History is about the present even as it pretends to explore the past. The questions that we ask, the explanations that we crave, are sparked by events in our current world. It turns out that this particular history was largely hidden in the United States during the last two hundred years.

Kline opens with the shocking practice of team doctor Larry Nassar (1963-), pedophile and serial abuser of the gymnasts under his care who successfully took him down in 2017. He is serving decades in prison, where he was stabbed multiple times in 2023. She continues with the story of the Johns Hopkins University gynecologist Nikita Levy (1959-2013) who secretly photographed (or filmed) his patients’ genitalia with cameras concealed in pens that he wore on a lanyard around his neck. Abruptly fired when the story came to light, Levy died by suicide in 2013. Two years later 9000 victims were awarded a class-action settlement of $190M.

 It is not surprising, albeit horrifying, that such abuse could emerge in a medical specialty that centers on the most intimate aspects of women’s healthcare.  In a sequence of readable chapters, each of which could stand alone, Kline examines medical achievements in women’s health that could be (and have been) told in triumphalist tones: the speculum, gynecological surgery, the Pap smear, and oral contraceptives. All were invented by men. She also includes marriage counseling and patients as lay instructors in pelvic exams, both initiatives also promoted by men.

Without denying the potential value of these innovations, Kline brings every chapter into the present with the voices and actions of women who object because of painful incursions upon their bodies, denial of their humanity, and distortions of power. Her sources include archives, journals, histories (many written by women scholars), interviews, patient stories, and artistic creations—objects, music, films, poetry. Issues of gender, race, and class pervade the analysis.

The nineteenth-century inventions of the much-maligned J. Marion Sims (1813-1883) end with the 2018 dismantling of his Manhattan statue and the 2022 unveiling, in Montgomery, Alabama, of Michelle Bowder’s Mothers of Gynecology in honor of the three slaves who had been his research subjects. The chapter on Robert Battey (1828-1895) cites the critical secondary literature on how his procedure to remove ovaries by the vaginal route became vastly overused for all female complaints, even mental illness; however, it also draws upon his papers, kept in Atlanta, allowing the reader to comprehend how his initial motivation was to end the menstrual cycle for patients.

Similarly, Kline explores the previously unexamined papers including numerous drawings and photographs of R.L. Dickenson who strove to comprehend female sexual response while purporting to avoid prurience. As much as we are put off by the excruciating details of his oeuvre, letters from grateful patients demand reconsideration of his efforts to understand female sexuality.

The Pap test, which detects early cervical cancer, and the birth-control pill both advanced women’s healthcare. Yet they each prompted reactions from lay women: the failures and inaccessibility of Pap testing and consequent delays in diagnosis, resulted in cervical-cancer survivors‘ organizations; the impersonal implementation and insistence upon regular pelvic examinations spurred the vaginal self-examination movement. Kline lays out the medical achievements and plunges into the social reactions through interviews with the founders and leaders of these activist groups, tracking them down internationally. They express the militant goal to avoid the gynecologist (as if they are all brutal), and the unalloyed joy of seeing one’s own cervix (without the benefit of cytology). Some activists called for men to be banned from the specialty. One wonders if the strident anger and hostility directed at male professionals, many of whom try to practice with compassion and care, may well have incited previously unfelt, reactionary attitudes in the practitioners.

The use of surrogate patients for teaching history-taking and physical examination was proposed and advocated by Harold Barrows in the mid-1960s. A decade later, once academic and professional gynecology accepted the complaints of activists, it followed the trend and began to engage lay women as teaching assistants on how to perform pelvic examinations. Kline outlines Robert Kretschmar’s extension of the trend to pelvic examination at the University of Iowa. She also describes the Pelvic Teaching Program of Harvard and its involvement of the Women’s Community Health Center (WCHC). Even there, we read of pushback and disillusionment as relationships soured. What kind of a woman would do that? – and why? The originally enthusiastic female participants were underpaid and treated as passive objects rather than instructors. Prostitutes had been engaged, as well as gender activists who “started feeling like [they] were in the same positions as are prostitutes….and then started saying ‘Yeah, we are. We are.’” (p. 206) The professors eventually learned to quietly observe, but the students themselves tainted the experience with sexual inuendo and disrespect. Kline provides statistics on how widely lay instructors are used today.

Also using statistics, she exposes today’s teaching of the pelvic examination on anesthetized women who have not given consent. Although the American Association of Medical Colleges deemed the practice unethical in 2003, it is still widely used, most often on racialized, “public” patients.

Kline also highlights the medical, social and financial obstacles to care for transgender people.  Citing surveys from 2015, she reminds readers that most medical students receive no training on care of trans people and that trans men should receive Pap tests but most do not, because of their own discomfort and the ignorance of health care professionals.

Under Kline’s gaze, the benefits of each medical achievement tend to unravel in clinical practice. She rarely outright condemns or criticizes the physician actors; however, she uses irony, targets hypocrisy, and never fails to highlight the opportunities for self-promotion within the benefits that they provided to their patients. Just as she observes gynecologists second-guessing or failing to believe their patients, she views their own stated motives and goals with skepticism. Instead, she allows the male physicians to skewer themselves in their own words with choice quotes. Believing his patients’ pains were psychological, James C. Wood described how he cleared a clogged ward: “’I wanted their beds above all things for real surgical cases, and I knew not one of them wanted to be cut’ So he started scheduling them for various surgeries and, within a week, all ten beds were ‘well emptied for legitimate hospital use’” (p. 102).

Issues of power, trust and consent underpin the fallout of these stories and explain why many women avoid pelvic examination despite its undeniable advantages. In a counterpoint to the miserable tales of criminals at her opening, Kline closes with a patient’s tribute to a sensitive gynecologist on Martha’s Vineyard. The patient has long suffered from an iatrogenic injury owing to the diethylstilbestrol (DES) treatment given to her mother during pregnancy. Her doctor, Dan Pesch, listens well, comprehends her justified fear, grants her control over decisions, and yet manages to wield all the advances of last two centuries to catch her cancer early. Compassion, Kline observes, “can literally save lives.”

Now—will she next expose the hidden history of the prostate exam?

Exposed: The Hidden History of the Pelvic Exam
Wendy Kline
Cambridge and Hoboken: Polity Press, 2024.