Consent should be mandatory
September 24, 2018 6:54 PM   Subscribe

Tens of thousands, perhaps hundreds of thousands of women around the world have had pelvic exams while under anesthesia, without their consent or being informed, sometimes with multiple medical students doing an exam each on a single patient. In 2014, The American College of Physicians released a paper suggesting that pelvic exams were not an effective diagnostic tool, and yet, hospitals continue to let medical students get inside any woman under anesthesia, including procedures unrelated to reproductive health.

A study at University of Oklahoma “found that a large majority of medical students had given pelvic exams to gynecologic surgery patients who were under anesthesia, and that in nearly three quarters of these cases the women had not consented to the exam.” Medscape references a study done in Canada found that 72 percent of med students admitted to having done a pelvic exam on an anesthetized patient. A common argument for these non-consensual pelvis exams is that many patients would say no.
posted by SecretAgentSockpuppet (87 comments total) 57 users marked this as a favorite
 
A reminder that RAINN is here to help if you're feeling overwhelmed by the last ... however long this has been going on.

And Bella Donna, over in the What the fucking fuck is fucking going on thread, posted this collection of MeFi Self Care links with cute puppies and assorted soft and kind things.
posted by SecretAgentSockpuppet at 7:00 PM on September 24, 2018 [20 favorites]


A common argument for these non-consensual _________ is that many _________ would say no.

JFC. This is 2018 expressed as a Mad Lib. Or maybe a Cards Against Humanity card.
posted by ricochet biscuit at 7:15 PM on September 24, 2018 [52 favorites]


Shouldn't part of being trained as a good gynecologist be how to develop a level of trust where a pantient consents to a pelvic exam?

I wonder how many non-consentual prostate exams were given.
posted by East14thTaco at 7:25 PM on September 24, 2018 [33 favorites]


...I just had laparoscopic gyno surgery to diagnose endo. I... need to talk to my doctor. I'd like to think she wouldn't do this. I also know that UCSF is a teaching hospital. fuck.
posted by Homo neanderthalensis at 7:30 PM on September 24, 2018 [4 favorites]


Oh thank fuck this is illegal in California.
posted by Homo neanderthalensis at 7:31 PM on September 24, 2018 [42 favorites]


I’m just going on record, having attended the most old school ivory tower grey-haired white male dominated Med school in the U.S., and I find this horrifying and surprising. I’ve never seen it, I’ve never heard of it. (We had a women’s health collective teach us and male prostate exams were done with volunteers.) In the teaching medical center I’m affiliated with now I’m not connected to this part of Med student education, but I’m sure as hell going to ask about it now. This is so black and white unethical I am amazed at how easy and widespread these articles found the practice to be. I’m imagining being a cowering med student and being told to do this by the person who is grading you and can kick you out of the OR. This shit shouldn’t have to be legislated, but apparently it needs to be legislated. What the fuck.

I agree that there is no reason to be doing screening pelvic exams, except for cervical cancer screening the way it’s currently being done in the US, and honestly, that’s probably going to change in the next decade or so.

That having been said, Med students, at least those going into primary care, gyn, and ER need to know how to do this, not for screening (which if it’s not indicated, is literally an assault, even if consented to on the “recommendation” of a doctor) but to evaluate a person with concerning symptoms. Three times now, I’ve diagnosed ovarian cancer that didn’t show up on the scans and I persisted in looking for it on the basis of my examination. One of those people even lived because it was an early diagnosis. Pelvic inflammatory disease is a relatively common thing that can only be diagnosed confidently with a skilled pelvic exam. But I’ve had people who have refused pelvic exams when I thought it was an important part of the evaluation and you know what? No means no, even in medicine, and all you can say is “I respect your decision and we’ll do the best we can without that part of the evaluation.”

But under anesthesia with knowledge or consent? Again, what the fuck. I’m surprised that no OR nurse or anesthesiologist or scrub tech narced on these fuckers. Even if you’re an evil bastard, the legal liability alone should make you think twice.
posted by Slarty Bartfast at 7:35 PM on September 24, 2018 [94 favorites]


Oh my God. I've had surgery under general anesthesia three times (first time when I was 13), and it's legal in my state. Who the fuck would think this was okay? Jesus.
posted by lovecrafty at 7:48 PM on September 24, 2018 [6 favorites]


Soon they're going to stop doing procedures under anesthesia anyway so this won't be a problem anymore.
posted by bleep at 7:51 PM on September 24, 2018


...I volunteered to receive extra gynecology exams to help care providers learn about doing them on trans guys. The organizers turned me down after I answered screening questions. Put up some $&?!@ flyers, people will do this thing willingly. For fuck's sake.
posted by bagel at 7:53 PM on September 24, 2018 [40 favorites]


calling rape (or sexual assault depending on your jurisdiction) an "unauthorized pelvic exam" is amazingly offensive and there is no excuse for anyone to repeat this aggressive attempt at euphemizing and medicalizing assault just because the articles do. And the articles shouldn't. Murder doesn't turn into "unauthorized vivisection" just because it's a doctor doing it.

Consent is the only distinction between a standard gynecological exam and an assault. The perpetrator learning something from it is of no more significance than another kind of perpetrator taking physical pleasure from it. Doctors no more have special rights to commit sexual assault because it's professionally advantageous than cops have special rights to commit murder for the same reason. which is to say: de facto, they do. we need to not help them by conceding their arguments and accepting their own terms for what they do.
posted by queenofbithynia at 7:53 PM on September 24, 2018 [91 favorites]


This 2003 Washington Post article about the practice has a lot of jaw-dropping quotes. (Some direct, some paraphrases; some about pelvic exams more generally yet still in the context of discussing whether consent is necessary.)

“There is no rape content to it”

“It’s the consumers who have driven this as an issue”

“There is no substitute for the operating room lessons learned by examining women who are unconscious”

“I never heard of anyone out of some kind of respect for the patient just limiting it to a few”

“There is no way around the need for future doctors to practice pelvic exams”

Pure unadulterated misogynistic rape culture. From the same folks that pledged to first do no harm.
posted by somedaycatlady at 8:09 PM on September 24, 2018 [39 favorites]


what the fuck
posted by turbid dahlia at 8:25 PM on September 24, 2018 [8 favorites]


with stuff like this, who needs the Milgram experiment? it's right here. Authorities say it's okay. So med students do it. And then they say it's okay, because they did it, and they had to do it.
posted by BungaDunga at 8:26 PM on September 24, 2018 [14 favorites]


Oh my God. I've had surgery under general anesthesia three times (first time when I was 13), and it's legal in my state.

My first reaction exactly. How many times have I been under general? How well did I know each surgeon? Did I have any discomfort Down There after any surgery? Jiminy tap dancing Cricket on a pancake.

And that WaPo article! I can't even.

Add this to being body-shamed and not being taken seriously to the list of reasons for women to distrust the medical establishment.
posted by The Underpants Monster at 8:58 PM on September 24, 2018 [7 favorites]


From the WaPo article: "Still, he said he has no plan to amend the hospital's policies. "I'm a policy minimalist," he said."

Are you fucking kidding me? A 'policy minimalist' when it comes to patient consent?

I wish any of these articles had quotes from a lawyer, ideally both civil and criminal. Personally, I think everyone involved with this practice should be in jail.

The idea that if consent were asked then they couldn't do the thing they want literally could justify any crime, starting with theft, ending with murder.

The fact that these exams are not medically needed makes this even more obscene than I could imagine.

This practice, as it exists, reflects upon the entire profession. I will never side-eye someone who says "I don't trust doctors" again.
posted by el io at 9:04 PM on September 24, 2018 [23 favorites]


The practice is abhorrent, but I have a nitpick about the wording in FPP.

The paper linked states that pelvic exams are not an effective *screening* tool, that is, it is not sensible to do a pelvic exam on everyone without symptoms on the off chance of diagnosing serious disease. This is different from pelvic exams being a *diagnostic* tool, ie using pelvic examination to gather information about an illness in a woman presenting with symptoms.

Throwing the baby out with the bathwater and saying that pelvic exams are never indicated is misleading and potentially harmful to women by giving them inaccurate impression about what is required to investigate a gynaecological issue.

The paper has been misunderstood in the current context. The inappropriateness of examination without consent has nothing to do with the use of it as a screening tool. Examination without consent by medical students is not a procedure being done for a health benefit and we don't use those metrics to decide whether it's appropriate or not.
posted by chiquitita at 9:33 PM on September 24, 2018 [11 favorites]


I think there's a simple way of telling whether doctors themselves believe their own bullshit justifications for this practice: did they keep records of the patients upon whom they performed these abuses?

If not, they're lying; in the unlikely event they did keep records, it might be very interesting to compare UTI rates with appropriately matched controls.
posted by jamjam at 9:34 PM on September 24, 2018 [13 favorites]


We had a women’s health collective teach us and male prostate exams were done with volunteers

For those who aren't familiar with them, there are teaching associates that travel to different med schools in order to show students how to perform pelvic and prostate exams. As part of the process, they offer their own bodies to serve as practice patients. I was introduced to this concept by some med school friends, who assured me that it's a real thing: there is indeed a guy who goes around to all the local medical schools each year, teaching students how locate the prostate, getting them to practice on his own anatomy. It's a great idea, though I can't pretend it's not hilarious knowing there's a guy out there who makes his living that way.
posted by dephlogisticated at 9:44 PM on September 24, 2018 [20 favorites]


Oh my god, how horrific. And I can only imagine the eye rolling and patronizing comments that would greet any woman who dared to ask if this might happen during her procedure under anaesthetic. I bet she'd have "Hysterical" or maybe "continues to be paranoid" written in her chart.

Burn it down, burn it all down.
posted by hurdy gurdy girl at 9:58 PM on September 24, 2018 [24 favorites]


So uh... *when* was this outlawed in CA? Because I have had a LOT of surgeries over the years and so has my mom and while I'm 99% certain my latest was ok I am still kinda freaking out and I'm having trouble accessing the PDF of the study...
posted by Homo neanderthalensis at 10:04 PM on September 24, 2018


In the lead-up to my wife's pregnancy, it was discovered that she had a fibroid (a common kind of benign tumor) near one fallopian tube. She was referred to an obstetric surgeon (I think? Maybe some other kind of surgeon?), a 30-ish man with a baby face who glanced briefly at a grainy ultrasound print-out and then told her she should have that ovary removed and when would she like to schedule that? He was pushy. She and I sat there dumbfounded and horrified. Her OBGYN had not suggested anything like this would be necessary, and here this guy was ready to operate right now. Fuck that. We had some more imaging done and it turned out the fibroid was not impinging on anything and it was fine. Two children later, it is still fine. It's very easy for me to imagine that guy deciding to do random pelvic exams on any anesthetized woman unlucky enough to cross his path.
posted by qxntpqbbbqxl at 10:13 PM on September 24, 2018 [5 favorites]


I'm sorry- what? What the everloving fuck?

I will 100% be asking my doctor about this.
posted by fshgrl at 10:15 PM on September 24, 2018 [2 favorites]


Having been under general anaesthesia several times since the age of 5, and wide-awake for at least one “non-consensual pelvi[c] exam” at age 22, and working now as an accountant for the OBGYN wing of a teaching hospital, I...just wish I didn’t know any of this. I wish the one time I do remember, I could retcon out of my memory. I wish I hadn’t seen this today. I want my ignorance back and my memory back underwater where it belongs.

It is admittedly cowardly and spineless of me but I never think about it when I can help it, and since the fall of USA Gymnastics I just don’t have the valor to spare anymore. When asked to recount the abuse I’ve survived, this is the part I black out. And I’m not in one of the “good states,” so...how nice for those who are, I guess.

Mods, would an above-the-cut CW be too much to ask? I know I am just livid right now and I should not have clicked on it anyway, but an extra speed bump might have given me pause, so I could go on pretending it didn’t apply to me.
posted by armeowda at 10:18 PM on September 24, 2018 [10 favorites]


Just a reminder that pelvic exams are not recommended for asymptomatic people, yet doctors still require them.
posted by Violet Hour at 10:25 PM on September 24, 2018 [4 favorites]


Would I let med students practice simple procedures on me while I was fully alert? Maybe. But I would never consent to anyone doing anything to my body while I was unconscious (mandatory surgery aside). That’s just creepy—you’re not conscious to know what they’re doing, how long they’re doing it for, whether they’re taking extra liberties, you can’t tell them if they’re hurting you, etc, etc.

I can’t think of any medical benefit to performing the procedure on unconscious people, though I guess students might feel more comfortable not being monitored by the patient during their first attempts. Still creepy as hell, and the patient should absolutely be asked for consent, with full awareness of the level of (in)experience of the student who will be working inside of them. Makes me think, there should be cameras in every OR, and each surgery patient should be given full footage from the procedure, to keep everyone in the room honest.

I’m not sure how this can be taken as anything other than an attack on the patients. And attacking a defenseless person—who may never realize what was done to them—or who did it—is one of the most cowardly/evil things I can think of.
posted by mantecol at 10:27 PM on September 24, 2018 [5 favorites]


So uh... *when* was this outlawed in CA? Because I have had a LOT of surgeries over the years and so has my mom and while I'm 99% certain my latest was ok I am still kinda freaking out and I'm having trouble accessing the PDF of the study...

Looks like the ban was enacted in California as Section 2281 of the Business and Professions Code, effective January 1, 2004, thanks to the passage of AB 663 back in October 2003.
posted by The Situationist Room with Guy Debord at 10:55 PM on September 24, 2018 [6 favorites]


Great, another reason to be terrified of anesthesia
posted by bq at 10:55 PM on September 24, 2018 [3 favorites]


So I was safe, but now I have to tell mom she might not have been. God I hate our medical system so goddamn much sometimes.
posted by Homo neanderthalensis at 10:58 PM on September 24, 2018


Looks like the ban was enacted in California as Section 2281 of the Business and Professions Code, effective January 1, 2004, thanks to the passage of AB 663 back in October 2003.

Shortly after the Washington Post article. I feel like there needs to be an update to that WaPost article, along with local papers around the country letting the populace know that this is still occurring in their states, along with a pointer to the California law.

This problem has been fixed (in California), and I honestly think that with enough sunlight on the practice by local media, the state legislatures will act. The public just needs to be made aware; with greater reach than Bust has (with all respect and thanks to Bust for their reporting on this).
posted by el io at 11:00 PM on September 24, 2018 [1 favorite]


This is utterly horrifying. Hospitals and doctors that pull that shit should have their accreditation yanked, and be prosecuted. It really should be a federal law, byt with THIS Congress and administration?
posted by happyroach at 11:51 PM on September 24, 2018 [1 favorite]


So since I have had three procedures done in a Canadian teaching hospital under general anaesthesia, I looked up the guidelines. According to the Canadian Medical Association Journal, it looks like they were changed in 2012, when I had the first one done, but the change merely stated that patients needed to give explicit consent if a medical student did the pelvic exam, and excluded other medical trainees like residents.

I don't even know how to react to this. I'm stunned.
posted by hurdy gurdy girl at 12:05 AM on September 25, 2018 [4 favorites]


well. that is fucked up like to the fucked up nth. i thought I was headed to bed. might need a drink on the way.
posted by mwhybark at 1:23 AM on September 25, 2018 [6 favorites]


This is shocking and bizarre. Why is it legal to perform any non-consensual, unnecessary procedure at all under anesthesia? Are there other procedures that are commonly performed with similar justifications? Can you give a conscious patient in your office a pelvic exam by force without their consent? If not, what's the legal difference?
posted by value of information at 2:41 AM on September 25, 2018 [16 favorites]


As a medical student (2003), I was told to do this by one gyn-onc surgeon. I am ashamed to say, I didn't have the confidence to tell her no. It is definitely not done at my hospital today.
posted by Easy problem of consciousness at 3:04 AM on September 25, 2018 [13 favorites]


Well this is a fucking delight to wake up to.

PoliSci people ... this would be a state legislature issue, yes? So I'd contact my state assemblyperson and my state senator to get the 'change this' ball rolling?
posted by kimberussell at 3:58 AM on September 25, 2018 [1 favorite]


PoliSci people ... this would be a state legislature issue, yes?

Mostly, but it would probably be possible to ban it federally too.
posted by GCU Sweet and Full of Grace at 4:23 AM on September 25, 2018 [3 favorites]


This goes a long way toward explaining the eye-rolling attitude that many gynecologists have toward patients who have been sexually assaulted. I mean, if you’ve already done that yourself I would imagine that your empathy is pretty limited.
posted by corey flood at 5:50 AM on September 25, 2018 [23 favorites]


This is restricted to obgyn surgeries, right? NOT THAT IT MAKES IT OKAY. I'm just looking for clarification. When I had the tumor in my face removed and was under anesthesia, do I need to worry about whether or not I was violated?

This is horrific.
posted by cooker girl at 5:56 AM on September 25, 2018


Fuck. I stopped going to the gynecologist over 25 years ago. I know there are preventative healthcare reasons to continue annuals. I just couldn't stand the thought of my creepy male gynecologist poking around my nether regions any more. Yes I know there are female gynecologists. I just...I just won't do it anymore, health be damned.
posted by yoga at 6:03 AM on September 25, 2018 [15 favorites]


yoga, I feel you. I get it.
posted by cooker girl at 6:07 AM on September 25, 2018 [11 favorites]


This is a facebook comment from a friend of a friend on this issue, and speaks to your question, cooker girl:

"Oh yes. Minor knee surgery and a resident is present? pelvic exam. Having your tubes tied laparoscopically and a resident is around? Pelvic exam. I used to do teaching at the U of Mn medical school and you wouldn’t believe how many internal medicine surgical residents thought they ought to be able to opt out of the Ob/Gyn teaching sessions because their supervisors had “taught them” on an unconscious patient. It’s real."
posted by libraritarian at 7:06 AM on September 25, 2018 [14 favorites]


This is restricted to obgyn surgeries, right?

unfortunately in my experience, no.
posted by poffin boffin at 7:25 AM on September 25, 2018 [5 favorites]


WHAT THE FUCK.

Also, there is so much around giving a pelvic exam that I would think would be SUPER DIFFERENT about giving one to an awake, aware person, that I don't even get how this is good preparation for doing actual patient pelvic exams in the future.

Also, WHAT THE FUCKING FUCK.
posted by augustimagination at 7:28 AM on September 25, 2018 [1 favorite]


Looks like I'll be making some phone calls today.
posted by cooker girl at 7:32 AM on September 25, 2018 [2 favorites]


Someone posted a tweet from a guy saying "How do women not die of rage aneurysms every day?" Oh, wait, that was because of the story of the guy who choked a woman unconscious, masturbated onto her body, left her on the side of the road, and got NO JAIL TIME.

I don't know how we don't stroke out every day. We certainly have enough reasons to do so.

Crone Island, here I come.
posted by corvikate at 7:57 AM on September 25, 2018 [34 favorites]


im not going to a fucking island. they can go to an island. they can go in the fucking ground.
posted by poffin boffin at 8:06 AM on September 25, 2018 [76 favorites]


This is going to be my postcard issue for today for state and federal representatives.
posted by bq at 8:54 AM on September 25, 2018 [3 favorites]


Thanks for posting this. I'd always rather know, I think. I've been under three times, twice at a university hospital, so I'm sure this probably happened to me. It's affecting me more than I expected. You think you're a regular person, and then you get reminded that you don't even own your body.
posted by heatvision at 9:01 AM on September 25, 2018 [15 favorites]


This is mindblowing. I've heard about it before, but still mindblowing.

I mean, how do you not get that doing this without actual informed consent is literally sexual assault?
posted by uberchet at 9:14 AM on September 25, 2018 [1 favorite]


I'm deciding whether or not I want to find out. Like, I thought I was already at maximum "want to set things on fire with my brain" and will knowing actually help.

FUCK.
posted by Orange Dinosaur Slide at 9:16 AM on September 25, 2018 [3 favorites]


Joy. I still remember crying when my doctor kept doing INCESSANT pelvic exams when I was in labor a million years ago. Shouldn't have bothered with the tears - they could have given the entire medical staff access as soon as I went under for surgery.

It's mental warfare at this point. They want women to just give up. Some days, I am far too close.
posted by Space Kitty at 9:22 AM on September 25, 2018 [6 favorites]


How would one find out if this had been done? Do they put it in the medical records? I suspect not.
posted by Mavri at 9:26 AM on September 25, 2018


Horrible, and I wish it surprised me.

The medical profession hates women. A gyno once insisted I have a transvaginal ultrasound, even after other tests and scans strongly indicated endo and I explained that I had severe vaginismus. He wouldn't take no for an answer, and I tried to be game to get it over with, but couldn't make it. I was so fortunate that the tech was a sympathetic woman who sensed my unwillingness, seemed reluctant to do it at all, and stopped when I started screaming. Those doctor's orders felt kinda like violence against both of us.

As a cancer survivor and someone who has had a TAH, I've been under general anesthesia several times. I don't doubt at all that I've been a victim of this. I was already a sexual assault survivor at the age of five; I know how others would treat my body if they knew they could get away with it.
posted by the liquid oxygen at 9:36 AM on September 25, 2018 [19 favorites]


Just horrific. After a terrible birthing experience 8 years ago I just cannot bring myself to get a smear, the thought of something like this happenning under anaesthesia just terrifies me. Rage aneurysms indeed. Do no harm is a joke more than ever.
posted by RandomInconsistencies at 9:43 AM on September 25, 2018 [7 favorites]


I'll be honest, I thought long and hard about posting this. And spent considerable time trying to frame it in such a way that wasn't incoherent rage screaming.

I am aware of how triggered most of us are, and I did not want to make that worse. But I weighed that against the fact that with knowledge, perhaps we can stop this.

I am truly sorry for adding to anyone's trauma.
posted by SecretAgentSockpuppet at 9:50 AM on September 25, 2018 [23 favorites]


yeah i am rethinking my planned fpp for today as well bc i'm just tired.
posted by poffin boffin at 10:01 AM on September 25, 2018 [2 favorites]


My intent in posting the following is to provide some possible hope. It is IN NO WAY meant to dismiss or minimize the atrocities perpetrated upon women by the medical profession.

For the past 11 years, up until the beginning of this year, I was a labor & delivery nurse. I worked both in small community hospitals and in large academic teaching institutions. The overwhelming majority of my patients were conscious throughout the time they spent in my care, but that is obviously no guarantee against assault or coercion.

I never saw anyone receive a pelvic exam to which they did not consent. On the contrary, I saw over and over again that providers told women before an exam, "If for any reason you want me to stop, I will stop." And then they did, immediately, if the woman said stop. I have personally said and done the same during cervical dilation checks during labor.

Now I'm an operating room nurse. I work with all specialties in a large teaching institution; because of my previous experience in L&D, I'm frequently assigned to circulate or scrub in gyn surgery cases. The vast majority of my patients receive general anesthesia.

Before every surgery, I meet my patient or their legal representative and with the signed consent form in hand we review it together. I confirm their understanding of what the surgical team will and will not be doing during the procedure. If they seem even slightly unclear about anything, I page the surgeon and we don't go back to the OR until the patient or their legal representative feels that they have the level of understanding they require. NOT ONE THING that is not on the consent (short of lifesaving procedures) is done.

An example: Friday, the gyn chief resident realized that our current patient was due for a Pap. The junior resident suggested that we perform it while the patient was under anesthesia. The chief resident immediately said, "Absolutely not. She wasn't consented for it."

Would any harm have come by doing the Pap then? It's possible but unlikely. Would the patient have been grateful that we did it while she was already in stirrups and comfortably asleep? Maybe. But we, the medical team, have NO right to decide that. Only the patient or their legal representative has the right to determine what happens to their body. Not consented for it? Then it's not done.

Unconsented pelvic exams will never happen in any room in which I'm present in any role. Period. I am willing to be fired for insubordination if necessary in order to defend my patient's bodily autonomy. The single most important part of my job as a nurse is to protect you. If you are my patient, I will protect you.
posted by jesourie at 10:44 AM on September 25, 2018 [102 favorites]


> I’m just going on record, having attended the most old school ivory tower grey-haired white male dominated Med school in the U.S., and I find this horrifying and surprising. I’ve never seen it, I’ve never heard of it. (We had a women’s health collective teach us and male prostate exams were done with volunteers.)

I wonder how much the attitude about this practice varies from "why the fuck would we do this no never" to "oh sure, super convenient" between regions, different uni hospitals, and different supervising physicians. This is the crux of the problem with medical education, isn't it? We've got a variety of different conventions and judgement calls in a field that relies heavily on the power of authority, hierarchy, and paternalism. For practices like this which cross ethical lines, there's too much incentive to step around them or sweep them under the rug rather than question them openly.

Here in Philadelphia, I guess would be a little surprised if it's a super common practice because I have witnessed the alternatives in several hospital settings. I have been asked during my regular gyn exam if a med student could also perform a pelvic (I consented). Also, I know numerous people who have served as model patients/volunteers for pelvic and prostate exams, some of whom were themselves pursuing nurse practitioner or other medical degrees -- it's decent extra cash if you're the sort of person who isn't easily embarrassed. Lastly, this isn't proof or anything, but I've been under anesthesia twice in hospitals here for day surgeries, and I really don't believe that I got any extra non-consensual exams, based on the way the whole thing was set up and the way both surgeons ran things. On the other hand, I am a nosy, articulate white woman with lots of informed questions for medical personnel, so perhaps it was just deemed too great of a risk to commit medical assault on me.
posted by desuetude at 10:46 AM on September 25, 2018 [3 favorites]


Where I've worked, in no contexts do we explicitly ask for consent for students' specific roles during surgery; they do lots of things you would think are icky if awake. When I was in medical school (in the US ~ 2007), we were explicitly told not to do this in general surgery and that we would be shielded from any repercussions from staff who asked us to. The only place where students would occasionally do pelvic exams under anesthesia (that I was aware of) was is gynecologic surgery and family planning where a vaginal exam is part of the surgery. The (more) defensible justification was that patient are explicitly told about med students being taught during the surgery, and the students are necessarily taught to do everything involved. They also do ano-rectal exams in colorectal procedures if that's an anticipated part of the procedure they're learning about. I'm very seldom near a gyn OR nowadays, but have never encountered a student pelvic exam in other surgical contexts.
posted by a robot made out of meat at 10:54 AM on September 25, 2018 [1 favorite]


This first came on my radar more than 15 years ago because of a University of Toronto study (published in 2001) which found 47% of 108 medical students felt pressured to act unethically in a clinical setting and cited practicing gynecological and other procedures on unconscious patients without prior consent as a particular cause of concern. I recall reading about it in the papers - people were upset, medical students confirmed that this was still a reasonably common practice, and the mental image that stuck with me was a description of students queuing up to perform pelvic exams all on the same unconscious patient. This was long enough ago though that I'm having trouble finding online copies of the stories I read in Canadian newspapers, but here's an article that references the UofT study: Using the Unconscious to Train Medical Students Faces Scrutiny - Wall Street Journal, 2003.

Apparently, despite the news coverage, nothing much changed. A 2006 guideline published by the Society of Obstetricians and Gynaecologists of Canada and the Association of Professors of Obstetrics and Gynaecology stated that medical trainees did not require explicit prior patient consent for pelvic exams performed for educational purposes.

In 2007 Canadian medical student David Wainberg was asked, as part of his rotation in obstetrics and gynecology, to perform a pelvic exam on an unconscious woman. He refused because he felt doing so without consent would be unethical. David's older sister Sara Wainberg was also a medical student, and when he told her about his experience she realized "I had done this numerous times in my training and it had never occurred to me that it might be unethical.". She polled her fellow students at McMaster University and found that 72% of them said they had also done exams on unconscious patients without consent.

Dr. Sara Wainberg went on to study the issue further during her residency. She and fellow researchers polled 102 patients at the Calgary Pelvic Floor Disorders Clinic, finding that:
  • 81% of the women polled were not aware that a student might do a pelvic exam in the operating room
  • 72% expected to be asked for consent before such an exam was done

As mentioned previously it is a common argument that if women are asked for explicit consent before trainees are allowed to perform pelvic exams they will refuse and the trainees will lose out on needed practice opportunities. But the researchers found that 62% of the women polled would consent if asked (and an additional 5% would consent if they could be assured the exam would be done by a woman).

Details of Dr. Wainberg's story & research hit the Canadian news in 2010, and once again there was outrage that pelvic exams were being performed by trainees for educational purposes on anesthetized women without their explicit consent. Canadian medical schools defended their practices, saying that when patients at teaching hospitals signed general consent forms to allow trainees to participate in their surgeries they were implicitly consenting to pelvic exams by trainees. The Canadian public was not amused.

In late 2010, in response to public pressure, the Society of Obstetricians and Gynaecologists of Canada and the Association of Professors of Obstetrics and Gynaecology updated their 2006 guideline to require explicit verbal consent from patients before any pelvic exams are conducted by students.

In 2012 the issue was in the news again because a report published in the Canadian Medical Association Journal expressed concerns that the new requirement for explicit verbal consent only applied to pelvic exams performed under anesthesia by medical interns and did not cover exams performed by medical residents.

Time to end pelvic exams done without consent - The Globe and Mail, Jan 28th 2010
When unknowing, hardly implied - The Globe and Mail, Jan 31st 2010
Doctors add required consent to pelvic exam policy - The Globe and Mail, Sept 15th 2010
Pelvic exams without consent still possible under new guidelines: report - The Globe and Mail, March 26th 2012
Consent policy for pelvic exams by medical students flawed, legals analysts say - The Toronto Star, March 26th 2012

TLDR, I am so tired of this shit.
posted by Secret Sparrow at 11:49 AM on September 25, 2018 [31 favorites]


This is one of many reasons you always need to bring a relative or friend to the hospital if you are going. Never go to a hospital alone if you can avoid it.
That said, when I gave birth to my first baby, it was an experiment and the room was full of people including some students. I don't mind, at all. Which is weird because I am very shy. I just felt that if I could help future mothers, that would be more important than my own issues.

On the other hand, something I've thought about regarding Kavanaugh, some guys in my high school class wanted to study medicine so they could grope women. For real. They realized that most women with health issues are old, so they changed studies, but yuck. I'm always a little tentative with male doctors until I get to to know them.
posted by mumimor at 11:55 AM on September 25, 2018 [8 favorites]


I just can’t get it out of my head today that thousands of women have woken up from non-gynecological, routine surgeries feeling genital discomfort and wondering whether they had been sexually assaulted while unconscious. Even if only one in twenty times there’s discomfort afterwards that’s thousands of women.
posted by bq at 12:24 PM on September 25, 2018 [9 favorites]


> It's affecting me more than I expected.

Yeah. I think about it every so often and want to vomit. I just don't know why they do this. There are absolutely women who would willingly serve as pelvic exam... examples? Either for a fee (they still pay students who participate in medical trials, don't they?), a free pap, or just an altruistic desire to help.

This makes me so fucking angry.

I haven't had a male gyno since an exam I had 20 years ago, when the doctor was performing a breast exam and he kind of... cupped my breast and asked if I was seeing anyone. I was still in the stirrups from my pelvic. It felt weird, but in that gray area where I felt like if I brought it up, I'd get a 'seems paranoid' note in my file.

Fuck.
posted by lovecrafty at 12:38 PM on September 25, 2018 [10 favorites]


SecretAgentSockPuppet I'm glad you posted this. The more people know, the more likely we can stop it.
posted by yoga at 1:04 PM on September 25, 2018 [15 favorites]


This is crazy. In the 1970s, my father failed a medical school class because he (and a whole group of others) refused to do perform exams on unconscious, unconsenting women. I always assumed that story was about how unenlightened things were back in the day. I had no idea this was still happening 40 years alter.
posted by attentionplease at 1:17 PM on September 25, 2018 [19 favorites]


props to your dad and his colleagues, attentionplease. Sounds like the start of a career as an excellent patient-centered doctor,
posted by chapps at 1:42 PM on September 25, 2018 [6 favorites]


a robot made out of meat: "Where I've worked, in no contexts do we explicitly ask for consent for students' specific roles during surgery; they do lots of things you would think are icky if awake."

I find your framing of this concerning. It's not about whether or not we find something "icky".
posted by Secret Sparrow at 1:50 PM on September 25, 2018 [25 favorites]


Um. WTF? I'm male. But I was anesthetized for a procedure when I was 8.
Years later, I learned I have PTSD from childhood.
Always were little bits of reasons to be suspicious of that situation. But that was 1965.
posted by Goofyy at 1:58 PM on September 25, 2018


Speaking as a man, if it benefits the future of medicine and my kid or his kid might benefit from the medical community's broader knowledge, I'm pretty happy for any part of me to be poked or prodded as long as I end up in the same reasonable shape I went under in.

Also speaking as a man, any doctor who has done this should be tried for and convicted of rape. Doctors who in any way advised or coerced a medical student under their tutelage to do this should get an automatic doubling of the sentence for just rape.

I remain shocked and amazed at what we're collectively comfortable living with when it comes to rape culture in America. It drives me crazy and I feel helpless to stem so great a tide.
posted by allkindsoftime at 1:59 PM on September 25, 2018


[medical students] do lots of things you would think are icky if awake

While I agree that medical student pelvic examinations would be significantly more likely to happen in gyn ORs given that many gyn surgical procedures are done in lithotomy and by their nature involve accessing the vaginal canal, it is a great deal more than "icky" that it happens.

There is a significant difference between medical students practicing a full bimanual pelvic examination on an unconscious patient without her consent and (for example) using a tenaculum inserted into the vagina and secured to the cervix as a uterine manipulator during a laparoscopic assisted vaginal hysterectomy. The latter is a necessary part of the planned surgery. The former is taking advantage of convenient patient positioning to learn to do something that is not evidence-based, and it is absolutely not OK.

I mean, medical students shouldn't do prostate exams during colorectal surgery just because the patient is in prone jackknife with their buttocks retracted. Medical students shouldn't do prostate exams during cystoscopy or ureteral stent placements just because the patient is in lithotomy.

Let's call the elephant in the room by name here: patients with prostates are identified (or misidentified, in the case of trans or intersex women) as men.
posted by jesourie at 2:12 PM on September 25, 2018 [11 favorites]


I just can't believe that anywhere within the sentence primum no nocere there's some justification for conducting experiments on non consenting adults. What fucking world are we living in? Consent should definitely be mandatory. Full stop.
posted by Sphinx at 2:13 PM on September 25, 2018 [7 favorites]


This feels timely -- one of my online friends is in med school now and just had to do this and was so badly shaken. Almost everything about her experience has sounded excruciating and terrible, and she's suffering so much it's hard to encourage her to keep going with her schooling, even though I know she has the ability to be a really great doctor. This in particular intersected with her own personal issues, and she didn't feel like she had the authority to go against her higher-ups.
posted by epersonae at 2:28 PM on September 25, 2018 [5 favorites]


That's why it keeps happening; young medical students don't speak up because they're afraid; their instructors have signed on to the belief that it's right and even good to do; and the patients, well, they just don't tell them anything.

I have never been treated as badly and brutally by anyone as I was by medical staff during my son's birth. I experienced many of the same aftereffects of an assault victim. As far as I can tell from talking to other doctors, most likely it was entirely because it was simply more convenient for the doctor and staff, who had more important things to do than to use care when treating me and my son.

The maternal mortality stats? This nastiness? My experience? It's all connected.

I was never unconscious during that time, I suppose I should be grateful for that. But I suspect I came a lot closer to dying than I knew.
posted by emjaybee at 2:43 PM on September 25, 2018 [14 favorites]


Also, I'm just remembering this FPP from January on what happens to our consciousness under anesthesia. Terror. Just pure terror at all of this.
posted by augustimagination at 3:15 PM on September 25, 2018 [2 favorites]


Given how many IRB hoops researchers have to jump through just to even do basic stuff, it is truly astonishing that this terrible practice seems to have been grandfathered in from a earlier, more brutal time. I mean, doing this to unconscious patients under anaesthesia is pretty much the exact opposite of informed consent.
posted by mhum at 3:55 PM on September 25, 2018 [2 favorites]


Just asked my dad about this. According to him the University of Chicago stopped doing this in the 1970s, because of the student protests against the practice. They failed the class, but decided it was worth it. A little disobedience went a long way then, and I imagine it still could now....
posted by attentionplease at 4:22 PM on September 25, 2018 [5 favorites]


Why am I fucking well not surprised that this happens?
posted by BlueHorse at 4:40 PM on September 25, 2018


This is all horrifying. And totally free from the sort of informed consent rules that IRB regulations cover, because it’s not “human subjects research.” (Isn’t intended to contribute to generalizable knowledge.). There damn well ought to be professional standards and hospital policies in place to prevent this shit, though.

I was recently asked if a student could observe my IUD removal/replacement. I was hesitant at first because he was a man and I generally avoid male doctors. I then thought it over and decided it would be okay, but they said he’d just sit this one out, he’ll have other chances and my comfort was more important. That shouldn’t be an extraordinary level of care or concern for me to have received.
posted by Stacey at 4:58 PM on September 25, 2018 [11 favorites]


This is utterly horrifying. I am just livid. Though I don't live in the US now, I know and love many people who do who might have been affected by this. Might be.

If there are any Australian women wondering if the same thing happens here, I don't think so. The AMA's Patient Examination Guidelines and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists guidelines for gynaecological examinations and procedures. See also the program developed by the University of WA to give medical students more practice performing pelvic exams. Spoiler alert: mannequins and consenting teaching associates only.
posted by Athanassiel at 12:41 AM on September 26, 2018 [1 favorite]


Even in situations where medical students or nurses do report, nothing ever comes of it. I reported this on my end-of-course evaluation for OB/GYN and gave as many specifics as I could recall; never heard anything further. Given the culture of this school, I would not be surprised if the surgeon were still practicing and forcing medical students to assault unconscious women (and berating them if they hesitated or voiced concern).

On the other hand, my medical school class protested en masse a preclinical lecturer who used demeaning terms for intersex and trans people, and he was taken off the lecture rotation (and was quite old so probably had retired from clinical practice already), so maybe there's hope. But it has to come en masse, I think, like attentionplease's dad's story; individual reports get just ignored even if there's a bunch of them.

One of the medical school administrators at my hospital (a different place where where I trained) came to the last faculty meeting and told us that reported incidents of harassment (note: not assault) had almost doubled in the last year and they were investigating. No incidents from our specialty, and she couldn't share details about other specialties, but the overwhelming attitude was "Well, students are just not used to the culture of medicine, and they are jumping on the #MeToo bandwagon." WTF. I emailed her afterward to clarify, haven't heard back yet, but seriously WTF.
posted by basalganglia at 4:04 AM on September 26, 2018 [9 favorites]


As if jumping on the #MeToo bandwagon was a bad thing.
posted by The Underpants Monster at 8:15 AM on September 26, 2018 [4 favorites]


Well, students are just not used to the culture of medicine

Here's something that I wonder (and genuinely don't know the answer to): is this practice limited to just pelvic exams? Or are there other diagnostic procedures that laypeople would find super invasive that med students and residents practice on unconscious patients who have not given full informed consent for? Like, do they also do this with prostate exams? Or endoscopies?
posted by mhum at 9:51 AM on September 26, 2018 [3 favorites]


I want to add, though, that nearly every single attending I've worked with, including the gyn attendings when I was a student, have explicitly asked for patient consent before even having a student/trainee in the room, let alone involved in the procedure. And have respected a no. I hold myself to that standard now that I'm an attending. It was just this one gyn-onc surgeon, who was a bully in plenty of other ways, too -- but one serial assaulter is one too many.

mhum: it's not nearly the same thing, but the closest thing I can think of is having residents, rather than the attending physician, close the skin after a surgery. That's so innocuous compared to the pelvic exam, but the fact that I've typed and deleted that sentence multiple times, because it's "giving away a secret," tells you something about how fucked up the so-called culture of medicine can be sometimes.
posted by basalganglia at 1:47 PM on September 26, 2018 [2 favorites]


one of my online friends is in med school now and just had to do this and was so badly shaken. Almost everything about her experience has sounded excruciating and terrible, and she's suffering so much it's hard to encourage her to keep going with her schooling, even though I know she has the ability to be a really great doctor.

To be a great, a good doctor, or a merely adequate doctor, you must have the ability to say No when ordered to assault someone. Then, you must exercise that ability by choosing not to assault them. You must not lie to yourself or others about what you "had" to do.

Risking your whole career just to not assault one unconscious woman is an awful and unfair choice to make. but sometimes the only choice you have is to be a hero-martyr or criminal. there should always be a third choice, sure. we should always have the escape route of just being a regular person, hard-working and compliant and totally ok, not a hero or a villain. in an ideal world. but when abusive authorities leave only those two choices open, you pick one. and you don't fucking have to pick the wrong one. you aren't responsible for the situation but if you're not the one under anesthesia, you're not helpless to resist.

people do awful things under stress and coercion, especially when unprepared, and the ones who are sorry enough can sometimes make up for it and learn to be decent people again. this particular situation is one of the very, very few situations where rape can be understood and forgiven, with enough time and remorse and work - not for the supervisors giving the orders, who are beyond repair, but for the students obediently carrying the orders out. but not for the ones who can't let go of a story where they had to do it.

not just doctors but cops and soldiers and many others are inducted into abusive work cultures where they're told they have to do awful things to others in order to continue, to survive, to not be fired, to be part of the group, to be successful. some people always say no. with or without feeling like they had authority to do so.
posted by queenofbithynia at 10:48 PM on September 26, 2018 [16 favorites]


queenofbithynia, medical training is profoundly damaging to the personal agency of the student/trainee. It largely selects for rule-followers, then relies on systemic isolation from non-medical peers; during most clinical rotations (i.e. when this would be happening) you are also separated from your classmates, alone with your supervising attending and/or residents. Many young doctors attempt to cope with this by shutting down any human spirit completely, emerging from training as bitter patient-hating shells. I have a conviction that a lot of the burnout, depression, and suicide among physicians stems from the systemic moral injury of medical education.

Yes, absolutely, saying no to an order like this should be first principles for being a patient-centered doctor. But relying solely on a hero narrative is not going to change things, because most medical students are not heroes. They are not going to stand up and say No to an attending surgeon holding a scalpel. This isn't even about feeling like you have/don't have authority, or an external consequence like a bad grade or failing a class or not getting into the specialty of your choice. As was pointed out above, this is a fucking Milgram experiment.

We actually want to stop this from happening to real actual women? Every jurisdiction needs to pass a law making it clear that unconsented exams under anesthesia is both malpractice AND assault. Make that law highly publicized, both to the students and to their supervising attendings; have it reiterated by clerkship directors and department chairs. Require continuing medical education on assault, and medical ethics more broadly. (And real, in-person CME in a seminar-style room where you HAVE to engage with the topic, not some 600-person conference plenary or worse still, a webinar you play in the background while writing medication refills.) Make ethics a required course for both premedical and medical training. Have students read William Carlos Williams' "The Use of Force" (and there are probably other more contemporary texts) and bring in a literature professor to have a meaningful discussion about it. Help them find resources outside medicine for a sanity check. Believe women.
posted by basalganglia at 4:21 AM on September 27, 2018 [11 favorites]


I've written a comment down and erased it over ten times now. I don't really have the right words to respond to this. I am appalled and infuriated and disheartened.
posted by vegartanipla at 9:20 PM on September 27, 2018 [2 favorites]


They are not going to stand up and say No to an attending surgeon holding a scalpel. Then they shouldn't get to be in society at all anymore, let alone be doctors. RAPISTS SHOULDN'T GET TO BE PART OF SOCIETY AND HAVE RESPECTED CAREERS. Why is this so hard to understand?
posted by Violet Hour at 2:35 PM on October 2, 2018 [4 favorites]


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