Performing intimate exams under anesthesia (EUA) is a standard part of medical training. Yet, some researchers and opponents argue that pelvic and prostate exams too often occur without explicit patient consent, resulting in a professional breach of conduct that undermines institutional trust, leaves learners morally conflicted, raises racial equity concerns, and has more states stepping in to prohibit the practice.
"Whenever I talk about this at conferences around the country, people always come up to me and say it's still happening at their institutions," Lori Bruce, MA, MBE, HEC-C, associate director of the Interdisciplinary Center for Bioethics at Yale University, New Haven, Connecticut, told Medscape Medical News.
Most think this is a women's issue, which occurs only in unconscious patients, she said. But Bruce found otherwise in a survey last year in which she polled the general public about their intimate exam experiences.
"Unconsented exams happen much more than we imagined, and they happen as often to men [having] prostate exams without consent as to women. Black [respondents] were nearly four times more likely to have reported receiving an unconsented intimate pelvic or prostate exam," she said, based on her research. And Bruce believes it can happen across the economic spectrum.
Concern about unconsented EUAs arose in the early 2000s. In a study at that time, 75% of medical students reported that their patients had not given consent to be examined during surgical procedures. An ethics committee of the American College of Obstetricians and Gynecologists published guidelines for EUAs and states began passing legislation with patient protections and medical training consent policies.
California is believed to be the first to adopt legislation outlawing unconsented pelvic exams for training purposes in 2003, followed by Virginia in 2007, along with a handful of other states.
In 2019, on the heels of the #MeToo movement and renewed calls to end unconsented exams, more patients and providers began to speak publicly about their experiences with the practice. Some posted on social media using the #MeTooPelvic hashtag. Last year, an award-winning documentary was also released about consent, At Your Cervix.
More states subsequently passed legislation, and some medical schools strengthened their EUA consent policies.
Today, nearly half the states in the country have enacted laws against unconsented intimate EUAs, with some carrying misdemeanor charges for both the individual conducting the exam and the supervising physician. Other states leave open the option to fine the physician and revoke or suspend medical licenses.
Much of the new legislation requires explicit consent for intimate exams involving the pelvis, prostate, and rectum, with exceptions for emergency procedures and, in some cases, the collection of court-ordered forensic evidence. In addition, several states, including Colorado, Indiana, and Ohio, have pending or recently introduced bills. Last month, sister bills in Missouri passed the House and Senate, gaining more traction than previous legislative attempts. A similar bill was introduced in the Kansas House several times, including this year, and is expected to be on the agenda again in the next session.
Intimate exams on patients without consent are "unethical and unacceptable," said Alison Whelan, MD, chief academic officer of the Association of American Medical Colleges. Although medical students learn sensitive procedures through simulation labs and gynecological teaching associates — individuals specifically trained to help students develop physical exam skills — EUAs require strict adherence to widely accepted guidelines.
"Learners in the clinical setting should only perform such examinations for teaching purposes when the exam is explicitly consented to, related to the planned procedure, performed by a student who is recognized by the patient as a part of their care team, and done under direct supervision by an educator," Whelan said.
Medical Students Bear Moral Burden
Arthur Caplan, PhD, director of medical ethics at New York University Grossman School of Medicine, New York City, has called unconsented intimate exams a "cousin issue" to abusive predatory behavior.
If the public is outraged that physicians "have misused their authority with athletes, then we should be equally outraged if that authority, even for a higher purpose [like] teaching and training, is still misused in terms of getting permission and consent," he said in a video discussing Connecticut's legislation to strengthen intimate exam requirements, which went into effect January 1.
Advocates of stricter EUA consent policies say the variability in consent practices destroys patient trust by ignoring the basic principles of respect and autonomy. Because patients are usually unaware a violation has occurred, reporting typically depends on medical students raising questions with educators and attendings, which they may hesitate to do for fear of repercussions.
Current practices, such as patients signing consent documents in the outpatient setting where students aren't always privy to the discussion, contribute to the lack of transparency, Karampreet Kaur, MD, a second-year ob/gyn resident at the Hospital of the University of Pennsylvania, Philadelphia, told Medscape Medical News.
A 2019 survey of medical students by Elle magazine found that nearly half did not meet patients before conducting an intimate EUA. Of the 92% who performed a pelvic EUA, 61% reported doing so without obtaining explicit patient consent.
Kaur recently coauthored a survey of students from six medical schools and found that 84% completed at least one pelvic EUA during their ob/gyn clerkships. About half of the students surveyed observed patients giving informed consent most or every time. Of those, 67% reported they never or rarely witnessed an explicit explanation that a medical student may perform a pelvic EUA.
This burden weighs on the consciences of medical students. Respondents reported that they wanted to honor patient autonomy but felt they lacked the authority to object to pelvic EUAs when consent was unclear, which led to significant emotional distress.
"It's not that physicians don't care," Kaur said. "I think most want to make sure patients feel safe and fully informed of the care they are receiving."
To Consent or Not
Incorporating a separate EUA consent form, typically signed during a preoperative visit but occasionally on the day of surgery, offers one potential solution as it ensures "clear and consistent language is used and forces documentation of this conversation," said Kaur. At her current institution, providers and medical students must review charted EUA documentation, then that information is "made clear to attendings, fellows, residents, students, and even the OR staff," she said.
In Kaur's survey, 11% of respondents supported a separate consent. Another study of third- and fourth-year medical students published last year found that 45% agreed with having a separate signature line on the surgical consent form.
Legislation introduced recently in Colorado states that medical students must meet the patient, and patients must receive a written or electronic document titled, in at least 18-point bolded font, "consent for examination of breasts, pelvic region, rectum, and/or prostate." The form must also include the names of medical students performing or observing an intimate exam for educational purposes.
Elizabeth Newman, MPP, public policy director at the Colorado Coalition Against Sexual Assault and supporter of the state's intimate exam bill, said the legislation will allow medical students to learn the intricacies of these sensitive body systems and provide better patient care, particularly following the rollback of Roe v Wade.
"Abortion is available and accessible in Colorado, and we are surrounded by states where it's not," said Newman. "Medical students in states where it's outright banned are coming to Colorado to learn how to provide abortion care in their residencies and fellowships, so we want to maintain that access and not take those learning opportunities away with this law."
Opponents of a separate form say it complicates the consent process. Kaur said she originally thought it would involve a lot of extra work, but it only takes 3-5 minutes. Few patients decline the exam after the conversation, and students benefit from the clear guidelines and transparency, she said.
"I had hoped that the many medical association guidelines [supporting] explicit consent would have influenced hospital policy, but it did not have that effect," said Bruce, adding that recent legislative efforts have largely been driven by concerned bioethicists, lawmakers, and some medical students and physicians. "It all circles back to the patient having the right to refuse; it's their body."
Steph Weber is a Midwest-based freelance journalist specializing in healthcare and law.
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Cite this: More States Nix Nonconsensual Pelvic Exams by Med Students - Medscape - Apr 13, 2023.