Conversations We Shouldn’t Still Be Having: Pelvic Exams Under Anesthesia

By Rachel Walden |

In the October issue of the journal Obstetrics and Gynecology, a medical student writes of his discomfort with a practice many people may be surprised to learn still occurs — medical students practicing pelvic exams, without explicit consent, on women who are under anesthesia for surgery.

The student, Shawn Barnes, writes that the practice left him “ashamed.”

“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,” writes Barnes. “To my shame, I obeyed.”

He continues:

As a medical student, I am all too aware of the hierarchy that exists during training. My medical education experience has reinforced the notion that the medical student should not question the practices of those above him or her. I was very conflicted about performing an act that I felt was unethical, but owing to both the culture of medicine and my own lack of courage, I did not immediately speak out against what I was asked to do by residents and attendings.

His commentary, titled “Practicing Pelvic Examinations by Medical Students on Women Under Anesthesia: Why Not Ask First?,” is available only by subscription/purchase, or through a library, as is a related editorial in the same issue, “Pelvic Examinations Under Anesthesia: A Teachable Moment.”

Carey M.York-Best and Jeffrey L. Ecker, authors of the editorial, remark that no one knows how often these exams occur, and they point out that teaching hospitals, which are expected to train students, do ask patients for general consent for students to be involved in their care. However, they rightly note that blanket consent is inadequate when it comes to pelvic exams:

After all, consent forms at many teaching hospitals include a statement outlining the involvement of students in patient care. Yet we believe that, even if such phrases may meet the letter of recommended conduct, they often are overlooked and a few words on an already too-long form do not represent true informed consent.

Barnes also calls these forms inadequate, and he also doesn’t buy the argument that women should expect such things when they go to a teaching hospital:

We first must remember that patients tend to seek care at facilities that are geographically nearby, where their regular physician has privileges, or where their insurance is accepted. Consent forms at teaching hospitals tend to use language stating that medical students and residents may be involved in that case. That involvement is not specified.

Practicing pelvic exams on women under anesthesia purely for teaching purposes — not for the women’s medical benefit — is not a new practice. However, many may have assumed it had largely stopped, particularly after a 2003 study (which I discussed several years ago) drew a lot of attention to the issue, causing many medical schools to clarify their policies and/or seek women’s explicit consent. Several professional medical organizations have also denounced the practice.

The study was based on a 1995 survey of students at five U.S. medical schools. The researchers found that only about a third of the students thought it was “very important” to get consent prior to doing a pelvic exam. Students who had actually done an ob/gyn clerkship were even less likely to think consent was important. Almost 10 percent of those students actually responded that explicit consent was “very unimportant.” The overwhelming majority (90 percent) of the ob/gyn clerkship students had performed pelvic exams on women under anesthesia.

Back to 2012 — Barnes informs readers that as a result of a bill signed into law this past June, Hawaii (where he studies) will join California, Illinois, and Virginia in making “unconsented” pelvic examinations against the law. For those interested in learning more, his testimony is included among these documents supporting the Hawaii bill.

This may be an opportunity for advocacy in other states, where it may be possible to get similar laws passed.

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14 Comments

  1. Morgan says:

    “… teaching hospitals, which are expected to train students, do ask patients for general consent for students to be involved in their care.”

    The key word here is “care.” If anyone, male or female, is at a hospital for something which does not concern their genital health, and the consent form says that students will be involved in their “care” and “treatment,” they should be able to expect that the students’ involvement should be only with their care and treatment, not their genitalia.

  2. Rachel says:

    Just as a clarifying point, this should only be an issue when the surgery in question is pelvic surgery of some sort – although we wish that this wasn’t an issue at *all* and so didn’t need this sort of clarification.

  3. Sabrina says:

    “Just as a clarifying point, this should only be an issue when the surgery in question is pelvic surgery of some sort”

    So, is that *SHOULD* be an issue, or *IS* it only an issue with women undergoing pelvic surgery? Should we be worried if someone is getting her appendix removed (do they still do that?) or will be under anesthesia for any old reason?

  4. Rachel says:

    Sabrina – I’ve heard from clinicians that this only gets done when some type of pelvic surgery is being done, not during surgeries like appendix or tonsil removal. I don’t think it would hurt to ask surgeons about their policy or student involvement, though, before any procedure.

  5. Mark says:

    This is a complete outrage and should be considered as rape if the patient has not given proper consent prior to being made fully aware of the role of the student.

  6. pailrider says:

    In civilised society this classed as gang rape, but within the law, however this practise was suppossedly stopped, more lies for self gain. If my wife goes for an op, I intend to take advice from my lawyer, I do not want my wife gang raped by so-called medical professionals.

  7. pailrider says:

    Follow up, congratulation the doctor that posted this article, pity he didn’t stand up and be counted. Does anyone realise the outcome if newbies didn’t follow instruction from their piers, think about it, their piers did a procedure that newbies outlaw, where does that leave the piers, guilty perhaps.

  8. pailrider says:

    Rachel your reply to Sabrina is wrong, pelvic exam are done on non related operations, after any operation within reason! I spoke to a girl on yahoo about this, she said,when she woke up after an op felt very aroused.

  9. Mark says:

    I feel that new medical students need to be made aware that this is a BIG issue for a lot of patients, even though their patient, or their husband may seem ok after an intimate procedure or examination, he probably isn’t, but chooses to stay quiet.

    First is the doctor/patient imbalance of power (especially when it’s a female patient and a male doctor) she probably looks at him as an ‘authority figure’ and does not question any thoughts, motives, or actions. Women have been taught from their mothers and grandmothers that the male doctor is the only male alive that can turn off from being male during an intimate examination or procedure. I feel that this idea has also been relayed to husbands and boyfriends too, who from what I have found, for the most part, choose to ‘suffer in silence’ rather than make an issue of, mainly due to male pride and machoism (as men, generally, we do not want to admit that there is a problem that we are having a hard time in handling).

    At every intimate female exam, or procedure, the doctor should raise the issue and ask if a female provider would be ‘preferred choice’. If this does not happen and the woman or couple can feel intimidated into accepting the male provider. Later, the relationship can suffer due to the invasion of the intimate space between the husband and wife. I know first hand of several relationships that have ended because of this, and I’m sure that if the truth was really known many relationships suffer everyday from this. A gynecologist should not send a woman home with the cost of a broken intimate relationship.

  10. Mark says:

    Just some clarifying points:

    – Every woman undergoing a pelvic procedure is consented for exam under anesthesia. This is not done for fun, but it order to fully appreciate and understand the anatomy before using any instruments, etc.

    – The exam is performed only by the surgical team – the team who will be directly operating on the patient. This includes the attending, resident, and medical student. Just like the rest of the procedure, the exam is a teaching moment for the residents and students.

    – Pelvic exams are not performed (unless necessary) during cases that do not involve pelvic anatomy. The last thing the GI team wants to do is walk the medical student through a pelvic exam (this would also require positioning the patient in a completely different way).

  11. Thank you for shining light onto this issue. And very well done may I say. I’m glad Mr. Barnes had the courage to speak out about his experience instead of allowing it to continue to be the norm. I am hopeful that Ohio will follow Hawaii’s lead and act on this topic with the legislature. How hard would it be to insert another initial line or check box on a form so that the patient could consent to such procedure if they wished?

  12. Kori says:

    @Mark – Not completely true. I went in for a laparoscopy for endometriosis in 2008. Prior to surgery I changed my consent form to state that only my surgeon could perform the surgery, and that only he is allowed to perform a pelvic exam on me. Right before I went in he tried to get me to take these stipulations out by claiming they were unnecessary as the hospital does not permit these practices. I refused. Later I found out through a newspaper article that my surgeon is actually the head of the resident program, and that, YES, they do indeed practice pelvic exams on anesthetized women.

    If all hospitals and doctors were ethical this wouldn’t be a concern. Informed consent is extremely important. If the residents and med students wish to preform any kind of physical exam they should ask for consent. They do not have any right to have a “teaching experience” on a patient without informed consent.

    I personally allow med students in the room during my exams, and I’ve had pelvic exams from residents. When I go into surgery, however, I decline this because I have a large cyst on my one ovary that has been ruptured before from rough/unskilled pelvic exams. I am at risk for an ovarian torsion with the size of my cyst (I had an ovarian torsion in 2008). I need to be conscious during the pelvic exam in order to tell the person preforming it if they are hurting me. I would not be able to do this is I am under anesthesia. It is for my safety and well being that I request this. I do not mind my surgeon performing a pelvic, but I am careful with med students or residents who are not experienced enough with my level of endometriosis to perform an exam on me while I am unconscious and unresponsive.