Nuances in Preventative Health Care for Women Who Have Never Been Married
- September 10, 2013
- Posted by: Sarah Azad
- Category: Medical Blog
Often, when my staff let me know that a patient is ready in an exam room, they add “and she’s refusing to undress until she talks with you.”
That nearly always means there’s a patient who is a virgin and has made an appointment out of some dire need, terrified that I will somehow force her to have a pelvic examination.
So when a reader of this blog sent in a request for advice for women’s healthcare guidelines for virgins back in January, I immediately understood the need for this article and promised to have it out by the end of March, during my maternity leave. Six months behind is not that bad…
First, you should see your doctor, either a primary care physician or an OB/GYN every year for an annual exam. Annual health exams are important to pick up on aspects of your lifestyle or exam that are not yet a problem but may very well become one. It allows time for your doctor to advise you on changes you may not have noticed in the preceding 12 months (usually weight gain), changes in your blood pressure or pulse, diseases in your family history that require special testing on you, and behaviors in your lifestyle that need to change.
An easy example is a patient who is overweight. Imagine a friend of yours who may be overweight and in your regular social circle, you may make subtle efforts to help her eat better or be more active, but who really sits down with a friend and says “sister, you’re in trouble and going to have a heart attack before you’re 50, time to seriously consider a diet.”?
When that woman walks in my door, we get her weight and blood pressure, and after an assessment of her lifestyle, it is one of many things that we’ll discuss. Depending on her BMI, age, and family history, she may need additional screening via blood tests for other health problems like diabetes, depending on the history of weight gain, she may need testing for thyroid disease, and almost always, she will need counseling on how to address—in a serious, sustainable way—her weight problem.
If you are young, healthy, and rarely get sick, you may think the visit will be a waste of your time, but if truly there is nothing the doctor has to offer you in terms of advice; it will be a short visit. It will also be a day in your life when a weight and other vital signs are documented to provide insight during your next, hopefully equally brief exam in a year’s time.
Second, if you are over the age of 20, you need regular breast exams. The American College of Obstetricians and Gynecologists recommends breast exams every 1-3 years from the ages of 20-39, and annually after the age of 40 (as of today, 9/9/13). Most doctors will do this every year, as you are there for your visit anyways. As long as you’re seeing a female physician (primary care or an OB/GYN), this shouldn’t be much of an issue.
Third, and the main purpose of this article, is the pelvic exam. So, what is a pelvic exam? It generally includes a survey of your outer genitalia (“private parts”). Then, a speculum (metal instrument) is placed in the vagina to allow for visualization of the inner walls and cervix. Finally, after removal of the speculum, two fingers are placed in the vagina and the physicians other hand is placed on your abdomen to feel for any masses or growths in or around your uterus and ovaries.
So, what do we do pelvic exams for? The number one reason is to screen for cervical cancer. Cervical cancer is the third most common cancer women get worldwide, however it is a rare diagnosis in the United States—because of Pap tests done at the time of your pelvic exam. Other reasons include a survey of your anatomy (outer genitalia, vaginal walls) for any abnormalities and to see if you have any asymptomatic masses on your uterus/ovaries.
Please remember, we are talking about preventative health care. If you are seeing your doctor for a specific problem: irregular bleeding, pelvic pain, vulvar/vaginal itching or discharge, etc, a symptom specific exam will likely be necessary. It is a rare gynecologist who will not be sensitive to the fact that you are being examined for your first time and having never had sexual intercourse. The exam is not comfortable, but is also not painful, and if there is some problem going on, has great benefit to you.
Back to routine, preventative health screening: the guidelines for initiating testing are now 3 years after first sexual intercourse or by the age of 21, whichever is earlier. The question about initiating Pap testing in women who are over the age of 21 and have not yet had intercourse is not yet a settled one. Guidelines recommend age 21 for very good reasons: 1. Patients may not be honest about prior sexual activity, 2. Patients may not be sharing a history of prior sexual abuse, 3. Patients may not include certain sexual behaviors in their definition of sex (sex toys, lesbian sex, digital stimulation, etc).
Does a woman, who has never had sexual intercourse, never used a sex toy, and never had intimate contact with another person (skin to skin contact in the genital area without sexual penetration), need a Pap Test? The answer is: no. Do patients lie about their sexual pasts? The answer is: all the time.
So, if you tell your doctor you are a virgin, and you are over the age of 21 with no previous Pap test, she will undoubtedly recommend a Pap test. If you have never engaged in any type of intimate behavior in your genital region, you can safely decline. Your doctor will likely document in your chart that you have “refused” a pelvic exam. That is not a flag, it will not raise concerns by future doctors reading your notes that you are against medical care, most doctors understand that women without prior sexual intercourse are uncomfortable—and often decline—pelvic exams.
What about the other parts of the pelvic exam? In the absence of sexual activity and any symptoms (pain, bleeding, discharge, etc), it is unlikely that there will be anything on your pelvic exam that will change your management. The benefits of that exam vs the discomfort to a patient who virginal is highly questionable, and to decline this part of the exam is also a safe decision. The one exception would be if you have a family history of ovarian cancer or are a BRCA carrier (a genetic mutation associated with a high likelihood of getting ovarian cancer). In these cases, depending on the details, there are very specific guidelines to when to initiate annual or semi-annual pelvic exams.
Our guidelines are pretty clear now that the absence of a Pap Test/pelvic exam should not stop women from getting annual preventative health screenings or prevent women from access to contraception. If you find yourself with a doctor who seems to be insistent on a pelvic exam and/or Pap test before providing you with comprehensive healthcare, and you have not complained of any symptoms, you can simply change doctors. You should ultimately find a doctor who is comfortable believing you when you say you are a virgin and letting you make your own healthcare decisions about things like Pap testing, after they’ve told you it’s a recommended guideline. Your relationship with your doctor should make your annual visits welcome and useful, not a terrifying experience that you keep putting off out of fear of being bullied into a pelvic exam, when all you want to do is make sure you don’t have diabetes like your parents.
And God knows best.
DISCLAIMER: Information in questions, answers, and other posts on this site are for general information, and are not intended to substitute for informed professional medical advice, and do not establish a physician-patient relationship. The site is not intended or designed for EMERGENCY questions which should be directed immediately by telephone or in-person to qualified professionals.
I’m very happy to know there is a website for Muslim women patients. May Allah bless you and everyone works on providing information and advices., May Allah reward you with the best of your deeds.
Hi Sarah, kind private work. Move on and help many.
Do u deal with inter faith or only Muslims?
I am a family physician at a residency in Texas. At my program, family medicine residents receive strong OB training, and one of my goals is to be active in obstetrics when I graduate. We take care of many refugees, many of whom are Muslim. I, personally, am of Iranian descent and speak Farsi, but I was born in the United States and am a Baha’i rather than a Muslim.
One thing that has come up several times for me is patients requesting female doctors. It’s not exclusively with Muslims, and not all Muslims ask for female doctors, but it happens more often than not. Honestly, it’s kind of frustrating.
One thing that I have been wondering is if Ob/Gyns and midwives in Arab or largely Muslim countries are exclusively female. How did these women get their care in their countries of origin, and how unusual is it for a woman to see a male physician?
Dear Dr. Zekri,
This is a great question. I understand how this request can be frustrating from a logistical standpoint, but there should be no personal offense taken by the physicians dealing with it. It’s about understanding where your patient may be coming from.
For a patient to express their preference in gender is a common occurrence across cultural divides. For example (this is just one example), if a woman has a history of sexual assault or molestation, especially if it was by someone she knew, you can (hopefully) understand how she would be hesitant to be alone in the room with another male, especially when it may entail him touching her body.
Statistics in the US show that 1 out of every 5 women (at least) have been the victims of sexual assault. Far more the victims of sexual harassment.
The recent #metoo campaign helped highlight how many women have been the victims of sexual assault and harassment.
Take them, all the friends, families and counselors who may have been informed, and you have a large group of women who may have a reason to feel more comfortable with their physicians if they are of the same gender. Again, this is just one example of something that personally would motivate a woman to seek the care of a female physician. It’s not about the quality of care of your male colleague, but it has context on her side. As complicated as humans are, there are so many more potential motivating factors.
As a physician in an all women’s medical group in the very diverse Bay Area, many women chose our practice because of all the excellent choices in our area, ours also currently employs only female physicians. Only a fraction of our patients are Muslim.
My professional experience is that men in the field of medicine are professional, respectful and caring. They generally provide excellent care to all their patients. In the field of OB/GYN, my male colleagues have also generally been consistently excellent professionally.
As for what happens in other countries, I can’t answer to that, being an American as you are.
From a religious standpoint, a Muslim woman is supposed to try to see a Muslim, female physician and if not available a female physician who is of another faith. If female physicians are not available, then a male physician is okay. The same is true for men, they are supposed to seek teh care of a Muslim, male physician. If one is not available then a male physician of another faith. If no male physicians are available, then a female physician is okay.
I hope this is helpful for context. I wish you well in your residency, Family Medicine and Primary Care are the backbone of our healthcare system and I thank you for reaching out on behalf of your patients and the excellent care you are providing for them.
Sarah Azad, MD
Thank you for the response, Dr. Azad.
I appreciate the insight, and I appreciate the call to compassion and understanding and abandonment of frustration. Many of the members of my gender have displayed offensive attitudes and behaviors towards women, and it is important for me to be ever-cognizant that I need to tread lightly to avoid discomfort in my patients, when possible.
Thank you also for your commentary on your understanding of the permissibility of seeing a male physician as a woman and vice versa.
Sana Zekri, MD