Lindsey: Dr. Blake, you just gave me a pelvic exam. With two cameras in the room. How was that for you?

Dr. Blake: The pelvic exam was pretty routine. That's about how they usually go, the cameras was a little different.

Lindsey: OK

Dr. Blake: Not used to that.

Lindsey: I have more questions for you, are you ready?

Dr. Blake: Yeah.

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Lindsey: What kind of doctor are you?

Dr. Blake: I'm a family medicine resident.

Lindsey: Who can perform pelvic exams?

Dr. Blake: Just about any general practitioner. So, a family doctor could, a nurse practitioner could, a licensed practicing nurse could, if you are having a baby and you go to the OB floor 'cause you think you're in labor, a nurse will do it. A gynecologist. So there's lots of people.

Lindsey: What training do you go through in order to do a pelvic exam?

Dr. Blake: uhh, we do one.  

Lindsey: (laughs) On a person.

Dr. Blake: On a person. In med school we have what we call "standardized patients" who are paid actors and we had a paid actor come in and get multiple vaginal exams.

Lindsey: What are all the reasons that someone should get a pelvic exam?

Dr. Blake: Pain, discharge, bleeding that's abnormal, pain with sex, and you know, there's more, but just really broad if you're having problems with your genitals you should get an exam. If you're having an IUD placed, obviously you need one, if you're having an abortion you need one, if you're having a baby you need one, uhm, if you're having a Pap and that's probably the most common one is the Pap...

uh, some STD testing depending on where you go. A lot of it now is becoming DNA-based or RNA-based meaning all you need to do is pee. Back in the day, not so long ago it used to be an exam with a swab. We don't do those here, we just have them pee. (laughs)

Lindsey: Thank you! So I don't need to come in when I'm 18?

Dr. Blake: Not unless you really want to.

Lindsey: I don't need to come in when I'm sexually active?

Dr. Blake: Nope.

Lindsey: OK, at what age should I come in?

Dr. Blake: 21.

Lindsey: Because?

Dr. Blake: Because that's when we start Pap screening. Probably a lot of your viewers' moms, back when they were becoming sexually active in their teens it was every year, maybe staring at 15, 16. Now we know that cervical cancer doesn't really happen a lot in that age group. We know that a lot of people who have HPV and have some cervical change just get rid of it! And so why do a Pap smear if your body gets rid of it? So we look for high-risk strains and there's a few of those and as you get older, into your 30's, if you still persistently have HPV we get a little bit more concerned, 'cause we're like, "Gosh, you're not clearing it." 

Lindsey: So when the recommendation was to get an exam when you become sexually active, what does "sexually active" mean? 

Dr. Blake: So to me it means, basically mucous membrane contact, whether that's mouth, anus, penis, vagina. So contact in those can potentially transmit disease, and that's what we're trying to prevent.

Lindsey: One person wrote and they said, "why are we calling it gynecology? Shouldn't it be called copology?" Referring to the cervix rather than the vagina.

Dr. Blake: Well gynecologists will tell you they do a lot more than just focus on the cervix. 

Lindsey: Kay.

Dr. Blake: It's about the entire uterus, the ovaries, all the female reproductive hormones- which you don't even necessarily think about, but like, that involves the brain as well- pituitary, breasts, obviously. So there's a lot more to it that just the cervix.

Lindsey: OK. So how do you make your services more trans-inclusive?

Dr. Blake: That is a good question and it just is really provider-dependent. You know trans medicine generally speaking isn't too difficult. It's fairly well laid out, how you approach it. It's just a matter of, has this provider had that training, had that education. The place to start would be ask your provider, you know, if you're considering going through transition, ask you provider, "Is this something you're comfortable with?" and they'll say "yes," "no," "gosh I don't know, nobody's ever asked me that before." and if they're willing and say "hey, yeah, I'll learn with you, we'll work through this together." If not, then you say, "Can you refer me to somebody else? Do you know who else I can talk to?"  

Lindsey: So this person asked "Is there a version of you for my penis and my testes?" and I think what they're referring to is, if we have gynecology, what is on the biosex male--

Dr. Blake: mhmm. Urology. But any kind of general practitioner should be able to cover a broad range of both urologic and gynecologic issues. The training that they have in particular is surgical.

Lindsey: A urologist?

Dr. Blake: A urologist and a gynecologist.

Lindsey: Are trained specifically to do surgeries on those types of anatomy.

Dr. Blake: Correct.

Lindsey: OK.

Dr. Blake: But in terms of the, what we call primary care, you should be able to get that pretty much anywhere.

Lindsey: What happens if there's something wrong? So if, after my pelvic exam, or during my pelvic exam ("something's up" noises) What would happen?

Dr. Blake: It's pretty rare that you would actually see something very abnormal on the cervix itself. That's why we do Paps, it's preventative. You know, you see the abnormal cells before we see any cancer. So sort of the next step after that would be colposcopy. Are you familiar with that at all?

Lindsey: mhmm. But they're not. 

Dr. Blake: They're not. So colposcopy is basically taking a magnifying device, again with the speculum exam, and you paint some - essentially vinegar, what we call acetowhite - on there and look for changes. And if there's changes, often times you take a biopsy, meaning you pull a little piece of tissue off and you send it to the lab and you see what's going on. That said, this is again, like the worst end, very uncommon. The most common thing is your Pap comes back and there's some abnormal cells, that are mildly abnormal and we say, "Lindsey you had some mildly abnormal cells, we'll check again in a year."

Lindsey: What do I do if my doctor discounts my experience? As in, tells me there's nothing wrong when clearly there is something wrong.

Dr. Blake: That's a tricky one because... I mean you're sort of asking me to speculate on what somebody's interpretation of their symptoms is, compared to their experience with who, in theory, is a trained healthcare professional. I mean I would trust their judgement. That said, people get second opinions all the time and there's nothing wrong with that. 

Lindsey: Or third opinions.

Dr. Blake: Or third opinions.

Lindsey: How do I open up the conversation about birth control?

Dr. Blake: We love to-- I love to give people birth control!

Lindsey: (laughs) Awww, that's so great.

Dr. Blake: And I think most providers do.

Lindsey: So I would just say, "I'm curious about birth control. Options for me?"

Dr. Blake: Yeah, I'm interested. My friend, and this is usually what people say, whether the "friend" is real or not :My friend has tried blah blah blah, do you think that would be a good choice for me?" And I say, "OK, tell me what you know about that," you know, whether it's the pill, that's kind of the most common one or the other one that's really up and coming are nexplanon which goes in the arm and then IUD's which go in the uterus. Mostly because they're just there. You don't have to worry about taking a pill every day.

Lindsey: OK. We'll do whole episodes on them.

Dr. Blake: Please do. (they laugh)

Lindsey: OK. We showed what my pelvic exam was like-- 

Dr. Blake: uh-huh. Other components might be a breast exam, and again, the bimanual exam, is what we call it.

Lindsey: So if other things go on that seem questionable, who would I report my grievances to?

Dr. Blake: Probably ask the provider "Why did you do that? What are you doing? Explain what you're looking for," and you should feel empowered to do that.

Lindsey: I like that.

Dr. Blake: Complain to the clinic. I mean they almost always have some kind of "tell us how we did today!" feedback form. Ask to speak to the clinic manager.

Lindsey: OK

Dr. Blake: So there's options.

Lindsey: What do you want them to know?

Dr. Blake: If you have a bad experience with somebody, then find somebody else. Don't be ashamed to ask the questions, don't feel awkward about birth control, don't feel awkward about a pelvic exam. Again, and I don't mean this to sound negative in any way but for a lot of us it's just routine, it's just what we do.

Lindsey: Thank you Dr. Blake for the pelvic exam and for hanging out with me and answering our questions.

Dr. Blake: You're welcome. It was a lot of fun.

Lindsey: Stay curious.