A medical student turned whistleblower reveals how his school forced patients to become unknowing victims of what could rightly be called "medical rape."  Standard hospital intake forms can hide blanket consent to unauthorized, invasive exams of the most intimate parts of your body: all while you are under anesthesia.

As a US-medical student in 2011, Shawn Barnes underwent the standard, AMA-sanctioned training on his way to becoming a licensed medical doctor. But an experience in his third-year of medical school would haunt him for years to come. Shawn was so bothered by the experience that he expressed his concerns to the school administration, only to be met with indifference. He pressed on in his effort to expose the problem, writing a paper on the matter that was published in 2012. What happened during his medical education, considered the gold-standard in the United States, that made such a negative impression on this young physician?

For Shawn, now an MD, it was a serious ethical and moral dilemma, which he describes in this video interview filmed as part of a planned documentary called “At Your Cervix.”[1] In the clip, Shawn explains how third-year medical students are required to perform clinical hours in various specialties, such as psychiatry, surgery, and OB/GYN. During the 3-4-week gynecological surgery rotation, Shawn was asked to do something as part of his training that he considered a serious breach of ethics and patient rights: he was instructed to perform as many as one hundred unauthorized pelvic exams on anesthetized, unconscious, and unconsenting women.

Shawn shared his experiences with filmmaker Amy Jo Goddard, another maverick who is bringing exposure to this controversial training method. Discussing the scope and frequency of the practice, Shawn and Amy estimated that as many as 6,000 unauthorized pelvic exams could have been performed by the students in his class alone. But Shawn is not alone in his outrage. A 2001 University of Toronto study found that nearly half of the 108 medical students polled felt “pressure to act unethically” in a clinical setting, and 61% reported witnessing a clinical teacher acting unethically.[2] Students further cited that “practicing...on unconscious patients without prior consent” was a serious moral issue, and yet, the medical establishment remains largely resistant to change.

In Shawn’s case, when he challenged the establishment at his school, administrators frowned on his assertions that anything was unethical, and were patently unwilling to consider terminating what they considered a highly efficient practice. Undeterred, Shawn focused on legislative change and was eventually successful in spurring the passage of a law making the practice illegal in Hawaii.[3] This bucking of the system did not come without personal cost: Shawn was blacklisted from applying for residency in Hawaii due to his activism. Besides Hawaii’s recent ban, unauthorized pelvic exams are explicitly outlawed in California, Illinois, Virginia, and Oregon. The practice is legal in all other states.[4]

Hospitals get around lawful and informed consent by including language in standard intake documents explaining that medical students may be involved in their care. Women who are in hospital for any type of gynecologic surgery could become victims of this practice, regardless of whether a pelvic exam is indicated in their particular hospitalization. In states where this practice is not outlawed, women undergoing gynecological procedures who sign these standardized forms are essentially signing away their right to not participate in training exercises involving multiple students performing an intimate and invasive exam while they are unconscious.

A brief examination of the 2005 essay, Pelvic Examinations Under Anesthesia: An Important Teaching Tool,[5] highlights some of the reasons why this training practice has become so inculcated. Some physicians argue that an anesthetized body allows for a better exam due to muscular relaxation, and that hiring professional or “standardized patients,” as they are referred to by academia, is simply too expensive to be a practical solution. The growing public awareness of the commonality of sexual assault (even by doctors[6]) renders these reasons overly simplistic. More importantly, these arguments are dismissive of patient’s rights.

While this practice may represent the ideal training scenario for some medical school administrators, it is inarguable that all patients should be fully informed regarding what is to take place—including risks, benefits, and potential complications—while under anesthesia. Slipping vague, boilerplate language into standardized forms should not meet the criteria of “informed consent” in any state or nation. The right to agree or not agree to participate in student training exercises, is another point to which people feel an unanimously strong accord. Shawn Barnes’ 2012 paper, published in the Journal of Obstetrics and Gynecology,[7] posed the obvious question regarding practice exams: “Why not ask first?”

The trailer for At Your Cervix offers insight into why this is such an important question—one that the medical establishment is slowly being forced to reckon with. In the clip, med-students perform pelvic exams on a standardized patient. These professional assistants are trained to provide guidance to student practitioners while exams are being performed, creating a valuable feedback loop that has proven to be an effective and agreeable training technique.

Learn more about AtYourCervixMovie.com

The arguments by the medical establishment against this type of informed teaching need to be challenged. To dismiss the role of a trained human aid for an exam that involves potentially uncomfortable interactions with hundreds, sometimes thousands of patients throughout a doctor’s career, is missing a critical opportunity. In this type of supportive and instructive environment, future doctors get feedback from fellow professionals on how to improve their individual examination skills. Standardized patients know their anatomy in medical terms and can instruct students on how to be more precise, as well as sensitive to each patient’s personal and anatomical differences. This can be important when dealing with overly tense patients, as well as those who are cognition-impaired. To dispense with all these benefits by asserting that the methodology will always be “too expensive” is a failure to understand what’s at stake. Perhaps institutions should consider the cost-benefit when compared to potential class-action lawsuits by the legions of victims of these unauthorized examinations.

As news of this disturbing practice spreads, women worldwide are reacting with shock and outrage. The issue received national news exposure in 2003 after The Wall Street Journal, ABC, and CBS News ran stories.[8],[9],[10] More recent coverage has added to a growing wave of alarm that is slowly being reflected in changing laws and attitudes.

Lauren Dobson-Hughes, former president of Planned Parenthood, tweeted about the issue in March 2018, and drew an influx of attention through retweets. An article in the online journal Bust garnered the attention of Millennials, as did an episode of the popular podcast, Throwing Shade, in which a report by the NYU Ethics Division was read, detailing the practice. The Globe and Mail, a leading Canadian news publication, published a story in 2010 that was recently updated, claiming that their reporting helped spur a change to Canadian law. Express consent is now legally required in Canada to perform all such exams.[11]

Image Credit: https://twitter.com/ldobsonhughes

One of the most respected voices in the current discussion is Phoebe Friesen, an Oxford scholar who published a 2018 paper entitled, “Educational pelvic exams on anesthetized women: Why consent matters.” The paper gets right to the point: the lack of true informed consent makes this practice indefensible. “Foregoing the process of consent within medicine can result in violations of both autonomy and basic rights, as well as trust.” Robin Fretwell Wilson of the University of Illinois calls the current standards of informed consent nothing more than “modern medico-legal terminology,” in her paper on the “unauthorized practice” of teaching pelvic exams on women under anesthesia.[12]

Click to view the full paper

Criminal law regarding unauthorized touching during medical exams can be vague and outdated in both language and scope. Laws also vary from state-to-state. According to an article in the AMA’s Journal of Ethics, current laws in some states may provide legal recourse to patients who feel they have been violated. The Ohio Criminal Code defines "sexual conduct" as, i.e.: inserting any body part or apparatus into the vagina or anus without the “privilege to do so.” (Sec. 2907.01(A)). The definitions of rape (Sec. 2907.02) and sexual battery (Sec. 2907.03) include the inability to resist sexual conduct due to physical impairment, and/or being unaware that the act is being committed.[13] Performing unauthorized pelvic exams to women under anesthesia could potentially meet all these definitions in a court of law.

The problem with pelvic exams stretches beyond non-consented incidents under anesthesia. A recent JAMA review suggests that routine screening pelvic examinations are inaccurate in asymptomatic women and are associated with harms that exceed clinical benefits. In other words, they are not evidence- but consensus-based, representing outdated practices that research indicates cause significant harm, including "discomfort, anxiety, psychological effects, embarrassment, and unnecessary procedures, including surgery (1.4% [29 of 2000] of women in one study)."

In conclusion, please be careful about consenting to routine screenings marketed as preventive and beneficial which are not, in fact, evidence-based. Also, please remember not to sign away your rights to be safe, protected, and informed while under anesthesia. Go on the record with your doctors regarding how you feel about this issue. Speak to a Patient’s Rights advocate at your hospital or through your insurance company before undergoing gynecologic surgery in any state where express consent for student or instructional exams is not required by law. Consider speaking to your elected representatives or putting your thoughts in writing. In some states, citizens can file initiatives to change laws and create civic protections from public harms. The wave of change to ban this abhorrent practice has begun; we can further it by spreading this message within our own communities. 

Learn more about the At Your Cervix Movie documentary and education project by visiting their site. 

References

[1] https://fiscal.ifp.org/project.cfm/26/