Under any other circumstances, it would be a crime. So why is this the exception?Content notice: Descriptions of sexual assault, medical trauma
When Ashley Weitz went to the emergency room at a local hospital in Utah in 2007 for severe nausea and vomiting, she was sedated with IV medication to help the vomiting subside.
While the medication was intended to bring her relief from her symptoms, what happened while under sedation had nothing to do with her illness: Weitz later woke up screaming when she saw a doctor performing a vaginal exam.
She hadn't been told this exam would be done, wasn't pregnant, and hadn't consented to an internal examination of any kind. However, what happened to Weitz wasn't an uncommon practice. In fact, it was legal.
In the majority of U.S. states, it's for medical providers, typically medical students, to go into an operating room and, without a patient's consent, push two fingers into an anesthetized patient's vagina and perform a pelvic exam.
Oftentimes, it's multiple medical students performing this nonconsensual exam on the same patient.
But unlike Weitz, the majority of patients have no knowledge that this has happened to them.
These nonconsensual pelvic exams are a common practice that medical schools and hospitals justify as part of teaching students how to perform them. However, they're missing a critical perspective: that of the patient's.
"I was traumatized by this," Weitz explains.
In the United States, sexual assault is defined as "any non-consensual sexual act proscribed by Federal, tribal, or State law, including when the victim lacks capacity to consent" - and medical providers that penetrate a patient's genitals without their consent, when they're incapacitated under anesthesia (with the exception of a life-threatening medical emergency), are engaging in behavior tantamount to sexual assault.
The fact this is often being done as part of a medical student's training doesn't make it any less of a violation.
No, I'm not suggesting medical students and doctors are predators with sinister intent - but their intent is irrelevant in the absence of the patient's consent.
The very act of penetrating someone's genitals without their permission or knowledge, absent a medical emergency, is criminal. We shouldn't redefine, accept, or minimize this behavior just because it's being done by a medical professional.
Actually, just the opposite: We should expect medical providers to adhere to a higher standard.
In , Dr. Shawn Barnes, then a medical student, spoke out (and later testified to change the laws in Hawaii) about being required to perform pelvic exams on unconscious patients who hadn't given explicit consent.
Barnes highlights how patients signed forms written in vague terms that stated a medical student may be "involved" in their care, but didn't tell patients this "care" included an internal exam while they're under anesthesia.
Barnes' experience in medical school isn't unusual, but many medical students are afraid to speak out about being required to do these nonconsensual exams out of fear of retribution.
The problem is
Two-thirds of medical students in Oklahoma reported being asked to perform pelvic exams on patients who hadn't consented. Ninety percent of medical students surveyed in Philadelphia performed this same exam on anesthetized patients, not knowing how many had actually consented.
And recently, several medical students around the country reported to the Associated Press that they, too, had conducted pelvic exams on unconscious patients and didn't know if any of them had actually given consent.
Many in the medical community scoff at the idea that this is unethical or could be considered assault since this has been standard practice for years.
But just because it's routine doesn't make it ethical.
There's also a common view in hospitals that if a patient already consented to surgery, and since surgery in and of itself is invasive, then an additional consent for a pelvic exam isn't needed.
Consenting to a medically necessary surgery, however, doesn't mean a patient also consents to a stranger entering the room afterward and inserting their fingers into their vagina.
Internal pelvic exams by their very nature differ from other types of exams done on other body parts. If we accept this standard - that the status quo should just remain, especially as it relates to patient care - then unethical practices would never be challenged.
Hospitals often rely on the fact that since most patients don't know this exam was performed, they can't do anything about it after. But, if this practice is as benign as many medical professionals claim, why not get consent?
It's really a matter of convenience. Hospitals seem to worry that if they have to get consent, then patients will decline, forcing them to change their practices.
Paul Hsieh, a Denver-based physician who writes about healthcare policy, reports that "Deliberately choosing not to ask due to fear of a 'no' answer and instead performing the procedure anyways violates the very concepts of consent, patient autonomy, and individual rights."
Some medical providers also claim that when a patient comes to a teaching hospital, they're giving implicit consent - that the patient is somehow supposed to know medical students can perform internal exams on them.
This convenient excuse ignores the reality that most patients don't have the luxury to decide between multiple hospitals.
They choose a hospital out of necessity: where their doctor has privileges, where their insurance is accepted, whichever hospital is closest in an emergency. They might not even be aware that the hospital they're at is a teaching hospital. For example, Stamford Hospital in Connecticut is a teaching hospital for Columbia University in New York City. How many patients would definitively know this?
Excuses aside, the fact remains: We need to stop pretending that medical trauma is an inconsequential form of trauma.
Patients who do find out postop that a pelvic exam was done without their consent report feeling violated and experience significant trauma as a result.
Sarah Gundle, a clinical psychologist and the clinical director of Octav in New York City, says that medical trauma can be just as significant as other types of trauma.
"A nonconsensual pelvic exam is a violation just like any other type of violation," she says. "In some ways it is even more insidious, because it is often being done without the patient even knowing, in a place that is supposed to protect patients."
Melanie Bell, a board member for the Maryland Nurses Association, also reported during a legislative committee hearing that there are also times when patients have awakened during the exam (like what happened to Weitz) and felt violated.
Compounding this type of violation is that this practice isn't only unethical, but when it's done by medical students, it's almost always medically unnecessary.
These exams are overwhelmingly performed for the student's benefit and provide no medical benefit to the patient.
Dr. Phoebe Friesen, a medical ethicist who has extensively studied this issue and authored a recent
"Countries and states that have banned this practice have not been limited in their ability to effectively train medical students. There are others ways to teach that do not require a pelvic exam being performed on a patient that has not given consent and often doesn't even know what has happened while they were under anesthesia," Friesen says.
Some hospitals, such as NYU Langone in New York City, report using paid pelvic exam volunteers for medical students to practice the exam on, eliminating the issue of exams without consent.
Performing pelvic exams without consent is in Hawaii, Virginia, Oregon, California, Iowa, Illinois, Utah, and Maryland. Legislation prohibiting this recently passed the New York legislature and is pending in other states, including Minnesota and Massachusetts.
While this practice is most common with pelvic exams, many of these bills also ban nonconsensual rectal and prostate exams being done on an anesthetized patient as well.
A number of legislators, including New York State Sen. Roxanne Persaud (D-Brooklyn), have become outspoken critics of this practice.
"There are certain expectations you have when you visit your doctor, and it's not that your body is going to be taken advantage of if they have to put you under anesthesia," she said.
And it's not just legislators speaking out, either. The American College of Obstetrics and Gynecology's (ACOG) has denounced this practice, stating pelvic exams on an anesthetized patient that are performed for teaching purposes should be done only with informed consent.
But some medical schools continue to use their influence to try to push back on legislation requiring consent. Yale Medical School reportedly warned lawmakers against possible legislation in Connecticut.
When speaking of her own traumatic experience, Weitz says, "When the medical community does not value a patient's bodily autonomy, it has a very negative impact on patient care."
Consent should be fundamental in medicine, but exams like these undermine the very premise of doing no harm to the patients that medical providers have sworn to heal. And if consent is deemed optional in medical care, where is the line drawn?
"If medical providers are taught to forgo obtaining consent," Weitz says, "then that way of practicing medicine continues."Misha Valencia is a journalist whose work has been featured in The New York Times, Washington Post, Marie Claire, Yahoo Lifestyle, Ozy, Huffington Post, Ravishly, and many other publications.