Pelvic examinations under anesthesia by medical students without consent

Line drawing showing bimanual palpation as part of a pelvic exam

Pelvic exams under anesthesia by medical students without explicit consent may be occasionally performed to teach medical students how to conduct pelvic exams. They are typically done during gynecological surgeries, but not exclusively. In 2024, the United States federal Department of Health and Human Services banned hospitals from performing non-consensual breast, pelvic, prostate, and rectal exams for "educational and training purposes" by medical students, nurse practitioners, or physician assistants. Hospitals that do not obtain explicit consent may be ineligible to participate in Medicare and Medicaid programs and may be subject to fines and investigations for violating patient privacy laws.

First-year medical students find such examinations more morally problematic than those who have completed clinical clerkships in obstetrics and gynaecology, an example of a phenomenon known as ethical erosion.

Frequency

A study done in 2003 found that 90% of Pennsylvania medical students had done pelvic exams on anesthetized patients during their gynecology rotation. One medical student described performing them "for 3 weeks, four to five times a day, I was asked to, and did, perform pelvic examinations on anesthetized women, without specific consent, solely for the purpose of my education."

A 2022 study of six American medical schools found that of the 84% of medical students that had performed pelvic exam(s) under anesthesia, 67% stated that they never or rarely witnessed explicit consent being obtained for a student to perform the pelvic exam under anesthesia. It is possible that such consent had been obtained when the clinician provided a discussion of the type of procedures to be performed, along with a discussion of the risks, benefits, and alternatives to the procedures; this discussion typically takes place at a preoperative visit.

Students have described pressure to do the examinations from their superiors. They have reported that they believed "they did not have the personal autonomy to object to performing pelvic EUAs that they believed were unconsented."

Support

The New York Times found that "doctors often argued that patients implicitly consented to being enlisted in medical teaching when visiting a teaching hospital, or that consent for one gynecological procedure encompassed consent for any additional, related exams."

People have described beliefs that if consent was asked, medical students would not be able to get experience performing pelvic exams; however, a majority of women polled stated that they would consent to such procedures. A utilitarian perspective argues that the educational benefit and consequential benefit to future patients is invaluable.

Others have opposed bans to maintain institutional autonomy and prevent government overreach.

Opposition

A social media hashtag, #MeTooPelvic, was created. People have described the exams as violating and traumatizing. They have been described as sexual assault, and a comparison to rape has been drawn due to the digital penetration without consent.

The Association of Professors of Gynecology and Obstetrics recommends that pelvic examinations only be done with explicit consent.

A 2022 study of third and fourth year medical students at the University of Pittsburgh School of Medicine found that 75% of students believed that explicit consent should be obtained for educational pelvic exams under anesthesia.

Legality

United States

The practice was first banned by California in 2003, followed by Illinois, Virginia, Oregon, Hawaii, Iowa, Utah, and Maryland in subsequent years. By 2019, it was still legal in 42 states, though some individual medical schools, such as Harvard, had implemented bans. By 2023, more than 20 states had enacted bans on such exams. In 2024, the United States federal Department of Health and Human Services banned hospitals from performing non-consensual breast, pelvic, prostate, and rectal exams for "educational and training purposes" by medical students, nurse practitioners, or physician assistants. Hospitals that do not obtain explicit consent may be ineligible to participate in Medicare and Medicaid programs and may be subject to fines and investigations for violating patient privacy laws. Additionally, the Office for Civil Rights announced that they were investigating complaints that patients’ health information had been disclosed to medical trainees in violation of the Health Insurance Portability and Accountability Act of 1996 Privacy Rule.

France

In 2015, it was revealed that some doctors had been using patients under general anesthesia as teaching tools for their students, performing rectal and vaginal examinations without consent. The most vocal critics were a group of fifty doctors, feminists, and social workers who wrote an open letter to the French government demanding an end to the practice. In response to the revelations, Health Minister Marisol Touraine requested an official report from the deans of medical schools at teaching hospitals. The report found that one in three pelvic examinations performed by first-year students, and one in five conducted by later-year students, were carried out without the patient's consent. In 2016, Touraine introduced new rules banning examinations on unconscious patients without consent. President Jean Marty of the gynecologists’ and obstetricians’ federation said the new rules were "disruptive" for patients and Bernard Hédon, head of the national college of gynecologists and obstetricians, labeled them as "prudishness."