Pelvic examinations under anesthesia by medical students without consent

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Line drawing showing bimanual palpation as part of a pelvic exam Pelvic exam nci-vol-1786-300.jpg
Line drawing showing bimanual palpation as part of a pelvic exam

Pelvic exams under anesthesia by medical studentswithout explicit consent may be occasionally performed to teach medical students how to conduct pelvic exams. They are typically done during gynecological surgeries, but not exclusively. [1] In 2024, the United States federal Department of Health and Human Services banned hospitals from performing non-consensual breast, pelvic, prostate, and rectal exams for "educational and training purposes" by medical students, nurse practitioners, or physician assistants. Hospitals that do not obtain explicit consent may be ineligible to participate in Medicare and Medicaid programs and may be subject to fines and investigations for violating patient privacy laws. [2]

Contents

First-year medical students find such examinations more morally problematic than those who have completed clinical clerkships in obstetrics and gynaecology, [3] an example of a phenomenon known as ethical erosion. [4]

Frequency

A study done in 2003 found that 90% of Pennsylvania medical students had done pelvic exams on anesthetized patients during their gynecology rotation. [5] One medical student described performing them "for 3 weeks, four to five times a day, I was asked to, and did, perform pelvic examinations on anesthetized women, without specific consent, solely for the purpose of my education." [6]

A 2022 study of six American medical schools found that of the 84% of medical students that had performed pelvic exam(s) under anesthesia, 67% stated that they never or rarely witnessed explicit consent being obtained for a student to perform the pelvic exam under anesthesia. [7] It is possible that such consent had been obtained when the clinician provided a discussion of the type of procedures to be performed, along with a discussion of the risks, benefits, and alternatives to the procedures; this discussion typically takes place at a preoperative visit. [8]

Students have described pressure to do the examinations from their superiors. [9] [6] [10] They have reported that they believed "they did not have the personal autonomy to object to performing pelvic EUAs that they believed were unconsented." [7]

Support

The New York Times found that "doctors often argued that patients implicitly consented to being enlisted in medical teaching when visiting a teaching hospital, or that consent for one gynecological procedure encompassed consent for any additional, related exams." [5]

People have described beliefs that if consent was asked, medical students would not be able to get experience performing pelvic exams; however, a majority of women polled stated that they would consent to such procedures. [4] A utilitarian perspective argues that the educational benefit and consequential benefit to future patients is invaluable. [1]

Others have opposed bans to maintain institutional autonomy and prevent government overreach. [1]

Opposition

A social media hashtag, #MeTooPelvic, was created. [5] People have described the exams as violating and traumatizing. [5] [11] They have been described as sexual assault, [9] and a comparison to rape has been drawn due to the digital penetration without consent. [1]

The Association of Professors of Gynecology and Obstetrics recommends that pelvic examinations only be done with explicit consent. [8]

A 2022 study of third and fourth year medical students at the University of Pittsburgh School of Medicine found that 75% of students believed that explicit consent should be obtained for educational pelvic exams under anesthesia. [12]

Legality

United States

The practice was first banned by California in 2003, followed by Illinois, Virginia, Oregon, Hawaii, Iowa, Utah, and Maryland in subsequent years. By 2019, it was still legal in 42 states, though some individual medical schools, such as Harvard, had implemented bans. [13] By 2023, more than 20 states had enacted bans on such exams. [14] In 2024, the United States federal Department of Health and Human Services banned hospitals from performing non-consensual breast, pelvic, prostate, and rectal exams for "educational and training purposes" by medical students, nurse practitioners, or physician assistants. Hospitals that do not obtain explicit consent may be ineligible to participate in Medicare and Medicaid programs and may be subject to fines and investigations for violating patient privacy laws. [2] Additionally, the Office for Civil Rights announced that they were investigating complaints that patients’ health information had been disclosed to medical trainees in violation of the Health Insurance Portability and Accountability Act of 1996 Privacy Rule. [15]

France

In 2015, it was revealed that some doctors had been using patients under general anesthesia as teaching tools for their students, performing rectal and vaginal examinations without consent. The most vocal critics were a group of fifty doctors, feminists, and social workers who wrote an open letter to the French government demanding an end to the practice. In response to the revelations, Health Minister Marisol Touraine requested an official report from the deans of medical schools at teaching hospitals. The report found that one in three pelvic examinations performed by first-year students, and one in five conducted by later-year students, were carried out without the patient's consent. [16] In 2016, Touraine introduced new rules banning examinations on unconscious patients without consent. President Jean Marty of the gynecologists’ and obstetricians’ federation said the new rules were "disruptive" for patients and Bernard Hédon, head of the national college of gynecologists and obstetricians, labeled them as "prudishness." [17]

Related Research Articles

Obstetrics and gynaecology is the medical specialty that encompasses the two subspecialties of obstetrics and gynaecology. The specialization is an important part of care for women's health.

<span class="mw-page-title-main">Gynaecology</span> Medical area for womens reproductive health

Gynaecology or gynecology is the area of medicine that involves the treatment of women's diseases, especially those of the female reproductive organs. It is often paired with the field of obstetrics, which focuses on pregnancy and childbirth, thereby forming the combined area of obstetrics and gynaecology (OB-GYN).

<span class="mw-page-title-main">Tubal ligation</span> Surgical clipping,removal or blocking of the fallopian tubes

Tubal ligation is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the implantation of a fertilized egg. Tubal ligation is considered a permanent method of sterilization and birth control.

Medical fetishism refers to several sexual fetishes in which participants derive sexual pleasure from medical scenarios including objects, practices, environments, and situations of a medical or clinical nature. In sexual roleplay, a hospital or medical scene involves the sex partners assuming the roles of doctors, nurses, surgeons and patients to act out specific or general medical fetishes. Medical fantasy is a genre in pornography, though the fantasy may not necessarily involve pornography or sexual activity.

<span class="mw-page-title-main">Speculum (medicine)</span> Medical device for investigating body orifices by direct vision

A speculum is a medical tool for investigating body orifices, with a form dependent on the orifice for which it is designed. In old texts, the speculum may also be referred to as a diopter or dioptra. Like an endoscope, a speculum allows a view inside the body; endoscopes, however, tend to have optics while a speculum is intended for direct vision.

<span class="mw-page-title-main">Rectal examination</span> Medical assessment or diagnostic procedure

Digital rectal examination (DRE), also known as a prostate exam, is an internal examination of the rectum performed by a healthcare provider.

<span class="mw-page-title-main">Rectocele</span> Bulging of the rectum into the vaginal wall

In gynecology, a rectocele or posterior vaginal wall prolapse results when the rectum bulges (herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of pelvic organ prolapse, such as enterocele, sigmoidocele and cystocele.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

<span class="mw-page-title-main">J. Marion Sims</span> American physician and gynecologist (1813-1883)

James Marion Sims was an American physician in the field of surgery. His most famous work was the development of a surgical technique for the repair of vesicovaginal fistula, a severe complication of obstructed childbirth. He is also remembered for inventing the Sims speculum, Sims sigmoid catheter, and the Sims position. Against significant opposition, he established, in New York, the first hospital specifically for women. He was forced out of the hospital he founded because he insisted on treating cancer patients; he played a small role in the creation of the nation's first cancer hospital, which opened after his death.

<span class="mw-page-title-main">Vaginectomy</span> Surgical removal of the vagina

Vaginectomy is a surgery to remove all or part of the vagina. It is one form of treatment for individuals with vaginal cancer or rectal cancer that is used to remove tissue with cancerous cells. It can also be used in gender-affirming surgery. Some people born with a vagina who identify as trans men or as nonbinary may choose vaginectomy in conjunction with other surgeries to make the clitoris more penis-like (metoidioplasty), construct of a full-size penis (phalloplasty), or create a relatively smooth, featureless genital area.

<span class="mw-page-title-main">Breast examination</span>

Breast examination, also known as clinical breast examination, is a physical examination performed by a medical professional on an individual presenting with signs and symptoms in a breast, periodically on some people with a family history of breast disease, or on a person with an incidental abnormal finding on imaging such as mammography. Some organisations recommend a breast examination as part of routine screening, typically in some high risk groups.

<span class="mw-page-title-main">Uterine prolapse</span> Medical condition

Uterine prolapse is a form of pelvic organ prolapse in which the uterus and a portion of the upper vagina protrude into the vaginal canal and, in severe cases, through the opening of the vagina. It is most often caused by injury or damage to structures that hold the uterus in place within the pelvic cavity. Symptoms may include vaginal fullness, pain with sexual intercourse, difficulty urinating, and urinary incontinence. Risk factors include older age, pregnancy, vaginal childbirth, obesity, chronic constipation, and chronic cough. Prevalence, based on physical exam alone, is estimated to be approximately 14%.

<span class="mw-page-title-main">Pelvic examination</span> Physical medical examination

A pelvic examination is the physical examination of the external and internal female pelvic organs. It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, discharge, urinary incontinence, or trauma. It can also be used to assess a woman's anatomy in preparation for procedures. The exam can be done awake in the clinic and emergency department, or under anesthesia in the operating room. The most commonly performed components of the exam are 1) the external exam, to evaluate the vulva 2) the internal exam with palpation to examine the uterus, ovaries, and structures adjacent to the uterus (adnexae) and 3) the internal exam using a speculum to visualize the vaginal walls and cervix. During the pelvic exam, sample of cells and fluids may be collected to screen for sexually transmitted infections or cancer.

<span class="mw-page-title-main">Sloane Hospital for Women</span> Hospital in New York, United States

The Sloane Hospital for Women is the obstetrics and gynecology service within NewYork-Presbyterian Hospital and the Department of Obstetrics and Gynecology of the Columbia University College of Physicians and Surgeons (P&S) in New York City. It was founded in 1886 with Columbia P&S as a training and treatment center for obstetrics. It has provided over 100 years of obstetrical care. The hospital is located within Morgan Stanley Children's Hospital.

A well-woman examination is an exam offered to women to review elements of their reproductive health. The exam includes a breast examination, a pelvic examination and a Pap smear but may include other procedures. Hospitals employ strict policies relating to the provision of consent by the patient, the availability of chaperones at the examination, and the absence of other parties.

<span class="mw-page-title-main">Postcoital bleeding</span> Non-menstrual vaginal bleeding during or after sexual intercourse

Postcoital bleeding (PCB) is non-menstrual vaginal bleeding that occurs during or after sexual intercourse. Though some causes are with associated pain, it is typically painless and frequently associated with intermenstrual bleeding.

A rectovaginal examination is a type of gynecological examination used to supplement a pelvic examination. In the rectovaginal examination, a doctor or other health care provider places one finger in the vagina and another in the rectum to assess the rectovaginal septum. The examiner will look for any scarring or masses that may indicate cancer or another disease. Typically, a rectovaginal examination is performed to assess pelvic pain, rectal symptoms, or a pelvic mass. It can also provide a sample for fecal occult blood testing.

<span class="mw-page-title-main">Squamous cell carcinoma of the vagina</span> Medical condition

Squamous cell carcinoma of the vagina is a potentially invasive type of cancer that forms in the tissues of the vagina. Though uncommonly diagnosed, squamous cell cancer of the vagina (SCCV) is the most common type of vaginal cancer, accounting for 80-90% of cases as well as 2% of all gynecological cancers. SCCV forms in squamous cells, which are the thin, flat cells lining the vagina. SCCV initially spreads superficially within the vaginal wall and can slowly spread to invade other vaginal tissues. Because of its slow growth, this cancer may cause no symptoms, or it may present with signs like irregular bleeding, pain, or a vaginal mass. This carcinoma can metastasize to the lungs or less frequently to the liver, bone, or other sites. SCCV has many risk factors in common with cervical cancer and is similarly strongly associated with infection with oncogenic strains of human papillomavirus (HPV). Diagnosis of SCCV is done by pelvic exam and biopsy of the tissue. Treatment and prognosis will depend on the stage, location, and characteristics of the cancer.

The American Board of Obstetrics and Gynecology is a non-profit organization that provides board certification for practicing obstetricians and gynecologists in the United States and Canada. It was founded in 1927, incorporated in 1930, and is based in Dallas, Texas. It is one of 24 medical boards recognized by the American Board of Medical Specialties. ABOG's mission is to define the standards, certify obstetricians and gynecologists, and facilitate continuous learning to advance knowledge, practice, and professionalism in women's health.

References

  1. 1 2 3 4 Seybold, Samantha L. (November 2022). "Not just 'bodies with vaginas': A Kantian defense of pelvic exam consent laws". Bioethics. 36 (9): 940–947. doi:10.1111/bioe.13084. ISSN   0269-9702. PMC   9826341 . PMID   36067372.
  2. 1 2 Bose, Devna (2024-04-01). "Hospitals must obtain written consent for pelvic and similar exams, the federal government says". AP News. Retrieved 2024-08-29.
  3. ↑ Ubel, Peter A.; Jepson, Christopher; Silver-Isenstadt, Ari (February 2003). "Don't ask, don't tell: a change in medical student attitudes after obstetrics/gynecology clerkships toward seeking consent for pelvic examinations on an anesthetized patient". American Journal of Obstetrics and Gynecology. 188 (2): 575–579. doi:10.1067/mob.2003.85. ISSN   0002-9378. PMID   12592274.
  4. 1 2 Friesen, Phoebe (2018-10-30). "Why Are Pelvic Exams on Unconscious, Unconsenting Women Still Part of Medical Training?". Slate. ISSN   1091-2339 . Retrieved 2023-12-05.
  5. 1 2 3 4 Goldberg, Emma (2020-02-17). "She Didn't Want a Pelvic Exam. She Received One Anyway". The New York Times. ISSN   0362-4331 . Retrieved 2023-12-05.
  6. 1 2 Barnes, Shawn S. (October 2012). "Practicing Pelvic Examinations by Medical Students on Women Under Anesthesia: Why Not Ask First?". Obstetrics & Gynecology. 120 (4): 941–943. doi:10.1097/AOG.0b013e3182677a28. ISSN   0029-7844. PMID   22996113.
  7. 1 2 Kaur, Karampreet; Salwi, Sanjana; McNew, Kelsey; Kumar, Nimisha; Millimet, Hannah; Ravichandran, Niharika; Tytus, Karla; Zhang, Angela Y.; Garrett Wood, Angelica; Grimm, Barry; Fairbrother, Erin L. (2022). "Medical Student Perspectives on the Ethics of Pelvic Exams Under Anesthesia: A Multi-Institutional Study✰". Journal of Surgical Education. 79 (6): 1413–1421. doi:10.1016/j.jsurg.2022.05.015. ISSN   1878-7452. PMID   35672245. S2CID   249382859.
  8. 1 2 "APGO Releases Statement on Teaching Pelvic Exams to Medical Students". Association of Professors of Gynecology & Obstetrics. Retrieved 2023-12-05.
  9. 1 2 Desjardins, Lisa; Mufson, Claire (2023-02-11). "Why more states are requiring consent for pelvic exams on unconscious patients". PBS NewsHour. Retrieved 2023-12-05.
  10. ↑ Hendrickson, Samantha; Bedayn, Jesse (2023-05-20). "More states are requiring patients to give consent for medical students performing pelvic exams". AP News. Retrieved 2023-12-05.
  11. ↑ Plake, Sarah; McCormick, Lisa (2022-10-03). "Without consent: Pelvic exams under anesthesia still happen without patient knowledge". KSHB 41 Kansas City News. Retrieved 2023-12-05.
  12. ↑ Zuchelkowski, Benjamin E.; Eljamri, Soukaina; McDonnell, Jill E.; Varma, Bhavya; Stern, Natalie G.; Rothenberger, Scott D.; Arora, Kavita Shah; Chang, Judy C. (2022). "Medical Student Attitudes on Explicit Informed Consent for Pelvic Exams Under Anesthesia". Journal of Surgical Education. 79 (3): 676–685. doi:10.1016/j.jsurg.2021.12.013. ISSN   1878-7452. PMC   9064935 . PMID   35058165.
  13. ↑ Green, Hannah Harris (2019-06-26). "Med Students Are Doing Vaginal Exams on Unconscious, Non-Consenting Patients". VICE. Retrieved 2024-08-28.
  14. ↑ "More states require patient consent for students to perform pelvic exams". ny1.com. Retrieved 2023-12-05.
  15. ↑ Cheng, Mira (2024-04-01). "Written patient consent required for sensitive exams, HHS guidance says". CNN. Retrieved 2024-08-28.
  16. ↑ "France to ban vaginal exams without consent". The Local. 2015-10-29.
  17. ↑ "New rule on rectal and vaginal exams". www.connexionfrance.com. 2016-11-30. Retrieved 2024-08-29.
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