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The Messy Ethics of Pelvic Exams

The Holiday season: a time to gather and schmooze, to swap stories and drink. When this writer wasn't partaking in the traditional eggnog-enraged family fights, I was able to hang with a few friends of mine who work in the field of sexuality and medicine. You know, people who can casually mention the word  abortion while passing a plate of sugar cookies. Gripe about their trials to get hospital staff to address transgender patients with the correct pronoun, or give their critiques of the newest sex toys on the market. Truly, my kind of people.

And of course, it's when the cork has been popped and the glasses become filled that I become privy to the juiciest and latest information. For example, did you know that more and more research is indicating that many head and neck cancers are actually caused by the HPV virus? Yet more evidence as to why it's necessary to use condoms and dental dams while performing oral sex. And have you seen the study that showed people on average wait two days before they go into the emergency room to have a sex disaster fixed? (Oh, those poor rectums.)

As I help train medical students to perform gynecological exams, I like to hear people's concerns, funny stories, not-so-funny stories, and irritations from all sides. During one of my holiday exchanges though, things became a little more heated than before. Let me explain why. There have always been tales floating around the Gynecological Teaching Associate and Medical Student world for years that many Teaching Hospitals (those that teach medical or nursing students) perform gynecological exams (sometimes multiple exams) on women when they are under anesthetics during surgery. Without their knowledge, and sometimes without their consent! Truth be told, this is pretty commonplace in the world of gynecological surgery.

But darker rumors and stories persist. Picture it: a woman comes in for throat surgery at a teaching hospital. At some point during the surgery, the head honcho will call on the "medical team" (aka: med students/interns) to practice their speculum skills on the patient. So, medical student after medical student will position themselves between the patient's legs, locate the vaginal opening, insert the speculum into the vagina, locate the cervix and then remove the speculum. Later, the patient wakes up, Doctor comes in, reassures the patient that surgery went well and the patient is none the wiser that earlier in the day they had, ohhh, seven pelvic exams.

When we deal with the body, things get messy. The first time I heard of this practice, it was from a doctor who had personally witnessed it. The second time was through the developing documentary At Your Cervix. Cast in an unflattering light, medical schools started weighing in on the issue. The schools' representatives insisted that they had never heard of the practice, and that it certainly didn't occur in their hallowed halls. I reasoned that maybe this was an antiquated practice that no longer happens, that the pelvic exam scam had gone the way of routine lobotomies.

But during a holiday party, after a couple mugs of mulled cider, a few medical revelers let the secret slip out, and I was once again reminded that sometimes all Santa brings is a mean, hard lump of coal called Truth.  Yes, pelvic exams cloaked under anesthetics is very much still a procedure that takes place at some teaching hospitals.


When I relay this procedure to my friends in the general public, most react very strongly. The use of the word "rape" is a very common follow-up retort within the general public. But within the medical community, the room goes quiet…tense…uneasy. Perhaps no one wants to cop to it because many still don't know how feel about it (and therefore can't justify it).

Medical students and interns are asked to memorize and comprehend an astonishing amount of facts and figures. The common analogy used to describe absorbing so much information is that it's like trying to drink from a fire hose. Yet "in the moment" bioethical questions (exploring the ethics in medicine) are difficult to come by. A recent study showed that medical students are more often, especially before their clinical rotations, receiving their moral guidance from TV shows like House than from their professors and mentors. It seems within this community, students and interns don't have a safe way to voice their discomfort with this practice. Over and over in classrooms I have heard "But what about the patient…but I don't know how I feel about….where do my beliefs fit in….?"  These questions hang in the air like a woman's legs in stirrups: vulnerable, dangling, and waiting for closure that never seems to come fast enough.  Yet the stock reply from a doctor who can't or won't answer is, "That's a great question. We'll address that later." It's no surprise that later never comes. This truly is where medicine becomes messy.

Without talking about an issue, there can be no way to change it. It's necessary for medical students to find allies in their education and be able to voice their concerns. Patients need to speak up for their rights within the healthcare system to protect their bodies as well as their pocketbooks. The barriers of secrecy need to be broken, but sometimes the courage to talk doesn't come easily. Next holiday season I'm going to get the conversation started with a festive cocktail I call Pelvis-Protectin' Punch. Feel free to stop on by and raise a glass.

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As an (almost) nurse this makes my stomach turn. I just read this article to my professor (who is the Nurse Manager of our OR) and her response was "Not in My OR!". and "Where the heck was the nurse?". (we are a teaching hospital.) If they are doing pelvic exams under anaesthesia without patient consent- legally this is assault. Everyone in the medical community knows this I think they're just afraid to say it. Honestly as a female nurse working in an OR they have a responsibility to their patients to tell the doctors "Not in my OR". and also if a women ever found out this took place and decided to sue the Doctors/Med Students/Nurses that were present they would all lose their license and honestly could face criminal charges.

So here I join you in raising a glass of pelvis-protectin' punch and if I ever hear of/have proof of this happening in my OR watch out because every one of those people present will get reported to their professional organizations and if further is needed to the Police.

Women have a right to consent to whom touches their bodies and how they do so. Being unconscious for a medical purpose doesn’t give someone any right to touch her unless her written and expressed permission is given beforehand.

not as vile as you make it sound

First off, this article is inflammatory. I'm a resident, and as a medical student I did do pelvic exams on anesthetized women. However, they were already under for a GYNECOLOGICAL procedure and REQUIRED a pelvic exam as part of the procedure. AT NO TIME did I ever witness a woman undergoing a pelvic that was unnecessary (i.e., you come in for a gall bladder removal and a troop of med students come in and do pelvics). AND THEY ALL WERE CONSENTED. It's not some free-for-all like the article describes.

And I note the above poster "Angela" the nurse is just steaming with righteous indignation at the thought of a medical student doing a procedure. We get it - you're a patient advocate. Good for you. Now, do you think I went into medicine to assault women? Your tone is insulting and demeaning to someone who was spent the last 12 years training to care for individuals. Your profession (nursing) certainly does not hold a monopoly on care and ethics.

I'm going to tell you

I'm going to tell you something that's pretty routine in the progressive and/or feminist blogosphere where there's a lot of critical analysis to be seen: If it's not about *you,* don't make it about you. You've never participated in an unauthorized exam or seen one done. Bully for you. But your personal experiences are not the experiences of all and sundry. Just because you've never taken part in a medical exam that is happening without the consent of the women or have not seen one done, *does not* mean that they don't happen. They may not be condoned by any reputable hospitable, but it doesn't mean they don't happen. It doesn't mean there are not questionable practices. It also doesn't mean that the way pre-op consent forms are written is not an issue.

Importance of Defining Consent

I'm glad to see people discussing this issue. I am the director, producer and co-writer of At Your Cervix, and have worked as a GTA in New York City for the last 9 years. We have been working on the film for many years, and I can tell you that we have heard many accounts of this practice from medical students and doctors. I do not know that it happens for other procedures, but it does happen for gynecological procedures. In that case, it's very important to look at what consent means. As mentioned in another comment, a resident might do an exam, but the question is: Is that exam for the patient's benefit, or for the student's benefit? If it is not the exam her doctor does to confirm her condition, it is not for her benefit, it is for educational purposes, and she must be asked whether an additional exam is allowable for educational purposes. It's absolutely unethical to think that because she is in for a gynecological surgery, she has consented to whomever is in the room to touch her genitals or examine her internally. One bimanual exam is very different from two or three or more.

Ari Silver-Isenstadt did research looking at the prevalence of this practice in Philadelphia in 2003 and found that 90% of students had "practiced" on anesthetized patients and whether they had consented was unknown in the majority of cases. I suggest you look it up if you want to read more.

We hope to create more dialogue about this issue and other issues around patient rights and consent with At Your Cervix. We also want to work to empower both patients AND students to speak up and advocate in unethical situations, which is really hard for people to do. Students need a lot of support to do this. I applaud those who are able to do so. At the same time, students need to learn, and many patients will be willing to help, if we let them CHOOSE to do so.

Amy Jo Goddard,

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Megan Andelloux
January 19th, 2010
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Megan Andelloux, also known as "Oh Megan," is a board-certified sex educator and sexologist. Megan defines herself as a "WASP" on a mission to bring the medical and pleasure-centric sexual models...