For nearly thirty years a conversation has been ongoing in the medical literature and community about the ethics of performing pelvic examinations on women who are under anesthesia without their knowledge or consent (Bibby, J., et al., 1988). These exams are often performed by medical students who may be cursorily introduced to the patient; they are justified under the guise of their educational value (Barnes, S., 2012; Wainberg, S., et al, 2010).
The literature shows over and over again that patients object to internal vaginal examination without being asked for explicit consent: In surveys, between 72% and 100% of patients expected to be asked for consent if a medical student were going to perform a pelvic exam; some would refuse if asked for consent, and some would characterize an exam with failure to obtain such consent as a physical assault (Wainberg 2010; Bibby 1988).
Indeed, one need not go to the medical literature to gauge the attitudes of women, patients, and the broader public on the question: numerous articles have appeared critiquing the practice and documenting objections from medical students, physicians, lawyers, and ethicists, as well as professional organizations, such as the American Association of Medical Colleges, the American College of Obstetricians and Gynecologists, and the American Medical Association. On top of that, five states (Hawaii, California, Illinois, Virginia, and Oregon) have outlawed the practice since this conversation began.
And yet, the best available and most recent evidence indicates that the practice continues (Friesen, P., 2018). As previous researchers anticipated some fifteen years ago, without active dialogue and “paradigm shifts” within medical education, the practice is likely to continue, as patients are often unaware that the exams have taken place, which leaves them unable to advocate for their own interests or enforce the existing laws against the practice (Wilson, RF., 2003). In addition, medical students fear reprisal or punishment from those supervising them for declining to participate in the practice, and attest that the culture of medicine teaches that the instructions of supervisors should not be questioned (Barnes, 2012).
The ethical arguments against unconsented pelvic examinations are well-established and I won’t rehash them here (The articles above and those referenced below provide a good overview.).
Instead, I would like to use this piece to spur our community towards action.
How can we defend allowing the practice of unconsented pelvic exams to continue to be a part of our education when it has been outlawed in five states?
How can we defend allowing the practice of unconsented pelvic exams to continue to be a part of our education when the AMA, the AAMC, and the ACOG have made policy statements against it?
How can we defend allowing the practice of unconsented pelvic exams to continue to be a part of our education when patients tell us that they do not consent?
The time to end this practice fully is now.
I’d like to suggest a simple rallying cry for change:
Informed consent means:
- Knowing the procedures of your care plan
- Knowing your providers.
Informed consent means knowing the procedures and knowing your providers.
(To be clear, I don’t mean to suggest that these are the only elements involved in informed consent, but I do mean to suggest that if they have not been satisfied, the patient has not fully or properly consented.)
If a medical student or any other provider would like to perform a pelvic exam on an a patient, they should introduce themselves to the patient, explain what a pelvic exam entails, and ask the patient for consent to perform one.
If you agree and think we need to finish this discussion and end the practice of unconsented pelvic exams, please consider sharing this article and/or its contents.
Thank you to all those whose work I have cited above, who have been advancing this conversation in medicine and in the public forum for decades.
Disclosures: I am a current medical student and a member of the AMA.
Barnes, Shawn S. 2012. “Practicing Pelvic Examinations by Medical Students on Women under Anesthesia: Why Not Ask First?” Obstetrics and Gynecology 120 (4): 941–43.
Bibby, J., Boyd, N., Redman, C., & Luesley, D. 1988. “Consent for Vaginal Examination by Students on Anaesthetised Patients.” The Lancet (British Edition) 2 (8620): 1150.
Friesen, Phoebe. 2018. “Educational Pelvic Exams on Anesthetized Women: Why Consent Matters.” Bioethics 32 (5): 298–307.
Wainberg, Sara, Heather Wrigley, Justine Fair, and Sue Ross. 2010. “Teaching Pelvic Examinations Under Anaesthesia: What Do Women Think?” Journal of Obstetrics and Gynaecology Canada: JOGC = Journal D’obstetrique et Gynecologie Du Canada: JOGC 32 (1): 49–53.
Wilson, Robin Fretwell. 2003. “Unauthorized Practice: Teaching Pelvic Examination on Women under Anesthesia.” Journal of the American Medical Women’s Association 58 (4): 217–20; discussion 221–22.