What is the Deal With Non-Consensual Pelvic and Prostate Exams?

Imagine going into surgery and waking up from anesthesia to find out that a medical student performed a non-consensual pelvic, rectal or prostate exam on you while you were unconscious. The student’s probing and uncertain fingers palpating the recesses of the most intimate body parts and searching for abnormalities. 

As bioethicist Arthur Caplan describes, “Sometimes, more than one student will practice the exam, with many sets of gloved fingers in the patient’s vagina without their knowledge.”

It sounds like a page from the Special Victims Unit. We are at our most vulnerable when we are unconscious in an operating room and go in with the expectation that our body will not be violated or an unnecessary exam will not take place without our explicit consent beforehand. 

But that is what has happened and is still still happening in some states. 

A recent survey of 101 medical students from seven American medical schools found that 92% had performed a pelvic exam on anesthetized female patients, 61% of whom reported not having explicit consent from the patients.

How can this practice be allowed to take place? Why is this practice allowed to take place more to the point? Although nonconsensual exams are more common with women it does happen with men as well. The practice of unconsented intimate exams occurs for “training purposes and diagnostic reasons” for the most part during gynecological and abdominal surgeries and prostate examinations. There has been much opposition to these procedures and of recent much whistleblowing but as yet no blanket legislative bans on a practice that leaves patients feeling battered and medical students feeling a moral erosion. 

Is it imperative that medical students learn how to palpate a vagina or pelvis on an unconscious woman or do a training rectal on an unconscious male? The initial exams conducted by the attending physician are of course necessary but are these educational exams something that should be overlooked and tolerated in a world when truth and trust are going out the window? Is consent less important than a medical student learning to identify an irregularity? The answer to why uninformed consent continues and happens lies in answers that were uncovered from small-scale studies done in the early 2000s. The study uncovered four rationale for why these exams took place without explicit consent. 

The first turned informed consent on its head: We cannot ask for consent, teaching faculty claimed, because if we ask, the patient might say no. Of course, removing the opportunity for autonomy because a person might exercise it makes a mockery of personal agency.  

The second justification rested on a weak factual foundation: that women implicitly consented to be used for medical teaching when they accepted care at a teaching hospital. But how many people would know that Beth Israel Deaconess is a teaching hospital for Harvard University, or that Stamford Hospital, 40 miles from Manhattan, is a teaching hospital for Columbia University. Neither name nor proximity would tip off reasonable patients. Indeed, in one study, most elderly patients had no idea they were being treated in a teaching hospital.  Insurance status only compounds matters. Many patients choose network providers for cost reasons, not because they are willing to be subjected to medical teaching. 

 Third, medical educators make legal claims about the forms patients sign — that a student’s intimate examination on unconscious patients is an ordinary component of the surgery to which they consented; and that consent for one procedure encompasses consent for additional related procedures. Any fair reading of these forms is that patient consent to procedures for their benefit, not for students’. 

The final justification would be the most compelling, if true: Not enough women will consent to help train students. Yet, studies refute this. Women routinely consent to pelvic examinations for educational purposes.

Those studies and those “excuses” catalyzed change. In 2003, the “FTC heard testimony about non-consensual student exams”. After the hearing “unethical and unacceptable” were the words used by the Association of American Medical Colleges to describe unauthorized exams.

In the months leading up to those hearings, the American College of Obstetricians and Gynecologists disavowed earlier guidance that had posited a duty by women to participate in “teaching exams.”

The practice of conducting non-consensual medical exams can and has been regulated in a number of states. But not all. Although there is movement in the right direction. 

Since January of 2019, more than 20 other similar bills were introduced across the country.

There are teaching hospitals and medical schools that condone the practice with the same abandon, lack of conscience, and betrayal where the aftermath feels much like rape. Uninformed consent remains commonplace. There are states that have yet to step in and ban the uniformed pelvic exams and evidence shows the practice is alive and well. Evidence shows it is defended as necessary for medical training on a discussion forum for medical students with “little concern for those who see the practice as alarming”. 

Clearly 100 percent of women would prefer to be asked before numerous strange fingers insert themselves into their slumbering private parts. However, on the flip side upon polling the majority of patients wish to help medical students to learn but granted they would like permission to be sought first before they are palpated while unconscious.  

There are alternatives to the anesthetized uninformed patient. In states where the practice of performing pelvic exams on the unwitting patient has been banned teaching hospitals have hired professional patients to guide medical students through the task at hand or they use “electronic teaching mannequins”. Others have just incorporated specific consent for pelvic exams into medical education. 

In the world of #MeToo we have to raise the bar on what is permissible touch even if, especially if, it is under the umbrella of medical training and education. Patients put their trust into medical professionals and regardless of whether under the watchful eye of the attending physician if our bodies must be utilized as a laboratory we have the fundamental right to be willing participants in that experiment even if, especially if, unconscious.  At a patient’s most vulnerable moment there is no time that the words warmth, sympathy, and understanding of the now modern version of the Hippocratic Oath are more important than when an unsuspecting patient’s body is used as an involuntary laboratory specimen. Perhaps the classical version should be where the professional looks to: I will keep them from harm and injustice.

Author: Sherri Margolin (Dark Matters)