By Emily Claus
Pelvic exams are one of the best ways to detect early signs of infections, cancer, and other serious health concerns in women. Learning how to conduct these exams is a key part of a medical student’s education, given that it helps them diagnose these diseases. That said, where do we draw the line between education and exploitation? Well, according to the American College of Obstetricians and Gynecologists (ACOG), pelvic exams performed on patients under anesthesia for educational purposes should only take place when the patient gives explicit and informed consent. Despite this, there are reports of patients being subjected to pelvic exams under anesthesia, conducted by medical students without explicit consent, which raises serious ethical concerns. These reports have been surfacing in the U.S., Canada, New Zealand, the U.K., and France. As it turns out, multiple U.S. states have begun passing bills that require informed consent of a patient to conduct pelvic exams under anesthesia, but have yet to be passed as an official law.
Alarmingly, physicians are not required to obtain explicit consent to perform intimate exams in many U.S. states. As of late, patients, medical associations, lawmakers and doctors have expressed strong ethical concerns. Some medical associations have stated that these exams should only take place with informed consent. These new federal guidelines should discourage hospitals from performing the exams without consent, considering that they risk a loss of funding if they don’t. Even so, the actual legal statutes vary by state. It’s also worth noting that in many states, these unconsensual exams are not actually illegal, they simply risk the hospital’s funding. While this discourages hospitals from conducting these kinds of exams, it does not guarantee that a patient’s body is left alone. These exams are conducted while women are under anesthesia for gynecological and other operations by doctors or doctor-in-training. They can take place even if someone goes in for a surgery that is completely unrelated to their genitalia. What’s more, these exams are often done purely for educational purposes, even if it is not medically necessary. Sometimes, people are left unaware that these invasive exams were even performed on them. To put it bluntly, people walk out of hospitals not knowing that their body was violated.
Considering the importance of these exams, it’s unsurprising that more than 40% of medical students have performed pelvic exams on anesthetized patients. The number of pelvic exams conducted per student varied widely, ranging from 1 to 25. The median was 10 exams, highlighting how common this practice is during clinical training. That said, more than half of these medical students (57%) did not have the consent of the patient. On top of that, a staggering 59% of medical students were not properly taught to get specific consent before performing anesthetized pelvic exams. In spite of all this, 94% of medical students consider this practice to be unethical. Why didn’t they refuse? The answer is simple, they can’t. If they are requested by their seniors or preceptors to perform a pelvic exam on an anesthetized patient, they aren’t allowed to refuse, even if it goes against their beliefs.
One notable case is the heartbreaking story of Janine, a 33 year old nurse. Janine went into a stomach surgery in 2017, where she explicitly told her physician that she did not want any medical students to be directly involved in her surgery. When Janine came out of surgery, a resident came up to her to tell her that her period had arrived, and was noticed during a pelvic exam. Janine was rightfully distressed—her sexual organs were inspected during an abdominal operation, by someone who was not her surgeon. Not only that, Janine had stated specifically that she did not consent to medical students participating in her operation. The situation is disturbing to begin with, but it led to intense emotional distress and feelings of powerlessness for Janine, who had survived sexual abuse. In an interview with Janine, she says, “Patients put such trust in the medical profession, especially on sensitive topics such as going under anesthesia.” When the hospital was later asked to comment on its policies regarding informed consent for pelvic exams, they refused. Clinical settings are supposed to feel safe, but situations like these strip away any trust that is built between patients and medical professionals. How are we, as patients, supposed to feel safe in these situations when the line between education and exploitation is so blurry?
One of the most common excuses for these unconsensual pelvic exams is that asking for consent might limit teaching opportunities for medical students. To disprove this theory, two surveys were conducted. In a survey of nearly 4,000 patients, 86% consented to receiving a pelvic exam under anesthesia. Adding to that, 88% of 274 patients seeking abortions consented to intimate exams. As long as people are informed of what is going on, they are willing to participate in these exams. Asking for consent before going through with it will reinstate a level of trust between the patient and the medical staff, and will ensure that the body of the patient is respected.
So, what does this mean for Singapore? Thankfully, there have not been any reports of unconsensual pelvic exams occurring. According to the Singapore Medical Association, when it comes to insurance-related intimate exams, implied consent is given by signing the insurance forms. Nevertheless, it is still strongly recommended for the doctor to communicate with the patient about the necessity and process of an intimate exam. If the patient denies consent, the doctor is not allowed to continue with the procedure. Despite this, it seems that there are not any laws that explicitly cover pelvic exams under anesthesia. Adding to that, it appears that the Singapore Medical Association does not have any information about obtaining consent from patients to perform pelvic exams under anesthesia specifically, nor about pelvic exams being conducted for educational purposes.
Notably, the article by the Singapore Medical Association that discusses the topic of clear communication and consent during intimate exams, titled “Breast and Chest Examinations of Female Patients,” revolves around the male doctors’, “reluctance to perform breast examinations for fear of allegations of possible sexual assault.” This topic stemmed from two incidents of women who accused male doctors of possible sexual assault during their chest examinations. That said, shouldn’t an article about communication and consent regarding intimate exams performed on women revolve around ensuring women feel comfortable when it is taking place? It is highly doubtful that those two women would accuse their doctors of improprieties just for the sake of it. Whether it be a lack of clear communication or understanding, or whether the doctor truly did something inappropriate, it is clear that the women felt violated. Simply put, the process of obtaining consent from patients should revolve around the feelings of the patient, not the doctors. This is in no way trying to minimize the fear of the male doctors, simply to bring women’s fears to light.
Ultimately, the root of the problem stems from the lack of policy awareness and personal education by medical students, as well as the disrespect and dismissal of women’s feelings. It is clear from the statistics that medical students do consider conducting pelvic exams without consent to be against their morals, but are not allowed to refuse if they are asked to perform one by their seniors. Beyond that, most students are not taught to get specific consent from the patient before performing these exams. For so long, medical research has been conducted only on men, and in a lot of cases, we still have a lack of data regarding women’s health. After overlooking women’s medical health for so long, we’ve finally gotten to the point where women are included in medical research. Unfortunately, it seems that, in a lot of cases, the respect for women’s bodies while conducting this research gets thrown out the window. It’s great that we are finally collecting medical data for women’s health, but it cannot come at the cost of women’s safety. What good does it do to finally include women in medical research, if we’re doing it through the exploitation of their bodies? It is crucial that we begin to implement policies at institutional and state levels that understand the importance of pelvic exams, and protect the ethics of patients rights.