Public health reporter André Picard published an editorial yesterday in the Canadian newspaper, The Globe and Mail, imploring the medical community to end the practice of performing vaginal exams on anesthetized women without their consent. The article about physician Sara Wainberg’s research and personal accounts of the practice has ignited comment storms, debate and outrage.
Pelvic examinations performed routinely in teaching hospitals on uninformed, anesthetized women prepped for unrelated surgeries is not breaking news. The topic bubbles up to the surface every few years, incites a media frenzy, then simmers back down into what Picard calls “one of those dirty little secrets of medicine” and again drops from the public eye.
The story is that the practice of digitally raping anesthetized female and male patients without their consent continues.
One of many articles on the ethics of performing pelvic exams on anesthetized women was written by Robin Fretwell Wilson, a professor of law at the University of South Carolina School of Law, who testified before the Federal Trade Commission and Department of Justice Hearing on June 10, 2003. In her article, Unauthorized Practice: Teaching Pelvic Examination on Women Under Anesthesia that appeared in the Journal of the American Medical Women’s Association in 2003, Wilson cites study after study showing that the practice is routine.
In February, Ubel et al reported that 90% of medical students at four Philadelphia-area medical schools performed pelvic examinations on anesthetized patients for educational purposes during their obstetrics/gynecology rotation. Although trumpeted as proof that physicians are lax in securing permission, the study was not clear on the matter of consent. Caldicott et al reported in January that 53% of students at a single English medical school performed pelvic or rectal examinations on anesthetized patients. Students acted without any written or oral consent in 24% of the exams.
Research in the United States, Canada, and Great Britain has shown that the unauthorized use of women is not confined to 1 or 2 medical schools. Using anesthetized patients before surgery to teach abnormal anatomy “has long been practiced.” Women are also used to teach normal anatomy. As late as 1992, Beckmann found that 37.3% of US and Canadian medical schools reported using anesthetized patients to teach pelvic exams.
Other data in Wilson’s article:
[In 2002], nearly half of Canadian medical students (47%) at the University of Toronto reported “pressure to act unethically” and named as the leading culprit the collision between medical education and patient care. Many were asked to perform pelvic examinations without consent.
Ninety-four percent of Oxford Medical School graduates learned to perform digital rectal examinations using male and female patients, many of whom were anesthetized.
Only 37.5% of teaching hospitals “inform patients that students would be involved in their care.”
Forty-two percent of US students are not forthright about their status when doing pelvic exams on conscious women.
Five percent of obstetrics/gynecology department chairs tell students to introduce themselves as doctors and just proceed.
Some states in the U.S. ban the practice of digitally violating anesthetized female patients. California Governor Gray Davis signed AB 663 into law during the first half of the 2003-04 legislative session which makes the performance of pelvic examinations on anesthetized or unconscious women without consent by doctors and medical students a misdemeanor and ground for the loss of their medical license.
The glaring limitation in the bill is, as Wilson wrote, ”[no] woman can enforce her own interests in being asked if she never knows an exam has taken place” and therefore the bill “suffers from the same limitations as existing causes of action for battery and the failure to secure informed consent.” While AB 663 increases the sanctions for unauthorized exams, Wilson argues that it does nothing to remedy the underlying pressures that have fostered the use of patients as teaching tools without permission.
Ironically, under the subheading “Exaggerated Fear of Refusal,” Wilson cites multiples showing that women will consent to pelvic examinations for educational purposes, even while anesthetized or during birth.
Dr. Ari Silver-Isenstadt, co-author of the aforementioned study about Philadelphia-area medical schools appeared on ABC’s Good Morning America show on June 10, 2004 to discuss the study. He told ABC that the study was based on his own experiences in medical school when “[he] was asked to participate in some of these educational experiences and [he] felt very uncomfortable…”
Naturally, many patients take issue with the idea that their anesthetized bodies will be probed without their expressed consent and knowledge.
One such patient was Zahara Heckscher, who was interviewed by the Washington Post in May 2003. According to the article, Heckscher was preparing to have an ovarian cyst removed at George Washington University Hospital and asked her surgeon if medical students would be practicing pelvic exams on her while she was unconscious.
Shocked when she received a “yes” answer, Heckscher “wrote a note on her consent form forbidding anyone other than her attending physician to perform a pelvic exam on her while she was under anesthesia.”
Not all doctors agree that patients at a teaching hospital should complain about the practice.
Former ACOG president, Dr. Thomas Purdon, expressed concern “that an important quality evaluation that’s been a mainstay of evaluation in the operating room for more than 50 years is getting sensationalized,” according to OB/GYN News.
“It’s a crucial teaching point to see how a procedure is done, what the pathology is, and to tie that to the pelvic exam,” said Dr. Purdon of the Arizona Health Sciences Center in Tucson.
Purdon also argued that this type of treatment is implicit.
In Dr. Purdon’s view, patients who get treated at a teaching hospital “should already know that it’s not just one single doctor who’s taking care of them.”
Purdon expressed frustration that people who go to university centers for care are “pick[ing] apart” something so important.
Although the practice of performing pelvic exams on paid volunteers has gained popularity in some institutions over the last 15 years, physicians are never going to get enough paid volunteers to adequately teach students, he said.
As an educator, “it’s frustrating for me that people who want to go to university centers for the latest treatments and technology pick apart something that’s an area of importance,” he said.
It’s common in a teaching situation for a medical student, one or two residents, and a faculty person to compose a surgical team. It’s not as if 12 medical students are in the operating room examining the anesthetized patient, he said.
Activist Michael Greger, MD, told the Washington Post that the voluntary guideline of having one or two students perform the exam is widely ignored. Said Greger, “If they have five medical students on an OB-GYN rotation, they aren’t going to let one do it and not the other four.”
Bioethicist and medical historian, Jacob Appel, analyzed the recent court-ordered hospitalization of then pregnant woman Samantha Burton for the Huffington Post in his article, “Medical Kidnapping: Rogue Obstetricians vs. Pregnant Women,” in which he stated:
Preventing a competent pregnant woman from leaving the hospital under these circumstances is no less egregious than compelling her to have an abortion. Forcing additional intrusive care upon her, such as unwanted vaginal exams or cervical assessments, is legally-sanctioned digital rape.
As André Picard wrote, “the problem is the result of a failure to communicate. It is also a striking example of a lingering bit of paternalism that is still all-too-present in medical culture – this notion that “we do the surgery and the details are none of your business.”
With sufficient evidence that the majority of women would consent to a pelvic exam if asked, the practice of medical students manually raping anesthetized women in the name of education is a pitiful relic of medical culture. Were it not for the many brave medical and nursing students over the years who spoke out against the practice of culturally-sanctioned digital rape in the operating room and in labor and delivery under the guise of frequent unnecessary cervical checks, this would remain a dirty little secret.