3 Unethical Ways Medical and Nursing Students Are Taught to Do Pelvic Exams

(Content Note: violation of consent, sexual assault, medical abuse)

Most of us don’t grow up enjoying sexual agency and bodily autonomy. In fact, it’s rare these ideas would even be talked about. Who ever hears about bodily autonomy as a child?

Rather, we’re told to kiss and hug adults we don’t want to touch, and our sense of agency and ability to consent is frequently taken away from us.

One silver lining of the recent string of exposed sexual assault cases, especially those with one presidential candidate, is that we’re at long last talking about sexual assault – and the ways in which blatant disrespect and sexual harassment affect people of marginalized gender, including women, rampantly in our culture and many others.

In a culture where there is so much sexual entitlement, including as expressed towards women, the idea of sexual agency is foreign. But to quote from my book, Woman On Fire:

“Sexual agency means to have control and dominion over your own sexuality. You are a free agent. You are the agent of your body, your sexuality, your sexual choices, your sexual expression, and your sexual pleasure and power. The power over your sexuality is in your hands. You have true independent sexual choices. As a sexual agent, you are susceptible to many conflicting influences as you work to [assert] your own place of power as a sexual being.”

There are countless ways our bodies are co-opted and our sexual agency is taken from us – all the ways the fate of our bodies and sexuality are put in the hands of men or anyone else who doesn’t own this body (which is everyone but the person who lives in it).

Our sexual agency and bodily autonomy is removed when:

• Medical providers or family members make decisions over our bodies we don’t consent to
• People commit sexual violence against us
• We’re taught that we owe our partners sexual (and other intimate) access
• Judges give rapists little or no sentence or punishment because their well-being and livelihood is more important than the survivor’s – which sends a message that what they did was acceptable
• People critique our bodies without our asking their opinion
• We’re sexually harassed at work, on the streets, in our families, or anywhere else
• Public spaces are not made accessible to us if we have a disability
• We’re made to hug people we don’t want to hug as children (imagine your parent making you give Donald Trump, or any adult you don’t want to touch, a hug)
• We’re denied health care and the ability to make healthcare decisions that are right for us
• We are denied safe, accessible public restrooms because of our gender
• We’re told we must carry a pregnancy to term, birth a child we do not want, have a cesarean, or experience our birth in a way we do not consent to
• We’re given pelvic exams or other bodily touch or probes by medical students or others we did not consent to give us exams, sometimes while under anesthesia
• We’re sexually assaulted while in the hospital, in a coma, or in other vulnerable positions
• Doctors talk about us and our bodies disrespectfully while we are anesthetized during surgery
• The media perpetuates ideas that our bodies are not okay and makes commentary supporting any of the above behavior

There are countless ways that our bodily autonomy and sexual agency are removed. This list could be as long as the day.

And one core value of feminism and other anti-oppression movements is that all people are the authorities of our own bodies – and no one else has the right to that authority.

However, medical providers, as official “authorities of the body” often take that authority over the body, often bypassing a patient’s individual right to consent to what happens to us in the name of medicine, or to make choices that might be in conflict with what the medical provider wants us to do.

And many people with vaginas are disenfranchised from the gynecological care that we need, which puts us at risk for health issues and compromising early detection of cervical changes and cancers when we avoid going. As such, gynecology is a microcosm of the bigger ways that our vaginas and our bodies are treated.

Most patients have had some kind of negative experience with the gynecologist. Most people who need pelvic exams dread them and often describe the experience as painful and traumatizing – or at best, just a necessary evil we have to deal with.

And one of the main reasons pelvic exams are such horrible experiences is because oftentimes, health care providers never learned how to perform the exam in an empowering and physically comfortable way. In fact, they routinely learn the procedure in unethical ways that are incredibly disempowering and harmful to patients.

And yet, this is something that is very rarely talked about – even within feminism.

To understand why we end up getting the care we get and why the quality of gynecological care is often compromised, it’s important to look at the origins of gynecology and how students learn to do their exams.

The doctor who has been widely considered to be the “Father of Gynecology,” Dr. Marion Sims, developed his groundbreaking procedures and instruments by experimenting on black women that he had enslaved, often waking them in the middle of the night to try out a new procedure – without anesthesia, even though anesthesia existed at the time, his colleagues holding them down while they screamed in pain.

He caused these women great pain and suffering. The three whose lives and sacrifices are well-documented were Lucy, Anarcha, and Betsey.

And this is nothing new. There are countless examples of people of color who have been routinely sterilized without consent in order to control their reproduction. Indeed, even Planned Parenthood was founded by a eugenicist who wanted to control the reproduction of poor women of color.

In the Tuskegee experiment, black military airmen were consciously infected with syphilis in order to find out what happens when we don’t treat it – a very dark moment in our medical history.

The list of reproductive wrongs that have been cast on people of color and those without political power and resources is long. Sadly, mainstream feminism has colluded in these wrongs by failing to bring them to the fore, erasing the particular ways that people, and especially women, of color are vulnerable to medical assault and experimentation from the platforms of feminist movements.

No wonder so many women feel so disenfranchised.

And yet, this is not just an issue of the past – it seriously impacts us right now. To this day, there are some detrimental practices employed in order to teach students how to do pelvic exams – practices that deny patient autonomy, choice, and consent. Here are three.

1. Using Anesthetized Patients

It’s common for students to “practice” the pelvic exam on anesthetized people without their consent.

This happens when a student is in their gynecology rotation, and they follow a doctor around to learn. If a doctor is scheduled to perform gynecological surgery on a patient, they’ll have the medical student “practice” a pelvic exam on the patient after they’re put under anesthesia, before the surgery starts. Sometimes, more than one student will practice the exam with many sets of fingers in the patient’s vagina without their knowledge.

And specific consent for this isn’t obtained. The patient is never asked if this is okay with them.

This practice (albeit somewhat implicitly) teaches students to completely disregard consent – and that their learning trumps the needs of their patients, which is highly unethical.

The patient is, in the end, an object that exists to serve the needs of the student. If the student expresses any moral objections to doing this, they may find that they’re stifled by the larger environment and are dissuaded from saying “no” to their preceptors.

Many people unfortunately think that this is a thing of the past, but as the filmmakers of At Your Cervix – folks who work in health care, and who have interviewed many medical and nursing students and professors – we can tell you that this is still a common practice.

Research has shown that up to 90% of medical students learn exams on anesthetized people without clear informed consent, and that the importance of informed consent erodes for medical students after their OB/GYN rotation.

2. Using the Student Body

In medical or nursing school, students learn hands-on skills focusing on different parts of the body in clinical lab classes.

In some schools, when it comes time to learn the breast and pelvic exams, students are required to learn those exams on each other. Most students feel like they can’t say “no” to this, even if it’s presented as an “option” because it might be the only time to learn the skill – and they fear repercussions from faculty.

Being forced to expose their bodies to fellow students and to their professors, and be touched in ways to which they don’t consent, is a form of assault and an invasion of student privacy.

Further, when students are taught that it’s okay to violate the body of another – and be violated themselves! – for the sake of learning, they’re taught to disregard themselves and others in the healthcare setting.

Similarly to the issue of practicing on patients under anesthesia, if students have any moral objections to this practice, they’re taught to disregard that, too. And this can have devastating consequences in the way that those students then learn to treat their patients.

3. Using Unsuspecting Patients

Teaching hospitals and clinics are directly affiliated with university medical and nursing schools, where students will get clinical experiences with real patients, giving them learning opportunities. Students learn and develop hands-on skills by practicing on patients, under the guidance of a credentialed healthcare provider.

In a gynecological clinic, if a patient comes in for a pelvic exam, a student will perform it with the health care provider watching over them, whispering guidance in their ear. Would you want to be the owner of the very first vagina a student examines?

Sometimes, patients are told to expect to have a student be “a part of their care.” More often, they’re not told anything, and an extra person in a white coat just shows up in the exam room with the health care provider without being introduced. Generally, the patient has no idea what’s going on (“Why is this other person in the room?”), and they’re not asked if it’s okay for the student to observe, let alone to do the exam.

When the patient isn’t asked if the student can be involved in the visit and what that means exactly, informed consent is completely disregarded – and the moral compass of the student shifts to justify the objectification of the patient for the sake of their learning.

All of these teaching practices are harmful – and they mirror larger social norms that simultaneously value the objectification of marginalized bodies and diminish the importance of consent and bodily autonomy.

Given that teaching hospitals often serve people who receive public health insurance, we see that people of color and in poverty are disproportionately impacted. Although at this point, most hospitals are in some form considered teaching hospitals, with some ties to a higher education institution.

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The most frustrating part of all of this is that it doesn’t have to be this way. If anything, the pelvic exam can and should be comfortable and empowering.

There is an ethical and pedagogically sound alternative way for students to learn to do breast and pelvic exams without using their patients or fellow colleagues: There are people who are highly trained to teach breast and pelvic exams called Gynecological Teaching Associates (GTAs).

GTAs know their bodies well and use their own bodies to teach the pelvic exam to students. They can expertly teach students how to perform an exam so that it’s comfortable – something an anesthetized patient or teacher cannot do. GTAs also focus on how to make the exam empowering through language and approach.

Even though GTAs have been around for over three decades, they’re underutilized – and if available, are only one way students learn the exam. Student education is often supplemented with other unethical teaching methods.

How the pelvic exam is taught and the way patients experience the exam is an issue at the heart of feminism: it speaks to how our bodies are objectified for another’s gain and how our consent is not valued. To change this, we must be advocate and demand a better way.

I’m directing and producing a documentary called At Your Cervix, which does just this. To learn more about the film and to be part of a campaign to improve pelvic exams, please visit us here.

We’re also raising the necessary finishing funds right now. Please make a donation to help bring this film into reality so that we can make sure that every pelvic exam is respectful, ethical, and pain-free for all patients.

We can change the way our bodies are treated and used for teaching, and improve care for us all.

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Amy Jo Goddard is an international sexuality speaker and teacher who offers intensive women’s sexual empowerment programs and sex and relationship coaching. She is author of Woman On Fire: 9 Elements to Wake up Your Erotic Energy, Personal Power and Sexual Intelligence, and co-author of Lesbian Sex Secrets for Men. She is the director and producer of the forthcoming documentary At Your Cervix. Find her online at www.AmyJoGoddard.com.