Prioritizing pain management during IUD insertions and other gynecologic procedures

On this episode of the CMAJ Podcast, Dr. Blair Bigham and Dr. Mojola Omole explore effective ways to manage pain during intrauterine device (IUD) insertions. They also address a broader issue: how women’s pain is often neglected during gynecologic procedures, and the failure of physicians to adequately seek consent. They are joined by Dr. Kristina Arion, an obstetrician and gynecologist at the Children's Hospital of Eastern Ontario, and Dr. Nadia Von Benzon, a lecturer and social geographer at Lancaster University.

The episode begins with Dr. Arion discussing the CMAJ article she co-authored, which outlines strategies for better management of pain during IUD insertions. She explains that the IUD is recommended as the first-line therapy for birth control and period management by the Canadian Pediatric Society and the Society of Obstetricians and Gynaecologists of Canada. Dr. Arion highlights how patient anxiety, lack of sedation options, and inconsistent practices contribute to unnecessary pain.Her key advice to doctors: listen to patients, explain each step of the procedure, and provide adequate pain management options.

Dr. Von Benzon broadens the discussion beyond IUD pain management to the neglect of women’s pain and autonomy during other gynecologic and obstetrical procedures. Her research article "My doctor just called me a good girl, and I died a bit inside: From everyday misogyny to obstetric violence in UK fertility and maternity services," illustrates how women’s pain is frequently dismissed and their consent overlooked. She discusses the long-term impact of these practices, with some women opting out of future pregnancies due to trauma. She advises healthcare professionals to clearly explain procedures, seek consent, and prioritize patient comfort and autonomy.

Dr. Omole and Dr. Bigham reflect on how patriarchal structures and time constraints within healthcare systems often lead to the failure to prioritize women’s pain and autonomy. The episode closes with a powerful call for healthcare providers to take the time to listen to their patients, ask questions, and ensure that consent and comfort are prioritized at every stage of care.

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Transcript

Dr. Blair Bigham:  

I'm Blair Bigham.

Dr. Mojola Omole:  

I'm Mojola Omole, and that's Blair Bigham. And I'm Mojola Omole. This is the CMAJ Podcast.

Dr. Blair Bigham:  

So Jola, today we're talking about a topic that maybe we shouldn't have to talk about in 2024.

Dr. Mojola Omole:  

And that topic is the patriarchy in medicine.

Dr. Blair Bigham:  

But we're going to be a little more specific than that and talk about pain management during IUD insertion.

Dr. Mojola Omole:  

And that also is the name of the article. The article outlines five ways to create a supportive environment and to manage pain for those people who are having intrauterine device insertions.

Dr. Blair Bigham:  

Jola, what's the word on the street with your friends and colleagues? Why is this article so important right now?

Dr. Mojola Omole:  

I think that there's a variation in practice of how people manage this. I would say that those who have been in family practice and are very passionate about women's health probably already do some of these techniques, and maybe they would just maybe want to learn something else to add to their arsenal of things that they can possibly do. But I do think there's a scope in practice to how people address insertion of intrauterine devices.

Dr. Blair Bigham:  

Or don't address it. I was pretty surprised that this procedure, which admittedly I've never had done, is really painful for some people. And if you're getting a colonoscopy, you're going to get some sort of analgesia, some sort of sedation. If you're getting a cysto, at least you're going to get local lidocaine. 

Dr. Mojola Omole:  

I do think that in general, when it comes to women's health, which also includes our non-binary patient population, that oftentimes we expect—and that it's just kind of known—that while it's going to be painful, what did you expect? It's kind of what we've been taught from a young age. I did not know until I was probably like 40 that my period was not supposed to be painful.

Dr. Blair Bigham:  

Well, we're going to be talking to the author about, “Five ways to support pain management during intrauterine device insertion”, but we're also going to be getting a broader perspective by jumping across the pond to speak to an expert in the United Kingdom who penned a provocatively titled study, “My doctor just called me a good girl, and I died a bit inside: from everyday —misogyny…

Dr. Mojola Omole:  

…and I died a lot when you said that.

Dr. Blair Bigham:  

That article talks about everyday misogyny in UK fertility and maternity services.

Dr. Mojola Omole:  

But first, we'll review the, “Five things to support people's pain during IUD insertion.”

Dr. Blair Bigham:  

That's up next. Dr. Kristina Arion is the lead author of the practice article in CMAJ. Dr. Arion is an obstetrician and gynecologist with a fellowship in pediatric and adolescent gynecology. She specializes in treating pediatric and adolescent patients at the Children's Hospital of Eastern Ontario in Ottawa. Kristina, thank you so much for joining us today.

Dr. Kristina Arion:  

Hi. It's my absolute pleasure. Thank you for having me.

Dr. Blair Bigham:  

Tell us, what were you seeing around you that made you want to write this article?

Dr. Kristina Arion:  

As you mentioned, I just finished my fellowship in pediatric and adolescent gynecology in Calgary, and the IUD is an excellent form of contraception, but also an excellent period control device. So we were prescribing these things left, right, and center, but obviously for younger patients, a lot of them who have not been sexually active, an office insertion is just not appropriate for them. So we have procedural rooms with oral sedation, IV sedation, rooms where we can have nitrous oxide available to our patients, and they were having excellent experiences. And one day on my way to work, I was listening to CBC, as I usually do, and they were talking about IUDs. I'm like, yes, IUDs for the win. But then there was this woman screaming, and I'm like, what is happening? Essentially, they were playing a TikTok video of this lady getting her IUD and how terrible it was. Unfortunately, there is a lot of fear and anxiety about getting an IUD because of how painful it is.

Dr. Blair Bigham:  

Kristina, there are many ways people can seek contraceptive care or help with severe periods, cramping, or bleeding. Where does the IUD rank in those choices?

Dr. Kristina Arion:  

The IUD is recommended by the Canadian Pediatric Society as the first line contraception and as well as the Society of Obstetricians and Gynecologists. Because

Dr. Blair Bigham:  

As first line,

Dr. Kristina Arion:  

Yeah,

Dr. Blair Bigham:  

I didn't even know that. That seems so basic.

Dr. Kristina Arion:  

Yeah, well because one, it acts locally right on the uterus.

Dr. Kristina Arion:  

There’s sually no side effects, if not minimal side effects. You don't have to remember to take a pill every day. So perfect use is typical use. You don't feel it, which is great. And the mirena IUD is good for eight years.

Dr. Blair Bigham:  

Eight years. Wow.

Dr. Kristina Arion:  

Yeah, they just changed that.

Dr. Blair Bigham:  

There is a convenience to it in that sense.

Dr. Kristina Arion:  

Yeah, exactly. So for so many reasons, and there are some risks of the procedure and some irregular bleeding that can occur for up to several months after it's inserted. Of course, no contraceptive is perfect, but this one is pretty good except for the insertion part, which can be quite painful.

Dr. Blair Bigham:  

How painful is it? 

Dr. Kristina Arion:  

That’s a great question. It's different for everyone. Pain is individualized, right? So some people could have no pain, and for some people, it could be off the charts, off the bed screaming. And there are some ways we can screen patients a little bit as to whether you are a more anxious patient, or if you have a history of trauma or chronic pain or pain with sex that we can discern. Would you be more appropriate for an in-office insertion, or do you need something more? Conversations that you have with patients can also allude to whether or not they need something more, but there's no one recipe for everybody.

Dr. Blair Bigham:  

You described in Calgary this suite of options that you had for pain management. I assume that this is something that isn't available in every family doctor's office.

Dr. Kristina Arion:  

You're absolutely correct. So the family doctor typically only has their office. There are things that you can do to help minimize pain with IUD insertions in a physician's office. But if patients need something more than that, they don't have the sedation room or the OR.

Dr. Blair Bigham:  

So how can you stratify who might be suitable for an office placement of an IUD, and who should really be, I guess, referred or escalated to a facility that can offer a better regimen to make the procedure more comfortable?

Dr. Kristina Arion:  

Yeah, absolutely. So one, I think that whenever we're talking about contraception or IUDs, you need to talk about the whole entire thing, really leave no details out. I think that some people leave some details out, and then patients are not ready for this IUD, and they feel blindsided sometimes. So if you tell them everything, then they know exactly what to expect. And in that process, I explain there are different types of pain and different moments of pain. So initially, with the speculum inserted inside the vagina, that can be a bit uncomfortable but is not painful. So that is like a pap smear. For an IUD insertion, we place a small clamp on the anterior lip of the cervix. It's called a tenaculum. That's to help reduce the risk of perforation. And some people don't feel that at all. Some people feel it as a pinch. Some people have more pain with that. So that's the first moment of pain.  

Next, we measure how long the uterus is so that we know exactly where to put it. And that is the crampy part that a lot of people complain about. Some people have really strong cramps, some people have minimal cramping. Then the IUD is put in after that second moment of pain. Then there's maybe that third moment of pain to put the IUD in. So those are the moments where people can experience pain. And then cramping can either subside immediately after, it can last for a few minutes, it could last until the elevator, it can last until you get home, or it can last for a whole other week. Everyone's different. We say take some Tylenol and naproxen before, so that's the easiest pre-medication that you can do. But for a lot of people, it's still not enough. You can also prescribe some stronger pain medications.  

So things like tramadol or ketorolac are things that have been helpful, or the physician themselves can use lidocaine. So lidocaine has been shown to improve pain experiences. Again, everyone is a little bit different, but there's lidocaine gel—4% has been shown to be helpful, not 2%. There's lidocaine spray—10% can be helpful. And then there's the lidocaine-prilocaine cream, which can also be helpful. So cream, gel, spray. And then the other one is, if family doctors are not aware, do not prescribe misoprostol. It is not helpful. It does not reduce pain with insertion, so please do not use it.

Dr. Blair Bigham:  

All of this sounds like something that could be done in a doctor's office.

Dr. Kristina Arion:  

Absolutely.

Dr. Mojola Omole:  

Something like the gel, just because I use it for when I do hemorrhoid and anorectal stuff. Is that something that a patient, if they're comfortable doing, could put some in themselves, try and guide it up to the cervix area prior to coming in?

Dr. Kristina Arion:  

Yeah, so that's a good question. Really, the benefit is when you apply it mostly on the cervix and obviously around the vagina as well, but you definitely want some on the cervix. So if they apply it inside the vagina, probably some will get to the cervix, but reliably, I don't know how much. If you want the best bang for your buck, the physician should be doing it. And then also, you only want to do it about five minutes before the procedure. If you do it half an hour before, the effect of the lidocaine is going to be gone.

Dr. Blair Bigham:  

In your article, you talk about taking a trauma-informed history. Walk us through that. What type of questions are you asking?

Dr. Kristina Arion:  

Yeah, so with any patient that I see in my clinic, I do a full history for any consult, but specifically go into a little bit more depth with a sexual history. First, I want to make sure that they feel safe in my clinic space, that they feel like they can talk to me. Of course, I say that everything that we talk about is confidential and just kind of gather: Are you sexually active? If they have been, have they ever had any negative sexual experiences before? Do they have a partner, do they feel safe? And then sometimes they start talking, and then it just all comes out. Sometimes you have to ask more in-depth questions: Have you ever felt unsafe in a medical procedure in a hospital? Have you ever felt unsafe sexually before? And then typically they explain. If you say, the reason that I'm asking these questions is because if we're thinking about putting an IUD in, I want to know how comfortable you'll be in, let's say, this office, or if you might need something additional to help manage some anxiety and trauma.

Dr. Blair Bigham:  

You perform hundreds of these insertions. Tell me, what have you heard from patients in your clinic about their past experience getting IUDs inserted?

Dr. Kristina Arion:  

Oh, it's all across the board. When it comes to pediatric or adolescent patients, it's typically their first IUD, so they don't really know what to expect, but we do a lot of those in the operating room or under some sort of sedation, and they have good experiences. When it comes to adult patients, when they're coming back for an in-office insertion, they usually had a good experience the last time. If they're coming to me saying, "I absolutely need something on board this time because last time it was a horror show," then I offer them more. But every place is different. So even here, I don't have a procedural sedation room in my gynecology clinic, but I have the operating room. It just depends. Operating room leads to more of a wait time to get this IUD in. The fastest way to get it in is in the clinic because you just book an appointment, and then we can do it. When it comes to sedation, there's oral sedation and then there's also IV sedation that we were practicing in Calgary. So the oral sedation route, I feel like family doctors could probably do this in their office. Of course, patients need to have someone with them to drive them home after. So the cocktail they were using was Tylenol, Advil, hydromorphone, Zofran, and Lorazepam.

Dr. Blair Bigham:  

Good combo. I like that cocktail.

Dr. Kristina Arion:  

The patients really did too. And so the nurses spend some time with the patient beforehand. They take all the medication, and then when they're ready for the procedure, they usually take it about 30 minutes before we do the IUD insertion. And of course, if they don't feel adequately anesthetized yet, we can still wait. And that's the most important thing when it comes to IUD insertions, it's more of those soft skills. It's communicating with the patient, asking them, are you ready? We can stop at any time if you're not adequately pain-controlled or if you're just too anxious and you feel like you need to go off to sleep, we can book this for another day. So making them feel like they're in control of the situation, especially those patients with a history of trauma, where they feel like they're not in control, but really handing them the rope saying, I'm going to tell you every single thing that I'm doing, and you tell me if it's okay to continue or not. And some patients will say, please don't tell me everything that you're doing, but at least they feel in control and they told you, no, you don't have to tell me.

Dr. Blair Bigham:  

Right. Tell me, what do you tell patients to expect? What are some of the phrases that you use?

Dr. Kristina Arion:  

Yeah, so I tell patients that this is a painful procedure. I don't gloss over it lightly. I say that it is, but that they may have less pain or they may have more pain. And it is individualized. That I have some patients who experience no pain, but I have patients that experience a lot of pain. And that's my segue into, we have lots of different ways to manage pain experiences, whether we do it in the clinic, whether you need something more like in a procedural sedation room or in the operating room. So if this is something that you want, I can help accommodate that in a way that you feel safe and secure getting it done.

Dr. Blair Bigham:  

Do you ever feel like patients feel they have to weigh pain with expediency? Like, we can just get it done now, or if you want to be comfortable, I can book you an OR in six weeks. I don't know what wait times are like in Calgary, but I imagine just getting somebody into an OR for what is probably listed as a low-priority or an elective procedure can cause some people maybe to say, well, you know what, I'm just going to grin and bear it, put a belt between my teeth and let's just get this done. Do you see that happen?

Dr. Kristina Arion:  

Oh, you're absolutely right. For sure. That's why most patients have it done in the clinic because wait times for the operating room are very, very long, like six months, if not...

Dr. Blair Bigham:  

Oh, wow.

Dr. Kristina Arion:  

If not more.

Dr. Blair Bigham:  

Who wants to wait? I mean, by the time they get to you and get told an IUD might help with their severe cramps or their bleeding, who wants to wait another six months?

Dr. Kristina Arion:  

Exactly. So like I said, that oral cocktail is good. There's also, if you're trained to do so in the clinic, you can put in either an intracervical or a paracervical block. An intracervical block is much easier. You just go at 12, 3, 6, and 9 and inject some lidocaine. The paracervical block is slightly more complex, where you have to go at the cervicovaginal junction a little bit deeper into the stroma. It's still doable if you have the skills to do that.

Dr. Blair Bigham:  

I can't imagine anyone being gung-ho or even being offered a colonoscopy without any type of analgesia or sedation. Are you surprised that in 2024 we're having a conversation about basic pain management like Advil and Ativan for people as they get an IUD inserted?

Dr. Kristina Arion:  

I wish I could say I wasn't surprised. I wish it was way better than this. Like you said, it's like a colonoscopy, there's no question about some sort of anesthesia on board, but for an IUD, it's, "Okay, just tolerate it." The reason is because a lot of women tolerate it quite well, but that's not a good enough reason for all of the other people that do need something. And the reason that there isn't anything more like a sedation room for anyone is because there's not enough investment in women's health. And I think that that's just been across time. I think it's starting to get better, but it's not there yet. Women's health is at the bottom of everything.

Dr. Blair Bigham:  

Well, hopefully your article is a good way to advance that, even just a little bit, and we'll be talking more about this with our next guest.

Dr. Kristina Arion:

Awesome

Dr. Mojola Omole:

Thank you. 

Dr. Kristina Arion:

All right. Thank you, guys.

Dr. Blair Bigham:  

Dr. Kristina Arion is the lead author of the article in CMAJ, titled “Five ways to support pain management in people receiving intrauterine device insertion”. She's an OB-GYN at the Children's Hospital of Eastern Ontario.

Dr. Mojola Omole:  

We're going to step beyond pain management during IUD insertion. Dr. Nadia Von Benzon is the co-author of the research paper that examined women's experience during other obstetrical and gynecological procedures. The study is titled, My doctor just called me a good girl, and I died a bit inside: from everyday misogyny to obstetrical violence in UK fertility and maternal services. This was published in the Journal of Social Science and Medicine. Dr. Von Benzon is a lecturer of social geography at Lancaster University. Thank you so much for joining us all the way from England today.

Dr. Nadia Von Benzon:  

Thank you for having me.

Dr. Mojola Omole:  

So how are you that, in general, in 2024, we're still discussing how to manage pain during IUD insertion rather than it being just like, okay, this is the standard of care that people should expect when getting an IUD inserted?

Dr. Nadia Von Benzon:  

Unfortunately, I don't feel surprised at all really that we're having this discussion because I think it seems to fit, really fit neatly—that's the wrong word entirely. It very much is in keeping with our research around fertility care and obstetric care, finding that the management of pain seems a really kind of secondary concern in the support of women and support of people becoming pregnant, giving birth, and in other aspects of obstetric care.

Dr. Mojola Omole:  

So your study doesn't have a really typical name. Why did you include that quote, "My doctor just called me a good"—it's actually super creepy—"a good girl, and I died a bit inside" in your title?

Dr. Nadia Von Benzon:  

Sure. So we have this website in the UK called Mumsnet, and it's a parenting website. It started out with the idea of bringing mothers together and providing a space that mothers could talk online together about all different aspects of childcare, from having babies through to raising children. And it's a site that I've done a bit of research on before, and I was just looking through the site one day, and I came across this thread with the title of the paper, and it was a story of a woman who had been receiving fertility treatment, and she heard the doctor say to her, it was something along the lines of, "You're such a good girl, I'm going to use a smaller needle for this fertility medication."

Dr. Mojola Omole:  

Extremely creepy.

Dr. Nadia Von Benzon:  

Extremely creepy, right? Okay. So I think most people would agree that's a really gross thing to have said to you. And this woman had come onto this parenting forum and shared this experience, and she said, "I'm thinking otherwise. I think he is a really good doctor. I've been really pleased with his treatment, but this has totally grossed me out. And I'm thinking that actually I need to find a new doctor." And the thing that I was really intrigued by wasn't so much this kind of story of this thing happening, because unfortunately it didn't surprise me that much, coming from this other research that I'd done, hearing about all of these awful experiences that people had. But what I was really interested in was the responses from the people that read it and responded to it, which ranged on this whole spectrum from, "This is an appalling thing to happen, and I'm so sorry, and you should run to the hills," right through to people that were really angry that this woman was even raising this as an issue, that, "You are self-centred,  this is a sort of snowflake generation thing. This person was probably just trying to make you feel comfortable. This was a nice comment. I'd love it if someone spoke to me like this, or my doctor does speak to me like this, and I really enjoy it, and you're just wasting—"

Dr. Mojola Omole:  

That's also worrisome.

Dr. Nadia Von Benzon:  

Well, quite. And this real kind of... from some people, this really strong idea that it was self-centered, it was selfish. It was wasting this really precious public resource to be complaining. And there were all sorts of comments between those two. And so I was really interested then to look at this discussion that had happened online alongside our data from the birth stories project, and to try and pick apart, actually, it starts to help explain, I think, why we're in this situation, why women accept substandard treatment, why women don't complain, why women in the UK in 2024—or 2020 at the time of the research—are still experiencing obstetric violence, experiencing misogyny, and don't complain, don't stand up for themselves. So that's where the title was coming from, direct from that comment in the Mumsnet thread.

Dr. Mojola Omole:  

What were some of the experiences that they were describing with pain or being dismissed that you got from your research?

Dr. Nadia Von Benzon:  

So we had examples of women who had episiotomies without having any consent, without being asked for consent, without being given any painkillers.

Dr. Mojola Omole:  

Oh goodness.

Dr. Nadia Von Benzon:  

We had an example of someone who was sewn up after an episiotomy without consent and without being given any analgesia. We had examples of people who were asking to have epidurals and just being told, like, "Oh, there's just not the time. Now's not the right time to ask." And either, "Oh, it's too early. We can't give you pain medication because you're not far enough along." And then that immediately changing to, "Oh, it's too late. It's too late. You're about to give birth."

Dr. Mojola Omole:  

What were the impacts of these experiences that they described?

Dr. Nadia Von Benzon:  

So really mixed. We had women who had been really deeply traumatized by these experiences. One of our participants said that all along they'd been planning on having two or three children, and the experience of having one child had been so difficult that they decided that that was it. She just couldn't go through with it again. We had other women who had sought counseling afterwards, had debriefs from midwives and found that useful, and other people who had actually sought professional therapy to help deal with it. But there was also... what was interesting was asking or finding participants then reflecting on the experience afterwards. So having shared with us these often really traumatic stories and then saying, "But then things really changed,” that as soon as they were out of that situation, they felt lucky that they had a baby who was alive, who was well. And for some participants, it was like, "Oh, for myself, now I feel like that was over, and I don't really want to think about it anymore, and I should just be thankful." But then a lot of people also found that when they did try and express their hurt or the trauma, they were being told by other people, "Oh yeah, but come on, your baby's okay. You are okay. Your baby's okay. Just forget about that bit." So, in fact, there was interesting mirroring of things that people were being told after their kind of traumatic experiences of birth, of this kind of, "Oh yeah, that wasn't great, but it's done now, and let's not waste resources by kicking up a fuss," or people just feeling that for themselves. I think that... I feel so lucky to live in a socialized healthcare system, but I think we do live in a culture where we are being told we are really lucky that our healthcare is free in the UK, and we've got to be really careful to protect it as a limited resource.

Dr. Mojola Omole:  

What was the reaction of the medical professionals when your study came out and you were publishing these quite painful to hear experiences around birthing? What was the medical profession's response?

Dr. Nadia Von Benzon:  

I don't have a good answer to that because there hasn't really been one, but I was just recently contacted by an NHS Trust in Birmingham where they'd like me to come and speak to the team that run the midwifery assistants for midwives. There's a team of midwives that run that group, and they've asked me to come and speak to them about the findings from our research. So I wonder if, actually, a lot of healthcare practitioners won't be that surprised by the findings. And also, I think we try really hard not to point fingers. Whilst amongst the stories, there are stories of anonymous individuals who clearly have done things that are wrong, but actually, I don't think at any point we really blame those kind individual midwives or those individual doctors, because it's very much a product of the system that they are working in. I'm sure if they had more time, more space, more training, and a better kind of understanding of what was happening, it would be different. I think it's easy to get acculturated to a system of, "We've got to get these women through as quickly as we can, and we've got to focus on preserving the life of that newborn and protecting the health of that mother."

Dr. Mojola Omole:  

But then creating a dehumanizing process almost, where you become a handmaiden—you're just a vessel to continue to increase the population and not actually someone who is going through an experience itself.

Dr. Nadia Von Benzon:  

Absolutely. And I think some of that is down to our kind of risk management strategies and the way that risk is recognized. I think hospitals are so worried about litigation and about what happens if things go wrong, and so they're focusing on the kind of high-level things—the things that they'd get sued over. People don't sue because a midwife was brusque with them, or they don't sue because, oh, somebody didn't have time to ask for consent. Hospitals get in trouble when babies die and when mothers die. And I just think that so much of the intervention is focused on preventing death that actually, as you say, we forget that's not a vessel for a baby—that is a person who has opinions about what you are doing to their body.

Dr. Mojola Omole:  

Yeah. What would you say is the takeaway for healthcare professionals? If you can surmise and be the voice for all the people who were part of this study, what would the takeaway be?

Dr. Nadia Von Benzon:  

I think a really key message coming through was that people want things explained to them. They want people to stop and ask for their consent. They want their midwife or their doctor to say, "Right now, this is happening. We're quite worried," or, "We need to act speedily. Is it alright if I insert my fingers into your vagina? Is it alright if I cut and do this? Is it alright if..." So often though, what was more interesting or worrying was that it wasn't necessarily lifesaving treatment that was being done without consent. It was quite run of the mill. You can almost understand, in the moment of trying to facilitate the birth of the baby, somebody does something without asking, but you think, what was the logic of not asking or not saying to them at all, "Now's the time to sew you up afterwards." So yeah, I think the absolute kind of bottom line is to speak and explain what's happening and ask.

Dr. Mojola Omole:  

Yeah, I think that's a bare minimum, to be honest

Dr. Nadia Von Benzon:  

Yeah. Yeah, absolutely.

Dr. Mojola Omole:  

Great. Thank you so much. Thank you.

Dr. Blair Bigham:

This has been great. 

This has been a great conversation. Dr. Von Benzon is a lecturer and social geographer at Lancaster University. She's the co-author of the article in Social Science and Medicine titled, "My doctor just called me a good girl, and I died a bit inside: from everyday misogyny to obstetrical violence in UK fertility and maternal services." Thank you so much.

Dr. Nadia Von Benzon:  

Thank you.

Dr. Blair Bigham:  

Jola, do you want to start?

Dr. Mojola Omole:  

Yes. Sorry. I'm thinking out loud as we're going along because I thought that both conversations were really thought-provoking, and I think as someone who's a cisgender woman who has had their own story around birthing and gynecological care, all of this resonated with me. And it wasn't surprising, just as someone who is an advocate in the women's health space, just the lack of attention, and just truly the lack of humanity that is placed on people who give birth and people who menstruate. It's odd that obstetrical care and gynecological care are probably one of the still-standing bastions of the patriarchy when it comes to medicine. It is archaic, the way we treat people who bleed monthly and who give birth in this country.

Dr. Blair Bigham:  

Archaic seems to be the right word. I can't believe just the acceptance of the system by our colleagues and patients.

Dr. Mojola Omole:  

No, I'm going to correct you on that. There's no acceptance of it. It's the fact that no matter what, when you have a profession that is dominated by cisgender women, nobody gives a bleep about what we say. We can argue, we can scream to the rooftop, no one will say anything.

Dr. Blair Bigham:  

But it sounds like Nadia's group isn't even necessarily arguing. It sounds like there's sort of just this expectation that, "Yeah, that's just the care that I'm going to get."

Dr. Mojola Omole:  

Well, because at a certain point, it's really exhausting. It's the same as fighting racism. It's exhausting to be experiencing something and then, at the same time, try to fight it. So you just put up with it, because honestly, that is part of how patriarchy works, is that it makes you tired.

Dr. Blair Bigham:  

Right. Do you see any change in either where you work or in speaking to your friends about this experience evolving or improving?

Dr. Mojola Omole:  

I think that every practitioner who is cisgender female has an understanding of it, but then there's a time constraint. When we talk about the IUD insertion, there's a time constraint that we don't pay people for caring. We truly don't.

Dr. Blair Bigham:  

The system is just not built around it.

Dr. Mojola Omole:  

Our healthcare system does not pay you to care. It just pays you to work. And I think that's part of why we're in dire straits with family medicine. We've just worked people, and we've worked their humanity out of them. They're not happy. So why would you stay in a space where you're not giving great care, but you can't because you can't keep your office open? 

Dr. Blair Bigham:  

Jola, we can't end on a gloomy note. What's the one takeaway that everybody needs to keep in mind in your eyes after this episode?

Dr. Mojola Omole:  

Just listen to your patients. Ask questions, and honestly, yes, some of it will make it not a five-minute or 10-minute consult, but a half-hour consult. But we, 99% of us, came into medicine, and about 100% of those who are in family care went into it because they really deeply care about their patient population. And so it's really just to listen to the person in front of you and ask those questions so you can give them the best care possible.

Dr. Blair Bigham:  

No response. That's it for this episode of the CMAJ Podcast. If you like what you heard, please give us a five-star rating wherever you download your podcasts, share it with your networks, leave a comment, reach out to Jola and I on X. Our hashtags are in the show notes. The CMAJ Podcast is produced for CMAJ by PodCraft Productions. Thanks so much for listening. I'm Blair Bigham.

Dr. Mojola Omole:  

I'm Mojola Omole. Until next time, be well.