret it in a sexual frame of reference. Then the examiner needs to be aware also of this possibility to be able to act in a way that is beneficial for the woman. The examiner therefore has a complex, two-edged task (3). During a PE, women feel dependent and at the examiner's mercy in a subordinated and shameful position which animals use to signal submission. This combination of connotations to both sex and subordination means that when women interpret what happens accordingly, the negative consequences of even “minor mistakes” may be enormous (3). On the other hand, if the examiner promotes women to take control over the situation, it may have unexpected positive effects. Hence, the power balance in the PE situation is asymmetrical (4). Even if the woman formally is the subject with the right to decide about her body, she feels that in reality power belongs to the examiner. The examiner needs to be aware of this in order not to unintentionally hurt or misuse power and to allow women's empowerment to arise (4). At present, it is a widely used word with many meanings. One origin was Freire's work with poor, illiterate people in South America (5). He meant that the first step in an empowering process was people's awareness of the unequal distribution of power (5). Next step was emotional reactions on the situation and active decisions to change it (5). In Freire's work, it meant that illiterate people became motivated to struggle for their right to learn to read and write (5). Swift and Levin (6) described empowerment as the “development of a certain state of mind (e.g. feeling powerful, competent, worthy of esteem), and the modification of the surrounding structures in order to reallocate power.” In this process, power is not seen as a zero-sum commodity, which means that people can be empowered without diminishing the power of others (6). There is an increasing awareness among women of the power imbalance of the situation. Emotional reactions may arise quickly, once a media debate starts. Experiments in ongoing studies have showed that when women learn how a PE is to be performed and they themselves have palpated the internal genital organs on a mannequin, they report that the new knowledge changed their position in the PE situation. The prerequisite is that examiners regard what happens in the PE situation as a confidence given from someone who has a subordinated position. Many women call their genitals “the most holy part of my body.” It would therefore seem logic that examiners would approach the PE with respect, devotion, and reverence. Examiners have great possibilities to do good, by confirming the value of what women give out (their most holy part) on a basis of presumed trust, and by stimulating them to take control over the situation. Do examiners make the best use of these possibilities? and if not, how could such a process be stimulated? How can examiners act to promote a redistribution of power from examiners to women? We argue that useful tools could be self-reflection, self-criticism, questioning of own attitudes and choices, and open discussions with colleagues and patients about which concrete behaviors may be used to implement empowerment of women in the PE situation.