Many iterations came before and have gone since, but the most controversial version of the speculum started out, in 1845, as a bent spoon. That was when an Alabama-based doctor named James Marion Sims set out to treat an agonizing medical condition, and in the process established precedent for the practice of modern gynecology—in more ways than one.

Sims was attending to a patient who had been thrown off of her horse, and in landing on her pelvis, developed uterine retroversion (a tipping, or tilting backward, of the uterus). In the process of attending to her, Sims was struck by the insight that a custom-fashioned tool would allow him to see better into the vaginal canal. His first foray into speculum design was a doubly bent spoon that allowed him to separate and hold apart the vaginal walls. “Introducing the bent handle of the spoon I saw everything, as no man had ever seen before,” Sims later wrote in his unfinished memoir, The Story of My Life. “I felt I was on the eve of one of the great discoveries of the day.” Sims’s first experiments with that speculum were all done on enslaved women. 

He ran a small private hospital—a “Surgical Infirmary for Negroes,” read an 1852 ad in Montgomery’s Weekly Advertiser, where he was “enabled to offer his professional services to his friends.” “It's really impossible to talk about the beginning of gynecology in America without talking about slavery because they were so deeply entwined and dependent on each other,” says Rachel Gross, science journalist and the author of Vagina Obscura: An Anatomical Voyage. Sims himself had slaves, and, Gross adds, “worked with other slaveholders to experiment on enslaved women in order to develop techniques that would help them continue to give birth, and continue to work.”

Sims used his new speculum to perform surgery on vesicovaginal fistulas, abscesses that often developed during difficult births, where the pressure of labor damaged tissue between the vagina and bladder or rectum. His surgeries on enslaved women were conducted without the use of anesthesia. Sims noted in his memoir that he operated on one woman, named only as Anarcha, 30 times. 

He was lauded for his work, becoming the president of the American Medical Association in 1876 and then the founder and president of the American Gynecological Association. In a tribute written after Sims’s death, the American doctor W.O. Baldwin breathlessly wrote that the eponymous Sims speculum “has been to diseases of the womb what the printing press is to civilization, what the compass is to the mariner, what steam is to navigation, what the telescope is to astronomy.”

Baldwin’s encomium conveniently overlooked one historical aspect, however. “The speculum has been around for a really long time,” historian Deirdre Cooper Owens tells American Experience. “You can go to Ancient Greece, and Ancient Rome, the site of modern western medicine, and you'll find specula that existed.” What changed with the popularization of Sims’s design were the mores around gynecology. “Most men did not perform vaginal examinations, or pelvic examinations on their female patients because of the gender ideals of the time,” says Dr. Cooper Owens. “Now, these things become a bit more nuanced when we’re talking about enslaved people, or poor people, or people who were institutionalized in asylums. They tended to be the ones that were exploited, as doctors experimented and used their bodies literally as canvases to learn from. That kind of paints the picture of American medicine that we know today.”

As for the speculum itself, others refined Sims’s design in the decades that followed. In 1870, Edward Gabriel Cusco introduced a two-bladed instrument that featured a screw mechanism to hold the blades open inside the vaginal canal. Cusco’s bivalve construction was further iterated upon by T.W. Graves, a Massachusetts-based doctor. It was Graves’s duckbilled speculum—which combined elements of Sims’s curved design and Cusco’s double-bladed device—that eventually became most popular within the medical establishment.

Then a century after Sims’s crudely fashioned cutlery, the speculum came to play a central role in the battle against cervical cancer, at the time the deadliest form of cancer for women. Dr. George Papanicolaou conceived of taking a swab of cells from the cervix for examination under a microscope; the speculum made it possible for physicians to gather the cervical tissue from patients. Thus was the pap smear born, drastically diminishing the numbers of casualties as a result of cervical cancer. 

However, today the incidence of advanced-stage cervical cancer is on the rise again, in part because fewer women are getting pap smears as a preventative measure. According to the National Institutes of Health, the percentage of women overdue for cervical cancer screening went from 14% in 2005 to 23% in 2019.  Some of that reticence, perhaps, has to do with the long reach of Sims’s paternalistic legacy. “A pap smear is not done in a neutral environment,” Gross asserts. “When you enter an office with a doctor, a very real power dynamic becomes established where you feel like there is sort of an authority of your body.”

The burgeoning “femtech” industry (a term coined in 2013 to describe technology geared toward female biology) aims to change that by making the experience of cervical cancer screenings feel less invasive—and that includes reimagining the speculum. But updating a 150-year-old design is only part of a larger picture. “People have really bad experiences getting pelvic exams and pap smears where they feel their body was violated, they weren't treated with respect or dignity,” says Gross. “That's not quite a problem with the tool, itself. That’s a problem with the culture of medicine, and the place of healthcare in our society, and how we communicate to women what this is for and what they’re allowed to know about their own bodies.”