If you happen to have had a gynecological surgery at a major teaching hospital in the U.S., there’s a good chance that after you were given the anesthetic, several medical students used your unresponsive body to learn how to perform a proper pelvic exam. Each student would have inserted two fingers inside your vagina and placed one hand on your abdomen, feeling for abnormalities in your uterus and ovaries. This would have been done entirely for their benefit, not yours. And after the surgery, you would have been sent on your way, with no mention of these exams and with no knowledge of your role as a teaching tool.
You, like many women, might feel that this constitutes a serious violation of both your body and your trust. This may sound like something that should have been left behind long ago in the days where medical paternalism was the norm. But this practice still appears to be commonplace in many teaching hospitals in this country. While little data has been collected in terms of frequency, medical students across the country are familiar with the practice and engage in heated debates regarding the ethics of the practice in online forums.
I first heard about the practice while teaching ethics at several medical schools in New York. When I asked my students to consider an ethical issue they’d encountered during their training, many of them brought up their experiences practicing pelvic exams on unconscious women who had not consented.
While discussing the importance of respecting an individual’s rights and bodily autonomy, many students agreed that obtaining women’s consent before this occurred would be preferable to sneaking in a lesson once they’ve been knocked out. Most of them admitted, however, that they would never feel comfortable raising their concerns with their instructors, given the rigid hierarchy that structures medical education as well as the intimate connection between those instructors and their chances at being placed for their residencies the next year. No one wanted to be seen as a troublemaker.
Interestingly, research shows that while first-year medical students largely find the idea of practicing pelvic exams on women under anesthetic to be morally problematic, the longer they spend in medical school, the less they see it as an issue. Some have labeled this process, which shows up in many aspects of medical education, “ethical erosion.”
Unsurprisingly, 100 percent of women say they would prefer to be asked before their pelvis is used as a teaching tool. Some say they would feel assaulted if they weren’t consulted beforehand. Most also don’t have the ability to learn that this has even happened to them. They have no chance to say no, thank you—or #MeToo. But in our current era of rethinking consent and the institutions that have perpetrated unfair treatment of women, now is the perfect time to finally end this practice.
I’ve spoken to many people who argue that we can’t get consent from every woman before medical students learn how to give a pelvic exam on them, because so few of them would agree to take part that medical students would never learn the technique. Just as the many patients at teaching hospitals share the burden of allowing students to learn the ropes of medicine while caring for them, women having gynecological surgeries at teaching hospitals just need to (unwittingly) do their part for the greater good.
It’s not clear that consent is such a barrier to student learning, however. When polled, the majority of women say they would consent to having medical students perform pelvic examinations on them while they are under anesthetic. Moreover, when consent for pelvic exams under anesthetic has been made routine, most women agree to take part.
There are also other ways to learn how to perform a pelvic examination. Following public outcry, performing pelvic exams on women without their consent has been banned in California, Virginia, Hawaii, Illinois, and Oregon, and several professional bodies in medicine have condemned it. Teaching hospitals in these places often hire professional patients to guide students through the process of giving a pelvic exam, or they use electronic teaching mannequins. Others have just incorporated specific consent for pelvic exams into medical education. It’s time for the rest of the country to catch up.
Others argue that these exams are no big deal. At teaching hospitals, medical students participate in patient care in all sorts of ways—from chest drainage to suturing—and this is just one more aspect of teaching that takes place. It’s far too burdensome to mention any possible involvement that medical students might have during a surgery within the consent form.
But there’s a difference between these practices and unauthorized pelvic exams on unconscious women, and it’s that, unlike other forms of treatment, these pelvic exams are done with no medical benefit to the patient. The purpose is purely for students to learn how to perform the exam.
A pelvic examination also has a different moral significance than suturing a wound. Women are frequently nervous before pelvic exams, reporting feeling vulnerable, embarrassed, and subordinate. Those who have experienced sexual assault often find the experience particularly distressing. This discomfort is a sign that pelvic exams are sensitive experiences and should be treated as such.
It’s time to make informed consent for educational pelvic exams on anesthetized women routine. Several legislative documents are available for inspiration, and New Zealand has developed a clear policy requiring written consent before such exams. Rather than just teaching our future doctors how to perform a pelvic exam, let’s also teach them how to respect women’s bodies.