You’ve Probably Had A Pelvic Exam You Didn’t Need. But Have You Had One You Didn’t Even Know About?

Depending on where you live, you may have gotten pelvic exams without even knowing it. In most states, it’s totally legal for medical students to perform exams – that aren’t medically necessary – for their own learning. Now states are weighing the pros and cons of requiring consent before performing them on unconscious women who get no benefit from the procedure, saying it’s wrong and destroying an already weak bond of trust between women and their providers. Doctors say what patients don’t know won’t hurt them, but shouldn’t women have a right to say no?

A History of Broken Trust

Women’s healthcare is a mess. OB-GYN doctors routinely dismiss our pain, diagnose sloppily, and use things like birth control as a catch-all solution to throw a Band-Aid on serious issues. All things considered, it’s no wonder women tend to have negative attitudes toward routine gynecological care. In one survey, 85% of women expressed negative feelings — defined as anxiety, vulnerability, and humiliation — toward pelvic exams, and a full 72% say they won’t discuss sexual concerns with their gynecologists.

This rocky relationship with our OB-GYNs has consequences for women’s health, as women try to figure out who to trust with their reproductive health. For one, although the OB-GYNs who perform them say that pelvic exams are crucial, even the American College of Obstetricians and Gynecologists has acknowledged that there is “little to no evidence” that routine exams benefit healthy women. The U.S. Preventive Services Task Force, an organization that advises the government on preventative care, concluded the same. In a review of several studies, the task force said that there wasn’t evidence to show that pelvic exams decreased the risk of illnesses like cancer or the risk of premature death, calling into question why so many doctors insist on making them so frequently.

Of the 2.6 million pelvic exams completed between 2011 and 2017, over half had no medical basis.

Most of the pelvic exams completed in the U.S. are unnecessary. Of the 2.6 million pelvic exams completed between 2011 and 2017, researchers estimate over half had no medical basis. Some doctors even threaten to withhold care if women won’t consent to a pelvic exam. Doctors already have a generation of women convinced that they need to be on birth control, and some will refuse to prescribe it if a woman won’t let them do a pelvic exam, even if she’s healthy. “Women should ask questions before consenting to these tests and consider switching providers if they’re told they can’t get birth control without a pelvic exam,” Melissa Simon, MD, MPH, from the Northwestern University Feinberg School of Medicine in Chicago told Reuters. “Neither a pelvic exam nor a pap test is needed in order to obtain contraception, except in the case (of) an IUD.”

Trauma and Consent

Invasive, unnecessary exams are bad enough. But what about when they’re not even consensual? Medical students are taught to view patients as course materials, and are frequently instructed to practice doing pelvic exams when women are unconscious and can’t protest. Pelvic Examinations Under Anesthesia (EUAs) have become common practice, often for women who are getting completely unrelated procedures. While medical ethicists have raised concerns about the practice since the 1960s, the lack of legal protections mean it’s still legal in most of the U.S., and many doctors ignore recommendations from ethical councils and committees to obtain consent from the patient before she’s anesthetized. It’s not rare, either: A survey of medical students showed that nearly 3 in 4 believed they had done pelvic exams without consent, sometimes “practicing” on unconscious women multiple times a day for weeks.

Many doctors justify the practice by saying that patients will never find out, but that isn’t always the case. For survivors of sexual trauma, the breach of trust can be especially violating. One woman named Ashley Weitz, who’d gone to the ER for a rapid heartbeat, woke up to a living nightmare. “I didn’t consent, and I know we didn’t talk about it, because I woke up in the middle of the exam screaming,” she recalled in an interview, “I don’t remember being put into stirrups, I don’t remember having my clothing removed." Weitz said her history of sexual abuse and assault made her question whether she was overreacting, and if consent was too much to expect as a patient. "I just wanted to be asked,” she said. Another woman only found out she’d had an exam because she experienced negative side effects after a surgery. When she returned for further care, the hospital told her consent wasn’t their problem: “They told me, ‘Is this a deal breaker for you? Because if so, you should have your surgery somewhere else.’”

“I woke up in the middle of the exam screaming...I don’t remember being put into stirrups, I don’t remember having my clothing removed.”

Gynecological training that strips women of their human dignity is producing doctors who do the same. More senior doctors put pressure on medical students to perform exams, creating a culture that scoffs at women’s informed consent. As one medical student puts it, “There is an enormous amount of pressure placed on students to perform the exams that are asked of us by our seniors, by our residents, by our attendants. And if we're not comfortable with the exam, it's difficult to say no.” Studies show that doctors who go through OB-GYN clerkships become desensitized to the use of unconscious women as educational materials, finding consent “significantly less important” than their peers who have not been through the same training. Bioethicist Phoebe Friesen says the attitude from students essentially becomes: “I can put my hand in this woman’s vagina because it helps with my training.”

Changing Tides 

The irony of the pelvic EUA debate? Most women would consent anyway. Aside from the fact that performing pelvic exams doesn’t even have a lot of educational value for med students, data shows that doctors don’t have to resort to sneaking in the procedure. Only 14% of patients said they’d refuse an exam under anesthesia if it was for educational purposes. Doctors’ laziness in getting informed consent might be more convenient for their schedules, but it’s clear that informed consent for women wouldn’t even throw a wrench in OB-GYN education. The medical establishment is continuing to erode women’s trust just because it’s less paperwork.

Luckily, legislation and medical norms are slowly catching up to this reality. Colorado is one of the most recent states to ban pelvic EUAs without consent, and 21 other states have already made it illegal. Proponents of the legislation say it’s important for rebuilding trust between women and their reproductive healthcare providers, and medical students themselves are beginning to advocate for more ethical standards of care. 

Closing Thoughts

Women’s medical care won’t improve without trust, and trust can’t improve if doctors continue to cut corners on human dignity. No educational need is worth skirting patient consent, and women deserve care that treats them like humans, not objects. Women shouldn’t have to fear sexual trauma any time they have a surgery, and while consent shouldn’t suffice as a medical ethic, it should absolutely be a necessary component. Legislators need to hold doctors to a higher standard, as it’s increasingly clear they won’t do it themselves.

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