Molly Callahan, a gynecological teaching assistant, helps medical students practice pap smears and breast exams
On her busiest days, Molly Callahan, has 16 speculums inserted into her vagina. She works full-time as a gynecological teaching assistant (GTA) – a layperson who helps medical students practice pap smears and breast exams before they work with actual patients.
It’s not as unpleasant as you might think. In fact, the point is to help students learn how to do it without causing discomfort. Contrary to common belief, pap smears – tests that screen for cervical cancer – don’t have to be painful.
“I don’t ever really feel physically in pain even after the longest week of work,” she said. “If [your] reaction to my job is that it sounds like torture, I hope you feel scammed,” added Callahan, 30, who is also the president of an international association for GTAs and MUTAs (male urogenital teaching associates). “I hope you go fire your gynecologist.”
Pap smears have reduced cervical cancer–related deaths by 86%, but many women avoid them due to confusion around guidelines, perceived lack of symptoms and, most commonly, speculum discomfort and embarrassment. One large study of US cancer statistics data found that from 2005 to 2023, 32% of women aged 21-29, and 15% of women aged 30-65, had never had a pap smear.
The negative association isn’t surprising. Looking at the cervix for indications of cancer became more common in the early 20th century, said Dr Kirsten Gardner, director of medical humanities at the University of Texas San Antonio, and methods centered innovation over comfort.
“So much of that conversation [on pap smears] was about the medical possibilities, not about the impact on the female patient,” said Gardner. “And when it did talk about impact, it was very much in the language of early cancer detection. It was never in the language [of]: ‘How does a woman feel? Is this painful? What can we do about the pain?’”
GTAs exist in part to answer that question. Pelvic exams and pap smears were historically performed on anesthetized patients until the 1970s, when GTAs became more commonplace in an effort to improve the ethics and educational quality of such exams. While GTAs teach medical students the basics, they also provide real-time reactions and feedback.
“They center the patient’s voice,” Gardner said. “Getting an experience with the GTA just reminds practitioners that they can talk to patients.”
Currently, more than 90% of medical schools in the US and Canada utilize GTAs – Callahan, who lives in Queens, teaches at 30 universities and hospitals. But despite the flexible schedule and pay rate – almost $100 per hour – Callahan estimated that there were only about 40 GTAs in the tri-state area, where there are more than 15,000 medical students.
GTA trainees learn anatomy and the tactics of breast and pelvic exams: how to swab the cervix, check for abnormalities, find the ovaries. They practice on a qualified GTA, then each other. It requires two months of training and a final test to ensure they are able to teach the exam to medical students.
Callahan became a GTA because of her mother, an actor, director and producer who was looking for additional income when a friend suggested it. Eight years ago, Callahan, who also went to theater school, was cobbling her life together after graduation. “She was like: ‘You’d be so good at this,’ which is a strange thing for a mom to say to a daughter,” said Callahan.
One stormy evening, I went to Teaneck, New Jersey, to observe Callahan teaching two labor and delivery nursing students from Fairleigh Dickinson University. Inside a fluorescent-lit classroom, Callahan sat upright on an exam table wearing a patient gown.
“I talk a lot about preserving people’s modesty and privacy as much as possible,” she said. “But to me? No, I don’t really care. It’s just parts. It’s just my meat suit.”
Callahan spent a few hours with the students – likely their only lesson on pelvic and breast exams during school, as is common for nursing students. First, she talked them through breast exams; the students doused their hands with sanitizer and sat at the base of the table. Callahan dropped her gown and explained that since appointment times are often short, they would be focusing on the areas of the breast where malignancies are most common: the outer tissue and in the underarms. They took turns gently pressing their fingers in a circular motion on Callahan’s chest.
“Don’t tell patients they look ‘good’ or ‘perfect’,” said Callahan. “Use positive but clinical language.”
She moved on to pelvic exams, holding a small mirror so she could see their movements. The student cautiously placed the back of her hand on Callahan’s inner thigh, a gesture Callahan teaches for consent and calming the patient before proceeding.
Then Callahan issued instructions: First, place two fingers on the labia and check for redness. Gently expose the clitoral hood to check for adhesions, which can indicate infections or skin diseases, and check the vestibular glands for cysts. Insert fingers, nail side down, to gauge speculum size. Explain what you’re doing at every step; if the patient winces, you are causing pain.
A proper exam is a collaboration that begins even before the appointment starts, Callahan said. For patients, it can be helpful to know the intricacies of a pap smear and what evidence-based care looks like. Patients can read guidelines and recommendations from the American College of Obstetricians and Gynecologists (ACOG) to stay informed on key information like how often to get a pap smear. There is also knowing your own body: what does your vulva look like? Do you experience pain during sex? Is your breast tissue naturally firm?
This is important because you may change providers between exams, or a provider may not remember you, Callahan said. By tracking any differences over time, “you can tell when something’s changing and not healing so you have really concrete [information]”.
One of the best things people can do is think about their own experiences with providers, especially negative ones, and identify what would make it better and more comfortable, said Callahan. Then ask for what you want at the beginning of an appointment.
“If you, the patient, know that there’s a certain part you really hate – like speculum exams are really painful – could you ask for the smallest size possible?” she said. (Speculums come in different sizes: small, medium, large and pediatric.) Larger speculums are sometimes used by default simply because “the more tissue you push away, the more you can see”, said Dr Corey Babb, medical director of the Haven Center in Tulsa, Oklahoma. Additionally, patients may request a blind swab, which omits the speculum, or to insert the speculum themselves.
For additional comfort, Babb said, speculums can be warmed and should be well-lubricated. Patients can also ask to be put under nitrous oxide, or laughing gas, if available.
A provider who makes you comfortable and is invested in your wellbeing is worth holding onto, Callahan said. And if the experience is negative, you can provide feedback, or file a complaint for more distressing cases.
On one of her days off, I met Callahan at Hex House, a members-only warehouse in East Williamsburg, where she sometimes conducts GTA training. In her studio, Callahan gestured toward a three-tier cart full of medical books.
“I love this one,” she said, pointing at a 1981 publication called How to Stay Out of the Gynecologist’s Office, by the Federation of Feminist Women’s Health Centers.
“Going to the gynecologist was such a nightmare [at the time]. So it guides you through doing a self-pelvic exam, how to treat yeast infections, how to do a vacuum-assisted abortion,” she said, flipping through images. “Full bush, obviously.”
Gynecology emerged in the 20th century as a male-dominated field that displaced midwives, Gardner said. In the 1950s, biologist and sexologist Alfred Kinsey conducted a study that became known as the Kinsey report. In his research, he gently stroked the cervix of patients with a cotton probe, which only 5% of 878 participants could feel. When he tried a larger object, 84% reported feeling a sensation. Yet only the former result made it into the final draft, and he concluded that the cervix was insensitive. J Marion Sims, “the father of gynecology”, practiced on enslaved women and never used anesthesia. Body parts like fallopian tubes, Bartholin’s glands and the G-spot were named after male doctors.
“They think they discovered these things,” said Callahan, who prefers location-based names, such as “uterine tubes” and “vestibular glands. “Give me a break.”
At the end of the teaching session, the two nursing students admitted that neither of them had ever experienced a slow, gentle pelvic exam themselves. Callahan put her clothes back on as the students waved goodbye.
Once home, Callahan said, she would let a hot stream of water wash away the long evening of being touched – her hips and back get stiff from all the sitting, and the work can be exhausting. It can be taxing to unteach conventions of the past.
“It’s wonderful to be a good example for all of the students,” she said. “The healthcare providers assume everyone hates this, and it’s so horrible and it’s so weird – and it doesn’t have to be that way. I think it’s really great to show them that you can treat [physical exams] with consideration and respect.”
Carmen Rising is a writer based in Brooklyn
