Pelvic exams under anesthesia? Feds finally require written consent
Yes, in 2024 the Feds needed to remind hospitals of the requirement for consent for sensitive medical exams by medical students
On Monday, the US Department of Health and Human Services (HHS) released a “Letter to the nation’s teaching hospitals and medical schools” to specifically address reports of people being subjected to sensitive medical exams under anesthesia without consent, especially by medical students.
“The Department is aware of media reports as well as medical and scientific literature highlighting instances where, as part of medical students’ courses of study and training, patients have been subjected to sensitive and intimate examinations – including pelvic, breast, prostate, or rectal examinations – while under anesthesia without proper informed consent being obtained prior to the examination.”
Most importantly, the reminder has financial consequences for training hospitals. Hospitals not complying with the consent requirement risk losing Medicare and Medicaid reimbursements.
I have no doubt there are clinicians and administrators all over the country who are irritated that yet another form, another piece of documentation, will be required to provide patient care. Some people will claim this is government overreach, interfering with the relationship between patients and physicians.
But regulation seems to be the only remedy that works.
Despite the open discussion of unethical, unconsented vaginal exams since the early 2000s, the problem persists. The day HHS released the letter, fewer than half of US states specifically required consent for these exams, leaving clinicians and medical students to figure out for themselves what their practice would be.
By making consent a requirement, the HHS letter increases protection for patients across the US.
Unconsented pelvic exams belie a core, lingering problem in medicine—the assumption that the patient’s opinion doesn’t need to be solicited. It is the underlying notion that doctors still know best. A belief that if a patient can’t express an opinion or remember what happened, does it really matter? The idea is that clinicians don’t have an obligation to ask permission.
No patient should ever wake up from surgery to find out that they have been violated.
While many clinicians have actively tried to move past these assumptions and aim for ethical practice, medicine changes very slowly. Government regulation can help ensure patients have access to the care they want, without suffering from body violations.
Anesthesia Ensures Compliance
Performing a sensitive medical exam on a patient who is sedated or deeply anesthetized without consent sounds a whole lot like drug-facilitated sexual assault (DFSA).
In January this year, Dr. Caitlin Sutton and I wrote about anesthesia as a tool to facilitate obstetric violence. Anesthesia drugs are powerful - rendering patients unconscious and unable to advocate for themselves. Once under general anesthesia, a patient won’t have any idea they have had an exam until they wake up with pelvic discomfort or until it’s disclosed later.
While patients are the primary people this practice harms, medical students are secondary victims. A 2022 study by Kaur and colleagues found that “While students regularly perform pelvic EUAs, their involvement is inconsistently disclosed to patients, causing significant distress to students and risking erosion of students' attitudes about upholding patient autonomy and informed consent.”
Mississippi Appendectomies and the History of Reproductive Injustice
When patients can’t be certain even the examinations they receive under anesthesia are consented to, what else do they need to worry about?
The US has a long history of forced or coerced sterilization - targeting Black, Latina, and Native women, poor people, and people with intellectual and developmental disabilities.
Many of these sterilizing procedures happened while women were anesthetized.
Carrie Buck became pregnant after being raped by her foster family’s nephew. Buck v. Bell became a landmark case, allowing states to continue the forced sterilization of people with disabilities. Carrie was deemed “feebleminded and promiscuous,” and her ability to procreate was taken away as the first person to be involuntarily sterilized in Virginia’s eugenics program.
In 1961, activist Fannie Lou Hammer consented to have a growth removed from her uterus, but instead, the surgeon removed the entire uterus. Black women suffering forced sterilization at the hands of physicians was so common that she ultimately coined the term “Mississippi Appendectomy.”
Jean Whitehorse, a Navajo woman, described presenting to a hospital in pain from acute appendicitis in the 1970s. Years later, she discovered that while having a life-saving medical procedure under anesthesia, her surgeon also performed a tubal ligation. A tubal ligation is a type of permanent sterilization that prevents eggs from moving from the ovary to the uterus, preventing pregnancy. Her experience and that of many other Native women is documented in the film Amá (the Navajo word for “mother”).
More recently, an audit of California’s prison system discovered nearly 1,400 women were sterilized between 1997 and 2013. Many were not asked for their consent or were coerced into consenting.
At Your Cervix
There’s a powerful documentary about unconsented pelvic exams called At Your Cervix. The director includes interviews with survivors, students, and physicians about consent and sensitive medical exams.
Here’s the trailer ⤵️
Gynecologic Teaching Assistants
It doesn’t have to be this way. The At Your Cervix film explores ethical, consistent ways to teach students how to do pelvic exams well. Gynecologic teaching assistants (GTA) are one way to improve care.
GTAs are people who use their own bodies to teach pelvic exam skills to medical students. I had the benefit of working with a GTA when I was in medical school - even back in the mid-2000s. Having had my own bad experiences with pelvic exams while awake, I was eager to learn how to do these exams in a way that was compassionate, effective, and ethical.
Learning with an awake expert like a GTA improves teaching, helping students learn how to conduct pelvic exams that are more comfortable and trauma-informed. Students trained with GTAs, report greater confidence in performing pelvic exams than those who didn’t have access to a GTA. An anesthetized patient—even one who has consented to an exam—won’t be able to give students feedback on what’s working (and not) in their technique.
Thankfully more programs incorporate GTAs into training for students.
HHS Letter is a Good Step, But Not Enough
With the new HHS guidance, students will have more confidence that patients have consented to sensitive medical exams. However, signing a form is only an attestation of assent. Many of the women who suffered forced or coerced sterilization also signed papers, not realizing what they agreed to.
We need sensitive medical exams to be taken seriously - prioritizing the patient’s opinion above other considerations.
References:
Wilson RF. Unauthorized practice: teaching pelvic examination on women under anesthesia. J Am Med Womens Assoc (1972). 2003 Fall;58(4):217-20; discussion 221-2. PMID: 14640251.
Burgart A, Sutton C. Chemical Restraints for Obstetric Violence: Anesthesiology Professionals, Moral Courage, and the Prevention of Forced and Coerced Surgeries. Am J Bioeth. 2024 Feb;24(2):4-7. doi: 10.1080/15265161.2024.2299629. Epub 2024 Jan 31. PMID: 38295250.
Buck v. Bell, 274 U.S. 200 (1927).
Kaur K, Salwi S, McNew K, Kumar N, Millimet H, Ravichandran N, Tytus K, Zhang AY, Garrett Wood A, Grimm B, Fairbrother EL. Medical Student Perspectives on the Ethics of Pelvic Exams Under Anesthesia: A Multi-Institutional Study. J Surg Educ. 2022 Nov-Dec;79(6):1413-1421. doi: 10.1016/j.jsurg.2022.05.015. Epub 2022 Jun 4. PMID: 35672245.
Kelly K, Wilder L, Bastin J, Lane-Cordova A, Cai B, Cook J. Utility of Gynecological Teaching Associates. Cureus. 2023 Jun 18;15(6):e40601. doi: 10.7759/cureus.40601. PMID: 37469809; PMCID: PMC10353857.
