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

By Rachel Walden — September 26, 2012

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.

22 responses to “Conversations We Shouldn’t Still Be Having: Pelvic Exams Under Anesthesia”

    • Bc the medical field was male dominated now the females in gyno practice are questionable as to their sexuality and reasons for being in the practice Female body is profitable eespecially during childbearing years and scare tactics coercion and typical bully tactics are acceptable practice at PCP offices and nurses learn this They have their own adgenda as wel since i was molested few times decades apart I know its about policy and personal choice since NO actual oversight in usa and less rights for patients in actuality! AMA is one of all fields that govern themselves and since revenue derived is what matters to our government.

      • What the hell are you talking about!? You instantly go to Male bashing for no other reason than b.c it’s currently popular trend.. its sexist and untrue. There are plenty of female practitioners nd from what I’ve read on the subject they preform the same procedures.. it has absolutely nothing to do w. Men. It is 100% the medical field in general. Male or female is irrelevant.. it’s a wrong form of practice that both genders preform. Not b.c of gender or fear.. they do it b.c they’re taught not to question authority. This is a societal issue the permeates across the board. Not just b.c “men” tell them to do it.

  1. “… 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. 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. We fixed this in California law a few years back, but this article will make me check in as to how it’s being implemented.

  4. “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?

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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.

    • You have absolutely no way of verifyig that story is true… just b c someone said they were aroused after surgery means absolutely nothing. Are you a doctor? Do you know how unknown medications effect the human body? Have you ever read side effects of just the simplest medications.. they’re outrageous. Now go into a surgical setting where more complex drugs are being used not to mention how they effect each individual. You absolutely cant not make blanket assumptions b.c someone said something on Yahoo… it must be happening everywhere all the time! That’s insane.
      I wake up every morning aroused, that means a ghost fondles me every night in my sleep! Absolutely obsurd. I need to see factual evidence on the topic.. I’ve been reading into this lately nd havnt been able to find any real factual evidence. So please point me in the direction

  10. 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.

    • When have you ever been to a doctor nd not been able to pick nd choose which doctor you see? Like this is crazy… you’re going to them for a service you can pick your doctor! If you dont want a Male doctor dont pick a Male doctor… it’s literally that simple.

  11. 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).

  12. 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?

  13. ‘@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.

  14. As a medical student, I feel that this article does not correctly paint the picture of what is current practice. All the pelvic exams of anesthetized women (by medical students) that I have encountered is on women who know a student is helping with a pelvic surgery. Although since a student is practicing performing the exam, the exam is not “just for practice” as it is important to understand the anatomy of the region you will be helping operate on and it is important to check to make sure that there haven’t been any changes from the pre-op visit (like that ovarian cyst that was felt in the clinic can’t be palpated anymore and may have ruptured).

    • This is your individual experience and we thank you for your in-put, however you can not speak for all establishments or behaviours, so the original article is important and informative. It is quite un-nerving as a woman to know that if I was to ever require surgery or find myself unconscious in hospital that Dr’s and their staff don’t seem to understand that their practices are neither normal or acceptable to a large percentage of the female population and they don’t have right of access to women’s bodies without their informed consent. Whilst Medics are still debating this, there is no reassurance to the female population or their concerned partners. The default assumption should be that women do not want this – unless they have expressly said otherwise.

  15. Just to let people know, this exact practice still happens in Missouri. I just had pelvic surgery. I signed a consent form and student pelvic exams were never specifically discussed verbally or in the consent. I asked directly and the doc told me there would be multiple students performing the exam. I said no thanks and wrote it out on my consent form. Sad that they don’t disclose this. If it was one or two students who met me before hand, I would probably agree to it. It is not ok to let a line of students use your vagina as an practice assembly line without explicit permission!

  16. What is the price of anesthesia to have a horrible pap exam? I once thought about taking enough medication I had for my vaginismus to induce me into a coma. Because my blood pressure gets to the point of a close heart attack anyhow from the raping pap. I figure if I die then my suffering will be over. Since I have children I just don’t have sex unless I’m on narcotics. Then I might not have pain.

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