by Siobhan Donovan November 09, 2016
Yesterday in our article, Because Women’s Health Matters, we mentioned that gynecology clinics and universities are the two most common sources of sample requests. Today we wanted to highlight one of our favorite sample recipients, Praxis Clinical- an unlikely combination of the two. Alexandra Duncan, the founder of Praxis, takes female reproductive health into her own hands. Literally. “I use my own body to teach medical students how to perform pelvic exams. And it’s the best, most empowering work I’ve ever done,” wrote Duncan in an article for Buzzfeed.
Have you ever wondered how gynecology could be empowering? We did. A gynecological visit can be intimidating, the science has a dark past. However, Alexandra Duncan’s interview left us feeling inspired. It’s reassuring to know that there are young, motivated, inclusive, and caring professionals out there. That’s something Good Clean Love is glad to support. Now, let’s dive into this enlightening Q & A on a variety of women’s health topics with the founder of Praxis.
Q: What is Praxis Clinical? What do you do?
A: We provide clinical skills and health education to patients, providers, and communities. Sometimes that means leading self-exam workshops at conferences or giving talks to undergrads who are really nervous about going home and getting their first Pap test. However, the biggest part of what we do is provide clinical skills training to universities and hospitals. We work with several thousand medical and nursing students a year (including all the students at Yale School of Medicine, Quinnipiac, and several departments at NYU). We also provide training for the State of Connecticut’s sexual assault nurse-examiners (SANEs), and annually retrain VA doctors and nurses as part of the Pentagon’s initiative to combat sexual assault in the armed forces.
Q: What type of workshops do you do? What does a gynecology workshop look like?
A: We provide trainings on gynecological exams and women’s health, andrological exams and men’s health, self-exams, and sexual and reproductive health. We recently collaborated with the Director of Clinical Skills at Yale School of Medicine to co-author four peer-reviewed medical articles and videos about performing gynecological exams. At the request of Yale Med we’ve just developed our first venipuncture clinical training, which will launch next month. We also run certification courses for clinical teaching associates (CTAs).
Most of our sessions are taught by CTAs: highly trained lay-people who use their own bodies to teach students how to perform the exams. As such, students in our session actually see and practice on individual people’s anatomy, and learn how everything works while being able to truly connect it to real embodied experience (“that wasn’t quite my ovary… move your hand here, try with a little more pressure… that’s my ovary!” “Think about where you found my cervix- what do you think that means about where my uterus is? Okay, apply internal pressure… now you’re holding my uterus!”). It’s a very powerful opportunity to help students connect the body, the person, and the anatomy.
Q: How does Praxis tailor its clinical trainings so that they are more sensitive/ relevant to the LGBTQIA+ community and trauma-impacted patients?
A: It’s extremely important to us that our sessions are LGBTQIA+ inclusive and trauma-sensitive. We make sure to use inclusive language, and offer specific tips to accommodate patients’ needs (for instance, a transwoman who needs a prostate exam can actually be on a GYN table in the standard position, with her feet up in the footrests). Some of the most powerful things are also the simplest, since most students want to be considerate but just aren’t sure how to be. We teach students how to start an exam with language like, “What name would you like me to call you?” and “what pronouns do you use?” We also tell them that they can ask a patient who is trans or genderqueer if there are specific words they use to refer to their own anatomy, and encourage the students to mirror that language during the exam to minimize body dysphoria.
The whole exam we teach is designed to be as neutral and non-triggering as possible. We have the patient sitting up on the table around 60 degrees rather than flat on their back. (Did you know there is actually no medical reason for the patient to be lying flat? It’s actually easier for a provider to assess the patient’s anatomy if they are upright.) We teach the students to offer the patient a hand mirror so they can follow along with the exam if they choose to. We teach students to avoid things like “open your knees,” “spread your legs,” etc., and instead have them place their hands far apart and ask the patient to “please extend your knees toward my hands.”
Q: Praxis’ website uses the word “empowering” a lot. What might be some ways that a gynecological exam could feel empowering?
A: We teach students how they can guide a patient through inserting the speculum themselves, which can be a really empowering option for anyone, but especially someone with a history of trauma who is struggling with the exam. There was actually a study done on this- for all that it can sound weird to start with, 91% of the women who participated said they’d ask to self-insert every time they went back to the doctor.
We’re passionate about empowering lay-people in healthcare and helping to reshape the provider-patient relationship. One of the most important parts of our paradigm is moving away from teaching models in which the ‘patient’ is simply an object upon which the students practice medicine (cadavers, plastic models, etc.), or even a live person serving as a ‘pelvic model’ whom a clinician teaches upon. In our sessions the CTA is the only teacher in the room, meaning that the students learn to look to the person on the table as the source of knowledge and authority over their own body.
Q: How did Praxis Clinical get started?
A: I started working as a full-spectrum doula during college, and from there found out about gynecological teaching associates. I trained as a GTA as soon as possible, and taught during my last two years of school. I knew I wanted this to be what I did with my life, but there wasn’t a clear path to making it one’s full-time job. I took a year after I graduated to basically throw everything at the wall to see what would stick, working with lots of different programs and creating my own curriculum based on what I thought was most important and best practice for teaching. I started Praxis around the time when Yale School of Medicine was looking to change their existing program and was talking to me about their options, and everything rather fell into place in an astonishing way. I’d been pursuing this work and this field in every way I could find, but there was a lot of luck and good timing involved!
Q: “Reproductive rights” is another term mentioned throughout your website and in your blog. Where does Praxis fit into the conversation of reproductive rights?
A: I think it can be hard to separate reproductive rights, access, and justice. I think a large part of our role is trying to change the assumption that the provider has more power over your body than you do. We want to live in a world where every person is the main source of knowledge and authority for their own body. Your body, your knowledge: your choice.
Q: Praxis Clinical requested samples of our organic personal lube back in April and we’ve been happily sending them ever since. In your opinion, what makes a good lubricant? How have donated lubricants impacted your practice?
A: The thing about the medical lubricants that are most easily accessible is that they become sort of white and gunky (for lack of a better term) after they have been inside your vagina for a little while. Perhaps only a GTA would notice, but it makes it look like you have a yeast infection. They also have chemicals we don’t want to be regularly putting in our bodies, and can throw off vaginal pH- something that really matters if you’re using them as frequently as we are! Healthy and natural ingredients, pH balanced… these are so important. You describe your restore lubricant as bio-matched; I think that’s exactly what we would have asked for in a lubricant if we had had the term!
Q: Praxis Clinical actually encouraged us at Good Clean Love to create a ‘medical card’ for our Bio-Match organic feminine hygiene products, making it easier to share information about our sampling program with other health professionals. What was it about our sampling program that stood out to you?
A: We actually are sent quite a lot of lubricant samples, but so many of us loved your restore lubricant that we were going through the samples incredibly quickly. Part of that was because we kept handing them out to the students and faculty we work with! We, like everyone else, work to get paid (and GTA work pays very well!), but you can’t possibly be in this field without being passionate about what you’re doing. We all want to see better healthcare across the board, and we love the idea of providers using this lube instead of the unpleasant medical kind that is the standard. We would give them samples and tell them about your program, but to get people to remember we need specific information we can hand them on a simple and memorable card. Additionally, we knew they would be more likely to respond to material aimed specifically at a medical audience. Basically, we love your lubricant and want to see it in more clinics! I spend so much time in medical settings that I had a good idea of what materials would appeal to providers, and I hoped you would be able to create something that would work in that setting.
Q: Lastly, Bingley is probably the cutest cat ever. Does he live at the clinic?
A: Bingley is 100% the cutest cat ever (except for his sister Agatha, who is in some of the photos), and he doesn’t live at the clinic- that’s my apartment! We teach at whichever school/hospital/etc. that’s hired us, but we functionally have a mobile office and supplies get delivered to my flat. We have an arrangement with Yale School of Medicine that lets us use their facilities to run our certification trainings for new CTAs, but we do a lot the behind the scenes work designing new sessions and refining techniques at my flat. The GYN table in the photos actually lives in my guest room! It’s better than when we used to cover the guest bed in chucks (absorbent pads used in hospitals) and make a very impromptu exam table. I actually might have a (non-graphic) picture of my colleague on the covered guest bed giving herself an ultrasound exam while we developed that session…
My pantry is entirely filled with boxes of speculums, hospital gowns and drapes, lubricant, etc. It’s an unusual collection, but my professional life is rather unusual overall, so I suppose it’s fitting.
Alexandra Duncan is the founder of Praxis Clinical. She was first certified as a gynecological teaching associate (GTA) through Rutgers University’s highly regarded training. She has taught medical, nurse-practitioner, physician’s assistant, naturopath, and midwifery students at many universities, including NYU, Rutgers, Yale, West Virginia University, Albert Einstein, Quinnipiac, Fairfield University, and Stony Brook, and has re-trained doctors and residents at several of these. She has worked with military doctors at Uniformed Services University, and assessed and retrained VA doctors as part of the Pentagon’s initiative to combat sexual assault in the armed forces.
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