Thursday, September 25, 2014

Patient Dignity 19: Doctor Are Examining Your Genitals for No Reason


When a girl becomes a woman, she is initiated into a bizarre and mysterious annual ritual. She takes off her clothes, sticks her arms through a backless medical gown, reclines on an examination table, and spreads her legs. A doctor fits her feet into a pair of stirrups, looks at her genitals, sticks a cold metal speculum into her vagina, cranks it open, and peers in. When the speculum is removed, the doctor inserts a finger or two, and pokes around to feel the woman’s internal organs. Sometimes, the fingers examine her rectum, too.

In 2010, doctors performed 62.8 million of these routine pelvic examinations on women across America. In total, gynecological screenings cost the U.S. $2.6 billion every year.

And yet, a new study published in the Annals of Internal Medicine reports that there is no established medical justification for the annual procedure. After scouring nearly 70 years of pelvic exam studies, conducted from 1946 to 2014, the researchers found no evidence that they lead to any reduction in “morbidity or mortality of any condition” among women. In light of the study, the American College of Physicians, a national organization of internists, has crafted a new set of guidelines warning doctors that exams conducted on otherwise symptomless women can “subject patients to unnecessary worry and follow-up” and can “cause anxiety, discomfort, pain, and embarrassment, especially in women who have a history of sexual abuse.”

In an editorial also published in Annals, internists George Sawaya and Vanessa Jacoby of the University of California–San Francisco, conclude that the pelvic examination has “become more of a ritual than an evidence-based practice.” Sawaya told me that the routine pelvic exam is such "a foundational cornerstone" of gynecology, it's hard to even trace its origins. The new report urging doctors to reverse course will be "very controversial," Sawaya says. "I expect a lot of physicians to raise their eyebrows."

Just two years ago, the American College of Obstetricians and Gynecologists admitted that “no evidence supports or refutes the annual pelvic examination … for the asymptomatic, low-risk patient.” Nevertheless, ACOG reupped its endorsement of the exam, writing that it “seems logical.” The procedure—which is routinely initiated early in a woman’s teen years and conducted annually—can aid in “establishing the clinician–patient relationship” and provide “an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks,” ACOG reported. In other words, according to ACOG, while the annual pelvic exam might not be worthwhile in and of itself, it can be a useful device for bringing a woman to her doctor every year to get some necessary information about her reproductive health.

These conflicting recommendations—one by internists, the other by gynecologists—speak to the effects of cultural shaming on women’s health. Some women—particularly women who have been abused—can experience enough anxiety and pain from the intimate exams that they become less likely return for future exams. That could deter women from heading to the doctor when they do have problematic symptoms or heightened cancer risks. Furthermore, women taking birth control pills typically have to undergo an annual pelvic exam before a doctor will refill a prescription, which could prevent some women from using this safe and effective contraceptive method. (The ACP insists that refilling an oral birth-control prescription should not require a pelvic exam.)

Meanwhile, other women experience enough generalized anxiety about their genitals and reproductive systems that the fear pushes them to see their doctors every year and undergo examinations that, it turns out, won’t actually tell them much of anything about their health. While the 70 years of studies parsed in Annals paint an incomplete picture of the full effects a pelvic exam can have on a woman’s well-being, they do suggest that the exams can produce both “false-positive results” and “false reassurance” among women.

The pelvic exam is just the latest women’s health ritual to be reexamined in light of new research. In 2012, the United States Preventive Services Task Force and the American Cancer Society released new recommendations suggesting that women should undergo routine pap smear tests every three years, not once a year. In March, an Food and Drug Administration panel voted to replace the pap smear—in which a doctor scrapes cells from the cervix that are analyzed under a microscope for visual abnormalities—with an HPV test targeted at identifying the strains of the virus most likely to lead to cervical cancer. And in 2009, the USPSTF changed its stance on routine mammograms, recommending that women begin undergoing mammograms at age 50, not 40, and that they do them every two years, not every year.

Proponents of yearly pelvic exams may say that they compel women to seek counsel from their doctors and receive vital information about their own health. (They also, of course, bolster gynecologists' job security.) But it's becoming clear that this line of thinking is self-defeating: There’s no reason for women to report to their doctors every year if they can’t even trust what they’re being told.

What happened to, "First do no harm?"

...and physicians wonder why their patients do not trust them.

There is no reason that a genital exam ever needs to be performed on anyone older than 2 years as part of an annual physical or as part of any other exam in asymptomatic patients. You can not distinguish between the physician who is being "thorough" and a serial sexual predator in the medical setting. In order to protect the patient, it is necessary to err on the side of caution. The patient should be given the option AND allowed to decline this exam without penalty. 

The physician's "fiduciary duty" requires the physician to sacrifice his own well being for that of the patient. This justifies the "without penalty to the patient" requirement. 


Thursday, September 18, 2014

Patient Dignity 18: Doctor-Patient Relationships and Domestic Violence

I have heard physicians and other providers respond to the fact some patients have been harmed by the healthcare system that they were not aware of ever harming their own patients. They say things like "No patient ever told me," and it seems that they assume that everything is fine since other patients return.

The first question to ask is what about patients that never return? The answer is "I don't know." That is because very few providers track patients that leave. In today's environment very few practices are taking on new patients let alone track down patients who have not been in for a regular visit. It is commonly assumed that these patients found another provider, moved out of the area, passed away, etc.

The ugly truth is that although those reasons may be true for some, there are others who have just decided to "opt out" of healthcare rather than suffer repeated indignities. I have also heard from people, I can't take any more after XX years." What? Why stay if you are being abused?

That prompted me to look at the bad doctor-patient relationship in terms of domestic violence and abusive relationships. All too often whether it be an abusive relationship between lovers/partners or doctor-patient, people say, "Just leave." If it seems like common sense to leave a lover/partner /spouse who is abusive, the lines may me a little more murky for the doctor-patient relationship.

By examining the more obvious abusive lover/partner/spouse relationship, we can gain insight why a patient may not speak up to a physician, and then we can understand why physicians may believe things are fine.

Let's start off with "Understanding domestic violence and abuse."  Then next we will look at the basic questions, "Why people abuse," "Why do people stay in abusive relationships," the "Characteristics of an abusive relationships," the "Characteristics of those who batter," and "What does an emotional abuser get out of the abuse," Finally  we will examine "Consent."

Note: I will highlight the aspects of abusive lover/partner /spouse relationships that apply to abusive doctor-patient relationships.  I will place my comments in purple italics. 

Understanding Domestic Violence and Abuse

Domestic abuse, also known as spousal abuse, or an abusive relationship, occurs when one person in an intimate relationship or marriage tries to dominate and control the other person. Domestic abuse that includes physical violence is called domestic violence. The very nature of the doctor-patient relationship makes it one of intimacy. 

Domestic violence and abuse are used for one purpose and one purpose only: to gain and maintain total control over you. An abuser doesn’t “play fair.” Abusers use fear, guilt, shame, and intimidation to wear you down and keep you under his or her thumb. Your abuser may also threaten you, hurt you, or hurt those around you.

Domestic violence and abuse does not discriminate. It happens among heterosexual couples and in same-sex partnerships. It occurs within all age ranges, ethnic backgrounds, and economic levels. And while women are more commonly victimized, men are also abused—especially verbally and emotionally, although sometimes even physically as well. The bottom line is that abusive behavior is never acceptable, whether it’s coming from a man, a woman, a teenager, or an older adult. You deserve to feel valued, respected, and safe. The same is true of the doctor-patient relationship.

Why People Abuse

People abuse their partners because they believe they have the right to control the person they’re dating. Maybe the abusive partner thinks they know best. Maybe they believe that as the more knowledgable person, more popular person, etc. in the relationship they should "wear the pants." Maybe they think unequal relationships are ideal.

Abuse is a learned behavior. Med school? Sometimes people see it growing up. Other times they learn it from friends or popular culture. But, no matter where it's learned, it's not ok and it's never justified. Many people experience or witness abuse growing up and decide not to use those negative and hurtful ways of behaving. It's most important to know that abuse is a choice -- and it’s not one that anyone has to make.

Why Do People Stay in Abusive Relationships?

People who have never been abused often wonder why a person wouldn’t just leave. They don't understand that breaking up can be more complicated than it seems.

There are many reasons why both men and women stay in abusive relationships. If you have a friend in an unhealthy relationship, support them by understanding why they may choose to not leave immediately.

Conflicting Emotions
  • Fear: A partner may be afraid of what will happen if they decide to leave the relationship. If a person has been threatened by their partner, family or friends, they may not feel safe leaving. Fear of being "blacklisted " and not finding another provider.
  • Believing Abuse is Normal: If a person doesn’t know what a healthy relationship looks like, perhaps from growing up in an environment where abuse was common, they may not recognize that their relationship is unhealthy. This may be more common for some one who has a chronic illness or disease from childhood. They may have grown up having their dignity and body violated without their consent and believe that it is normal. 
  • Fear of Being Outed: If a person is in same-sex relationship and has not yet come out to everyone, their partner may threaten to reveal this secret. Being outed may feel especially scary for young people who are just beginning to explore their sexuality. Fear of all the intimate aspects of our lives that we shared when asked about our "history."
  • Embarrassment: It’s probably hard for a person to admit that they’ve been abused. They may feel they’ve done something wrong by becoming involved with an abusive partner. They may also worry that their friends and family will judge them. Some people blame themselves for their illness. 
  • Low Self-esteem: If a person’s partner constantly puts them down and blames them for the abuse, it can be easy for a person to believe those statements and think that the abuse is their fault. Illness (especially chronic illness) and hospitalization causes depression.
  • Love: Your friend may stay in an abusive relationship hoping that their abuser will change. Think about it -- if a person you love tells you they’ll change, you want to believe them. Your friend may only want the violence to stop, not for the relationship to end entirely. Stockholm Syndrome? (Info link here:)


  • Social/Peer Pressure: If the abuser is popular, it can be hard for a person to tell their friends for fear that no one will believe them or that everyone will take the abuser's side. Physicians are highly respected individuals in a community, and by the nature of a "physician's fiduciary duty," they are assumed trustworthy.
  • Cultural/Religious Reasons: Traditional gender roles can make it difficult for young women to admit to being sexually active and for young men to admit to being abused. Also, a person’s culture or religion may influence them to stay rather than end the relationship for fear of bringing shame upon their family. Physicians are highly respected individuals in a community, and by the nature of a "physician's fiduciary duty," they are assumed trustworthy. Families may not believe their "own blood," especially if that person is the "black sheep."
  • Distrust of Police: Many people do not feel that the police can or will help them, so they don’t report the abuse. Physicians are highly respected individuals in a community, and by the nature of a "physician's fiduciary duty," they are assumed trustworthy.
Reliance on the Abusive Partner
  • Lack of Money: A person may have become financially dependent on their abusive partner. Without money, it can seem impossible for them to leave the relationship. Physicians are highly respected individuals in a community, and by the nature of a "physician's fiduciary duty," they are assumed trustworthy.
  • Nowhere to Go: Even if they could leave, a person may think that they have nowhere to go or no one to turn to once they’ve ended the relationship. Fear of being "blacklisted " and not finding another provider.
  • Disability: If a person is physically dependent on their abusive partner, they can feel that their well-being is connected to the relationship. This dependency could heavily influence his or her decision to stay in an abusive relationship. Dependency for tratments and/or medications.

What are the Characteristics of an Abusive Relationships?

What Is Abuse?

  • Abuse can be physical, emotional, or sexual. Physical abuse means any form of violence such as hitting, punching, pulling hair, and kicking. Abuse can occur in both dating relationships and friendships.
  • Emotional abuse (stuff like teasing, bullying, and humiliating you and others) can be difficult to recognize because it doesn't leave any visible scars. Threats, intimidation, putdowns, and betrayal are all harmful forms of emotional abuse that can really hurt — not just during the time it's happening, but long after too.
  • Sexual abuse can happen to anyone, guy or girl. It's never right to be forced into any type of sexual experience that you don't want.

Signs of Abusive Relationships

Important warning signs that you may be involved in an abusive relationship include when someone:
  • Harms you physically in any way, including slapping, pushing, grabbing, shaking, smacking, kicking, and punching. Abuse by physicians rarely sink to this level, but they can make procedures or exams uncomfortable and downright painful. They may order unneeded exams, procedures, and tests.   
  • Tries to control different aspects of your life, such as how you dress, who you hang out with, and what you say. Medication refills? No birth control without a pelvic exam (even though one is not required? 
  • Frequently humiliates you or makes you feel unworthy (for example, if a partner puts you down but tells you that he or she loves you) threatens to harm you, or self-harm. Physicians can make procedures or exams uncomfortable.  They may order unneeded exams, procedures, and tests, have additional people in the room during the exam, have you examined by students, have you photographed or exposed needlessly.   
  • Twists the truth to make you feel you are to blame for your partner's actions. A physician saying that your feelings and requests are irrational, excessive, contrary to the protocol for the procedure or saying that this is how things are always done. 
  • Objectifies a person, thus taking away aspects of their humanity. Physicians often do this to "desexualize" patient encounters.  
  • Unwanted sexual advances that make you uncomfortable are also red flags that the relationship needs to focus more on respect. In more blatant cases, the behaviors can range from sexual abuse to rape. Some people believe that forced sex with a partner, spouse or lover (someone you previously had sex with) is not rape. Any unwanted, forced sexual contact is sexual assault/abuse and unwanted, forced sexual intercourse is rape.  Physicians may easily commit sexual assault/abuse under the guise of healthcare. Trust your intuition. If something doesn't feel right, it probably isn't.   
  • When someone says stuff like "If you loved me, you would . . . " that's also a warning of possible abuse, and is a sign that your partner is trying to manipulate you. A statement like this is controlling and is used by people who are only concerned about getting what they want — not caring about what you want. Similar to saying "If you want me to keep treating you, then you will..." 

Signs That a Person Is Being Abused

In addition to the signs listed above, here are some signs a friend might be being abused by a partner:
  • unexplained bruises, broken bones, sprains, or marks Perhaps the results of unnecessary or extremely "rough" procedures/exams.
  • excessive guilt or shame for no apparent reason Especially in people having chronic or life long illnesses.
  • secrecy or withdrawal from friends and family This is to avoid talking about their illness or medical subjects (such as an annual physical exam).
  • Fear, anxiety, or phobias around certain subjects, depression, PTSD (or the symptoms of any of these).  

Characteristics of Those Who Batter

  • Emotional Isolation: These people do not see their friends as a source of emotional support, or do not have friends outside the primary relationship. If they do, they're generally superficial, social not emotional. This is one of the causes of the high rate of suicide among physicians. (Link to my post on physician suicide here:)
  • Dependency on the Victim: These people see their partner as being responsible for recognizing and meeting their emotional needs; in short, the partner has the power and responsibility to make them feel good, to nurture and to comfort them. This dependency closely resembles, what children attribute to their mothers, "Mom can make it "all better." This dependency can be material as well, including money, housing, clothing, transportation, etc. Physicians depend on their patients for their livelihood.
  • Externalizing the Responsibility for Behavior: Violent people tend to attach responsibility for their actions to persons and external situations and not to themselves. They rationalize their violence by attributing it entirely to the victim. Paternalism? I need to do this to make the patient compliant.
  • Minimization and Denying the Violence: The people generally minimize or denied the severity and frequency of the violence. For example, "I just pushed her," "I've got some problems, but I'm certainly not one of those wife-beaters" are common ways of minimizing the violence that has occurred. This was the way I was taught. The "Hidden Curriculum." 
  • Extremes of Behavior: These people are often described as being nice guys by friends, co-workers and even the partner. But the partner also sees the irritable, nasty, belligerent and hostile other side. These extremes in behavior make it difficult for many people to identify these people as batters. There have been many issues with the way physicians treat nurses.
  • Not in Touch with Own Stress: Most people who batter, tend to be very disconnected from their own feelings of stress. So, it is a potentially dangerous situation because they don't see the need to deal with that stress until it becomes extreme in size and is expressed through violence. This is one of the causes of the high rate of suicide among physicians. (Link to my post on physician suicide here:)
  • Drug and Alcohol Use: Drugs and alcohol are involved in more than 60 percent of violent episodes. Alcohol lowers inhibitions against violence, while heavy use of drugs like cocaine increases paranoia, which increases the likelihood of violence. Some people attribute their violence to the drugs or alcohol, claiming to feel out of control when under their influence. However, most of the people have been abusive with or without a substance problem. This is one of the warning signs of suicide among physicians. (Link to my post on physician suicide here:) The State of California feels that this is such a pervasive problem, that there is pending legislation to require random testing of physicians.
  • Internal Feelings of Depression and Despair: Often under the hostility and aggression are the feelings of depression and despair. These feelings tend to emerge in people at two points. First, when the person is actively working at and succeeding in controlling his aggression. Secondly, after his female partner has left him as a result of the violence. The second point is critical in that it is very common for the person at this point to think about suicide and homicide. This is one of the causes of the high rate of suicide among physicians. (Link to my post on physician suicide here:)
  • Instrumental Aggression: One of the most frightening and dangerous batter is a person whose violence becomes "instrumental" in getting what he want. It's no longer simply an out-of-control rage response, but a calculated way of gaining a desired reward. This person seems to show no emotion during the violence and remorse afterwards. Physicians depend on their patients for their livelihood. This was the way I was taught. The "Hidden Curriculum." 
  • Military Experience: It's estimated that over 58 percent of batters have had prior military experience. These people are given training in the use violence to deal with conflict. Most military people tend to hold the notion that they are in charge. These factors may increase the possible violence in the home. The abuses of medical school have been compared to that of "boot camp."

What Does an Abuser Get Out of the Abuse?

Abuse is almost entirely about control. It is often a primitive and immature reaction to life circumstances in which the abuser (usually in his childhood  [ Medical school maybe?] ) was rendered helpless. It is about re-exerting one's identity, re-establishing predictability, mastering the environment - human and physical.

The bulk of abusive behaviors can be traced to this panicky reaction to the remote potential for loss of control. Many abusers are hypochondriacs (and difficult patients) because they are afraid to lose control over their body, its looks and its proper functioning. This may explain why physicians (and medical students) refuse to be the subjects for medical school training and insist patients have that obligation. It may also explain why physicians (themselves) avoid the healthcare system, self treat, and are usually "fitness nuts."

They are obsessive-compulsive in an effort to subdue their physical habitat and render it foreseeable. Typical physician personality. They stalk people and harass them as a means of "being in touch" - another form of control. To the abuser, nothing exists outside himself. Meaningful others are extensions, internal, assimilated, objects - not external ones. Objectifying the patient.

Thus, losing control over a significant other (patient) - is equivalent to losing control of a limb, or of one's brain. It is terrifying. Independent or disobedient (noncompliant) people evoke in the abuser the realization that something is wrong with his worldview, that he is not the centre of the world or its cause and that he cannot control what, to him, are internal representations.

To the abuser, losing control means going insane. Because other people are mere elements in the abuser's mind - being unable to manipulate them literally means losing it (his mind). Imagine, if you suddenly were to find out that you cannot manipulate your memories or control your thoughts ... Nightmarish! In his frantic efforts to maintain control or re-assert it, the abuser resorts to a myriad of fiendishly inventive stratagems and mechanisms.

What is Consent?

(Informed) consent is an important component to the doctor-patient relationship, just as it is to lover/partner/spouse relationship. Legally there instances when consent in not required, even though it is not criminal, it is just as emotionally/mentally damaging to the patient to ignore their wishes.

As important as consent is, we don’t talk about it enough. So it’s understandable if you’re a little unsure as to what consent is – and what it isn’t. You may have heard the idea that “no means no,” but this doesn’t really provide a complete picture of what consent is because it puts the responsibility on one person to resist or accept. Implied consent and the issues that accompany it. It also makes consent about what a partner doesn’t want, instead of being able to openly express what they do want. Again, implied consent and the issues that accompany it.

Well, How Does It Work?

Some people are worried that talking about consent will be awkward or that it will ruin the mood, which is far from true. That is why consent is usually hidden in the form you sign when being admitted. If anything, the mood is much more positive when both partners are happy and can freely communicate what they want. Is this not true of healthcare too? First off, talk about what terms like “hooking up” or “going all the way” (or exam, exposure, treatment) mean to each partner. Consider having these conversations during a time when you’re not being physically intimate (or naked in the exam room).

If you are in the heat if the moment (in the Emergency Department, during a procedure or exam), here are some suggestions of things to say:

  • Are you comfortable?
  • Is this okay?
  • Do you want to slow down?
  • Do you want to go any further?
What Consent Looks Like:
  • Communicating every step of the way. For example, during a hookup (in the Emergency Department, during a procedure or exam), ask if it’s okay to take your partner’s shirt off and don’t just assume that they are comfortable with it. 
  • Respecting that when they don’t say “no,” it doesn’t mean “yes.” implied consent
  • Breaking away from gender “rules.” Girls are not the only ones who might want to take it slow. Also, it’s not a guy’s job to initiate the action (or anything else, really). Gender choice in healthcare, the disparity between the way men and women are treated and the choices each is given.

What Consent Does NOT Look Like:

  • Assuming that dressing sexy, flirting, accepting a ride, accepting a drink etc. is in any way consenting to anything more. Assuming that being put in a gown gives everyone and anyone in healthcare complete and unfettered access to the patient's body.
  • Saying yes (or saying nothing) while under the influence of drugs or alcohol. An instances when consent in not required.
  • Saying yes or giving into something because you feel too pressured or too afraid to say no. Paternalism!
Here are some red flags that indicate your partner doesn’t respect consent:
  • They pressure or guilt you into doing things you may not want to do. Paternalism!
  • They make you feel like you “owe” them — because you’re dating, or they gave you a gift, etc. Paternalism!
  • They react negatively (with sadness, anger or resentment) if you say “no” to something, or don’t immediately consent. Paternalism!
  • They ignore your wishes, and don’t pay attention to nonverbal cues that could show you’re not consenting (ex: pulling/pushing away). Paternalism!

Get Consent Every Time

In a healthy relationship, it’s important to discuss and respect each other’s boundaries consistently. It’s not ok to assume that once someone consents to an activity, it means they are consenting to it anytime in the future as well. Whether it’s the first time or the hundredth time, a hookup, a committed relationship or even marriage, nobody is ever obligated to give consent just because they have done so in the past. A person can decide to stop an activity at any time, even if they agreed to it earlier. Above all, everyone has a right to their own body and to feel comfortable with how they use it -- no matter what has happened in the past.

It is important to know that just because the victim “didn’t say no,” doesn’t mean that they meant “yes.” When someone does not resist an unwanted sexual advance, it doesn’t mean that they consented. Sometimes physically resisting can put a victim at a bigger risk for further physical or sexual abuse

...But Physicians, Nurses, and Other Providers are not Abusers...

One physician hurled a surgical instrument at his co- workers in a fit of anger. Another tried to stuff a nurse head- first into a trash can. A group of nurses banded together to blackball a doctor and get his privileges revoked. 
Bad behavior among doctors and nurses has always been health care’s dirty little secret. Almost everyone in the indus- try has a story to tell about harassment, insults traded back and forth or a screaming match in the operating room. 
But a new survey conducted by the American College of Physician Executives illustrates just how pervasive the prob- lem has become. And ACPE is working to find ways to curb the bad behaviors. 
According to the survey results, outrageous behavior is still common in this country’s health care organizations. More than 2,100 physicians and nurses participated in the survey, and some of the tales they related were surprising:
  • Physicians groping nurses and technicians as they tried to perform their jobs.
  • Tools and other objects being flung across the OR.
  • Personal grudges interfering with patient care.
  • Accusations of incompetence or negligence in front of patients and their families.
Source: American College of Healthcare Executives (2009 Doctor-Nurse Behavior Survey)

Patient Abuse. Gerald Hickson, MD, and colleagues analyzed patient complaints to his hospital, Vanderbilt University, and linked the results with malpractice suits. Researchers estimated that about 6% of physicians are abusive. Abusive doctors were defined as those receiving more than two complaint letters a year. They found that most physicians at Vanderbilt (80%) receive no complaints from patients (Hickson et al. JAMA. 2002;287:2951). However, physicians who regularly receive complaints have a much greater chance of being sued for mal- practice. 
Source: Society of Critical Care Medicine (Problem Doctors: Is There a System-Level Solution? 2007)

Physicians are prone to abuse. The system creates abusers then isolates them.

"After at least seven years of post-college graduate medical education on the emotional, mental, and physical condition of the human being, you would expect a physician to be a powerhouse of goodwill for his or her patients. Unfortunately, too many doctors fail to keep the welfare of their customers at the forefront, as their main concern. The needs to boost their own egos, self-preservation, and the quest for more money often result in inappropriate care and harm the patient" 
Source: John A. McDougall, MD (How to Protect Yourself from Abusive Doctors 2011)

"During residency, doctors trained in authoritarian systems are likely to internalize as normative a model of interaction with underlings and patients that desensitizes them to problem behaviors if not converts them into outright abusers themselves." Source: National Institute of Health (Cruelty in Maternity Wards: Fifty Years Later 2010)

"...use of harmful medical interventions to outright verbal, physical, and even sexual assault. Furthermore, the more extreme examples are not aberrations but merely the far end of the spectrum. Abuse, moreover, results from factors inherent to the system, which increases the difficulties of implementing reforms." Source: National Institute of Health (Cruelty in Maternity Wards: Fifty Years Later 2010)

You Can't Compare Healthcare to Domestic Abuse.... Can You?

According to (an online resource devoted to helping individuals recognize, address, and prevent domestic violence), domestic violence and emotional abuse encompass “name-calling or putdowns,” “keeping a partner from contacting their family or friends,” “actual or threatened physical harm,” “intimidation,” and “sexual assault” (“Domestic Violence Definition,” 2009, para. 2). In all cases, the intent is to gain power over and control the victim. One could add that perpetrators, obstetric staff or otherwise, feel entitled to exert this control on grounds of the victim's inferior position vis-à-vis the perpetrator... Source: National Institute of Health (Cruelty in Maternity Wards: Fifty Years Later 2010)

Why a Physician Might be Unaware of Patient Abuse

Whether caused by the the current physician or a past physician, if the abuse was intentional or unintentional, and if the abuse was real or perceived, the current physician may be unaware that the patient is a victim of medical abuse. The current physician may conclude, that if they were the cause of the abuse, the patient would certainly discontinue the doctor-patient relationship with them.

By examining abusive relationships between spouses/partners, where the abuse is overt and obvious, we can see that patients may remain in an abusive relationship with a physician. Just because a patient returns,  a physician should NEVER assume that they are treating the patient in an acceptable manner.

Many procedures and examinations may appear to be tolerated well by the patient while the doctor is present, yet the patient may collapse into tears or let the suppressed terror and panic show the moment the physician leaves the room or the patient leaves the office. Many persons who were badly abused as children were taught to suppress any expression of apprehension or displeasure, lest they be punished more. Not only may a previously abused patient be mustering their courage to tolerate what must be done, but also the same patient may consciously or unconsciously be anticipating being treated poorly should any discomfort or displeasure be shown.

It should be noted that because of the authority generally afforded to physicians by society, some patients will acquiesce to exposure, intimate examinations, even abuse under the guise of healthcare, despite internal fears and concerns about the procedure. The physician should be sensitive to this possibility and ensure that the patient has truly given "informed consent" and not simply tacit acceptance.

Update: October is Domestic Violence Awareness Month

September 22, 2014

Domestic Violence Awareness Month evolved from the first Day of Unity observed in October, 1981 by the National Coalition Against Domestic Violence. In October 1987, the first Domestic Violence Awareness Month was observed. That same year the first national toll-free hotline was begun. In 1989 the first Domestic Violence Awareness Month Commemorative Legislation was passed by the U.S. Congress. Such legislation has passed every year. (Source: National Coalition Against Domestic Violence)

By just as  violence and abuse occur in domestic relationships, violence and abuse can occur in the doctor-patient relationships. The National Institute of Health article;Cruelty in Maternity Wards: Fifty Years Later, details how domestic abuse parallels abuse in healthcare. By studying domestic abuse we can better understand and prevent abuse under the guise of healthcare.


Tuesday, September 16, 2014

Patient Dignity 17: The Military's Double Standard for Men

Warning: Parts of this post are NSFW (Not Safe For Work):
 It contains nudity and sarcasm.

It is funny how things connect in this world. The 2012 movie Cloud Atlas (Starring Tom Hanks, Halle Berry, Hugh Grant) is a good example of how things connect.

"An exploration of how the actions of individual lives impact one another in the past, present and future, as one soul is shaped from a killer into a hero, and an act of kindness ripples across centuries to inspire a revolution. (Source: IMDB)"

Infographic Source: Cinema Blend

So goes it with this "military theme" has grown the same way. It started with a book titled "Medical Rape," by Lars G Petersson.  (You can download it as a FREE ebook here:)  I have been having on going conversations with Lars, I introduced him on my blog here: Lars will be writing a future post for my blog too.

My next post: "From Mother Theresa to Dr. Mengele" dealt with examining how physicians enter medical school wanting to help and leave (quite frankly) as monsters. It looked at the Holocaust as the greatest example of physicians' betrayal of their "do no harm" oath and how this occurred.

In the process of doing research on patient dignity/healthcare abuses, I came across some interesting information about "The Medical Process for Candidates Applying for Entry into the Australian Defence Force." I referenced this in a comment on the Bioethics Discussion blog of Dr. Maurice Bernstein. Looking at my comment I realized that this would make a great post on my blog.

I began to see a pattern. Lars Petersson's book "has been written for all the men who have suffered as a result of abusive medical examinations by military institutions and their civilian associates." The focus of the book is on the "musterung" (the German military medical induction exam).

"From being a perverted male-only ritual of 'initiation', the whole matter, the musterung (the military medical induction exam), in the name of so called 'equal rights' between the genders, has developed into nothing but a state-approved sexual humiliation process of young men. Today female medical inspectors, though themselves under no legal obligations neither to serve or to strip, have almost completely taken over the dominant roles in this age old humiliation process. Today these women have grabbed for themselves what could look like almost unlimited power over thousands of legally forced, naked young men."

So here is the post I made from my comments on Bioethics Discussion:

Here is a perfect example of the double standard that men face: 

The Medical Process for Candidates Applying for Entry into the Australian Defence Force (PDF document). (My comments are in Purple.) It starts out:

Why is a Medical Examination required?Medical standards in the ADF need to be of the highest level to allow the successful completion of all military duties. These are often performed in isolated and stressful circumstances where there is no ready access to medical care.
The medical process will assess your suitability to perform military specific duties, and your ability to adapt to different living conditions. The medical process aims to ensure that you do not have a pre-existing medical condition requiring uninterrupted access to medication, medical care or special diets. 
OK, fair enough. Here are the other section headings...
What are the processes of the Medical screening?
Your Opportunities Unlimited (YOU) Session"Unlimited Opportunities," that must be a good thing... 
What is involved in the Preliminary Examinations?
What is involved in the Medical Examination?
Now it gets good....
...During this examination you will be required to undress down to your underwear (both males and females will be provided with a gown to wear, if requested)...
Wait, I have to request a gown? Why don't they just give me one?
--Looking and feeling for any abnormalities around the abdomen and anal regions. A rectal examination is not performed. Males will have the external genitals examined for abnormalities.
External genital abnormalities???
--Gynaecological examination will not be performed on females. If the Doctor deems a gynaecological examination necessary to determine your fitness you will be referred back to your own Doctor.
--Females are not required to have their breasts examined. If there is a problem identified in the medical history questionnaire, you will be referred to your own Doctor for further follow up.

Why do males need their external genitals examined for abnormalities? Are they that important to the defense of Australia?

I have to conclude from this that the country of Australia expects that if you don't have a weapon and you are under attack that you will have to pull out your penis and stab the enemy...

More Research:

Warning: Nudity!

I stumbled across the following pictures on a single web site. They depict soldiers in combat displaying their penises. You may be outraged by the following pictures, but I would hope that you are more outraged by the disparity of the respect of human dignity that men receive in all healthcare, not just the military.

Perhaps you may say these are men in stressful situations attempting humor, rebellion, commentary, or a combination there of. They could be a means of lovers experiencing sex while one is deployed. It could also be a perversion of soldiers with damaged psyches from dignity abuses.

I propose it is the latter. I reason this from the pictures that I did NOT want to post. Some were XXX rated. I will not describe them, but you can use your imagination to estimate them when you see what I am willing to post.

All these pictures are of active duty soldiers from various countries. Most were taken during the recent Middle East conflicts. I am not an expert in identifying what country each belongs to (due mainly to the lack of uniforms), but I can guess. I also made sure that their identities were obscured.

I think I found the answer why all militaries are concerned with men's genitals....

Australian (red berets)

Definitely British

This was titled: "British forces support Prince Harry"

Unknown, but in the Middle East

Unknown, possible US, in the Middle East

Unknown, possible US, in the Middle East

US forces in the Middle East (tell by the tanks)

Unknown (Possible Russian, Czech, German)

German, this explains the "musterung"

Unknown (Possible Russian, Czech, German)

Chinese (the Red ArmY)

I guess when they say "any weapon," 
they mean "ANY WEAPON"

Yes this post was filled with sarcasm. This highlights the double standard applied to men everywhere. Then people wonder why men avoid healthcare?


Saturday, September 13, 2014

Patient Dignity 16: From Mother Theresa to Dr. Mengele

I know that this title seems inflammatory, but this series of posts is all about AND from the view of (victim) patients. What is inflammatory are the cases of  Justina Pelletier and Dr. Stanley Bo-Shui Chung. These are but two of the thousands of examples of physicians betrayal and abuse of patients.

Patients who have had their dignity victimized often describe their experiences liking them to the indignities suffered by the survivors of the concentration camps. More than once I have heard providers referred to as Dr. Mengele. One common attribute that they share is the fallout in their lives after the event, namely PTSD.

That all humans are capable of evil is the foundational truth of Christian civilisation. This insight — known as “original sin” — has been around for at least 2,000 years. It has been repeatedly underwritten by the crimes of history. Yet, mysteriously, people still find it shocking.

What is more dangerous is the denial by the healthcare system that their practitioners ARE capable of doing such things, AND that human dignity commonly ignored. There are some instances that outright abuse, torture, and assault occur. I wish that I could say these were rare occurrences, but they have become all to common. 

So many people claim to go into healthcare for altruistic reasons but come out seemingly lacking any compassion or empathy. Patients are objectified, an entitlement to the patients' bodies permeates, and dignity and self-determination is sacrificed for efficiency, paternalism, and arrogance. Some providers are even worse.....

This has prompted me to look closer look at Nazi doctors in the concentration camps. If these physicians could abandon all ethics. Perhaps this can shed some insight to providers today.

Perhaps the most large-scale, infamous misappropriation and misapplication of medical personnel and practices and widespread perversion of medical research occurred in the Holocaust. As Lifton [Lifton RJ: The Nazi Doctors: Medical KillIng and the Psychology of Genocide.] recounts in his monumental study, The Nazi Doctors, the Nazi ‘biomedical vision’ seized on the metaphor of healing the racially diseased body of the German nation. 
In this context, killing those who constituted the disease was a therapeutic venture, much as the excision of a malignant growth. “The Nazis based their justification for direct medical killing on the simple concept of ‘life unworthy of life’ (lebensunwertes Leben) … Of the five identifiable steps by which the Nazis carried out the principle of ‘life unworthy of life,’ coercive sterilization was the first. There followed the killing of ‘impaired’ children in hospitals; and then the killing of ‘impaired’ adults, mostly collected from mental hospitals, in centers especially equipped with carbon monoxide gas. This project was extended (in the same killing centers) to ‘impaired’ inmates of concentration and extermination camps and finally, to mass killings, mostly of Jews, in the extermination camps.” [Lifton RJ: The Nazi Doctors: Medical KillIng and the Psychology of Genocide.] 
Lifton [Lifton RJ: The Nazi Doctors: Medical KillIng and the Psychology of Genocide.] quotes Martin Borman, “The Fuhrer holds the cleansing of the medical profession far more important than, for example, that of the bureaucracy, since in his opinion the duty of the physician is or should be one of racial leadership.” In the camps, Jewish doctors among the inmates on occasion were forced into assuming various roles in the Nazis' projects.
Lifton [Lifton RJ: The Nazi Doctors: Medical KillIng and the Psychology of Genocide.] found that many of the Nazi doctors coped with the tension between their usual selves and values and the roles that they had in the camps by ‘doubling,’ i.e., by forming a self that could tolerate and adapt to the total perversion of traditional medical values. “In sum, doubling is the psychological means by which one invokes the evil potential of the self. That evil is neither inherent in the self nor foreign to it. To live out the doubling and call forth the evil is a moral choice for which one is responsible, whatever the level of consciousness involved.” [Lifton RJ: The Nazi Doctors: Medical KillIng and the Psychology of Genocide.]

Even more disturbing than the mass killings of the concentration camps was how the prisoners were routinely stripped of all human dignity. The camps and the killing was all about efficiency. Having prisoners naked added to the efficiency and made them more compliant.

Within 90 minutes of arrival at the camps, after being stripped of possessions, clothes and all human dignity, prisoners were prodded naked down what the SS laughingly called Himmelstrasse  -  "the road to heaven"  -  to the "showers." 
They complied because the guards were authority figures and the purpose of undressing was for "hygiene" and "medical" reasons. The medical aspect was to choose the which prisoners were to be used for slave labor and medical experiments, the rest were sent to the gas chambers. 
Medicalization of the killing process was one of the many deceptions the Nazis used. It was partly for the victims so that they can be rendered non-resisting as much as possible, and for the Nazis, so they can see themselves as some way caring out a legitimate medical procedure. 
Auschwitz was not just an extermination camp, it was the clearest example of German doctors betrayal of all their ethical training. For the first time physicians could implement death into their medical research. Buchenwald was the first camp to use prisoners for medical experiments, but it was not the only one.

Doctors had been the largest professional group to join the SS. Their crimes were so great, that a separate trial took place in Germany for them. The object of their experiments was not how to rescue or cure, but to destroy and kill.

Read more about the key role that SS physicians played in the concentration camps here:

Even TodayThe United States Military, CIA Compelled Physicians to Abuse Detainees at Gitmo

Defense Department and CIA interrogation policies after 9/11 forced medical professionals to abandon their ethical obligations to "do no harm" to those in their care and some prohibited practices, including force-feeding of hunger strikers, continue today, a report issued Monday alleges.

The report, Ethics Abandoned: Medical Professionalism and Detainee Abuse in the War on Terror, was carried out by a 19-member task force of Columbia University's Institute on Medicine as a Profession and the Open Society Foundations. The researchers spent two years examining public records of medical professionals' involvement in military and intelligence interrogations and treatment of detainees.
It accuses the counter-terrorism operations of having "improperly demanded that U.S. military and intelligence agency health professionals collaborate in intelligence gathering and security practices in a way that inflicted severe harm on detainees in U.S. custody." (Source: LA Times, November 4, 2013)

The "restraint chair" used to immobilize and force-feed detainees on hunger strike in the prison hospital at Guantanamo Bay, Cuba. A report issued Monday said doctors and other medical professionals have been forced by the Pentagon and the CIA to take part in abusive practices that violate their ethical commitments. (Joe Raedle / Getty Images)

Even more:
A piece in the medical journal Tropical Medicine and International Health is raising questions about possible medical abuse at the prison facility because of the use of a controversial anti-malaria drug connected to serious side effects, including depression, anxiety, panic attacks, nausea, vomiting, sores and suicidal thoughts and behavior. (Source: Mintpress News, August 30, 2012)

How to explain the "Mother Theresa to Mengele" Phenomenon 

There are two famous experiments that can explain the transformation that takes place among medical providers as they go through their training. They are the "Stanford Prison Experiment" and the "Milgram Experiments."

The results of these experiments was so traumatic to the participants that the Stanford Prison Experiment was stopped in less than half the time it was planned. Some have deemed these experiments unethical and should never be repeated.

The Stanford Prison Experiment

Stanford University ran an experiment that was to become famous. Known as the Stanford Prison Experiment, 24 participations were arbitrarily split into two groups, with 12 role-playing prisoners and 12 role-playing guards. The experiment was to last 2 weeks and was going to investigate the mental and emotional changes that a person goes through when they are a prisoner.

The experiment is explained in great detail in the book The Lucifer Effect by Philip Zimbardo. It is a rather harrowing read; in very little time what started out as role-playing became real life. The guards took to their new positions with brutality and mental and physical abuse was rife. The prisoners became insular and it was like an accelerated course in learned helplessness. They either became robots blindly following the guard’s requests or began to rebel – trying to escape or going on a hunger strike.

The experiment was meant to last for two weeks but was stopped after six days when three prisoners had been released early due to mental breakdowns.

All participants, whether they ended up being prisoners or guards, considered themselves pacifists and non-violent types, your quintessential hippies. But the setting and the situation changed all of this in a very short space of time. The book goes on to review the situation at Abu Ghraib prison, where prisoners were tortured and photos were taken showing the depraved behaviour. It was like history repeating itself but without someone pulling the plug after six days.

During the summer of 1971, an unprecedented experiment was conducted by Stanford University psychology professor Philip Zimbardo, involving a mockup of a prison built in the basement of the university’s Psychology Department. 24 undergraduate students were paid $15 a day to participate in what was intended to be a two-week experiement. They were either assigned a role as a prison guard or as a prisoner, and the guards were told to run the ‘prison’ as they saw fit with the one condition that they were not to use violence.  
The students who were assigned roles as prisoners were ‘arrested’ by Palo Alto police officers who escorted them to the prison, fingerprinted them, after which the prisoners were given ill-fitting smocks and rubber sandals with their given ‘numbers’ sewn. Some prisoners were forced to be naked as a method of degradation.
The whole thing went out of hand relatively quickly, despite the fact that both the guards and the prisoners knew that they were participating in an experiment. A riot ensued on the second day; the prison quickly became filthy and unsanitary. Prisoners began to show severe acute emotional disturbances even within the first few days, forcing the prison ’superintendent’, Zibargo himself, to intervene on behalf of two prisoners who were eventually ‘released’ from the experiment. The guards also became progressively more sadistic, denying food to unruly prisoners, forcing them to spend time in isolation, and even making them clean the bathrooms with their bare hands. The experiment ended after six days, when it became clear that the situation was spiralling out of control in its eerie realism. 
"The Stanford prison was a very benign prison situation and it still caused guards to become sadistic, prisoners to become hysterical… it promoted everything a normal prison promotes … sadism, confusion and shame. " 

The following is a 29-minute long BBC documentary on the experiment:

It’s disturbing to note how people, irrelevant of personality or character, are able to impose authority, or on the other hand submit meekly without questioning, and furthermore to assume roles that are entirely made up. One must realize that an experiment of its kind, for its unethical nature, will probably never be reproduced again.

Yet, this is repeated thousands upon thousands of times each day in the U.S. healthcare system where dignity is trampled upon, building trust is not done, and authoritarianism is used in the name of entitlement (to patient's bodies), efficiency, and paternalism.

The Milgram Experiments

In the post Holocaust era, the question of how normal people could commit such horrid acts to one another haunted the American psyche.  Stanley Milgram decided to investigate this occurrence, in what turned out to be one of the most famous modern psychology experiments in history.

Milgram wanted to see if normal people would comply if authority figures told them to do inhuman acts.  To do this, he set up a scenario where his subjects would think that they were giving escalating shocks to a person to the point where it could be lethal.  The only prodding these subjects would receive to continue giving higher voltage shocks was from an authority figure in a white lab coat telling them that they must continue with the experiment.

The results of his experiment (which are summarized here:) were disturbing, because the majority of subjects did continue to “shock” someone until the lethal levels when prodded by the authority figure.
Two slips of paper marked "teacher" were handed to the subject and to the co-subject. The co-subject was actually an actor who, in posing as a subject to the experiment, subsequently claimed that his slip said "learner" such that the unknowing subject was inevitably led to believe that his role as "teacher" had been chosen randomly.
Both learner and teacher were then given a sample 45-volt electric shock from an apparatus attached to a chair into which the "actor-learner" was to be strapped. The fictitious story given to the "teachers" was that the experiment was intended to explore the effects of punishment for incorrect responses on learning behavior.

A succession of unknowing subjects in their roles as teacher were given simple memory tasks in the form of reading lists of two word pairs and asking the "learner" to read them back and were instructed to administer a shock by pressing a button each time the learner made a mistake. It was understood that the electric shocks were to be of increased by 15 volts in intensity for each mistake the "learner" made during the experiment.

The shock generator that the "teacher" was told to operate had 30 switches in 15 volt increments, each switch was labeled with a voltage ranging from 15 up to 450 volts. Each switch also had a rating, ranging from "slight shock" to "danger: severe shock". The final two switches being labelled "XXX".
The experiment was conducted in a scenario where the "learner" was in another room but the "teacher" was made aware of the "actor-learner's" discomfort by poundings on the wall.

No further shocks were actually delivered - the "teacher" was not aware that the "learner" in the study was actually an actor who was intended, by the requirements of the experiment, to use his talents to indicate increasing levels of discomfort as the "teacher" administered increasingly severe electric shocks in response to the mistakes made by the "learner".

The experimenter was present in the same room as the "teacher" and whenever "teachers" asked whether increased shocks should be given he or she was verbally encouraged by the experimenter to continue.

These encouragements were, in fact, pre-scripted by the research team and followed this pattern:-
Prod 1: Please continue or Please go on.
Prod 2: The experiment requires that you continue.
Prod 3: It is absolutely essential that you continue.
Prod 4: You have no other choice, you must go on.

These Prods were to be deployed successively by the researchers - a higher number Prod could only be used if a lower number one had proved unsuccessful.

Each experimental session was terminated whenever Prod 4 failed to induce the "teacher" to continue administering electric shocks. In this scenario 65% of the "teachers" obeyed orders to punish the learner to the very end of the 450-volt scale! No subject stopped before reaching 300 volts!

At times, the worried "teachers" questioned the experimenter, asking who was responsible for any harmful effects resulting from shocking the learner at such a high level. Upon receiving the answer that the experimenter assumed full responsibility, teachers seemed to accept the response and continue shocking, even though some were obviously extremely uncomfortable in doing so.

How does this Happen to Physicians?

The process of becoming a doctor is so extremely challenging to most physicians cannot help but feel their survival is threatened from time to time. So behaviors/attitudes get driven into their mental programming as a Survival Mechanism. Physicians learn them at a deep subconscious level and can’t turn them off.

So what are these learned behaviors? Here are some. Some of the following learned behaviors desexualize the human body but also lead to abuses of human dignity:

  • being a workaholic
  • looking professional
  • hide emotions/feelings
  • being a "loner"
  • use scientific, technical language
  • focus on getting the task done
  • using a chaperone
  • objectifying the patient
  • using power to control and/or intimidate patients to do what they’re told

No instructors, professors or attendings has ever tried to "brainwash" physicians consciously and on purpose. The expectations and attitudes that create this subconscious programming are built into nearly every facet of their medical education as NORMAL and "the way things have always been done around here".  [Have we heard that before?]

To most physicians in private practice the programming is invisible and unrecognized and the automatic behaviors it produces are dysfunctional and baffling. This “brainwashing” virtually guarantees physician burnout in their 40’s and 50’s AND for abuses of patient dignity to occur.

How deeply are physicians brainwashed?

Basic training in the military is 8 weeks. In that time they can condition an 18 year old to take a bullet on command. Medical education is a minimum of 7 years, for some physicians it could be 12 years.  I believe there is no more thorough conditioning program on the planet than becoming a doctor.


Is there a Mr. Hyde hiding in the good Dr. Jekyll?

What is the good of saving a life if the quality of that life is not worth living (PTSD)? Just because "that was the way you were taught" OR "that is the way it is done here" does NOT mean that that is the correct and most dignified way to perform a procedure. The protocols for many procedures 25 years ago would NEVER be acceptable today.

This is how some patients feel during a procedure:

Don't believe me, OR are you lying to yourself?

Consider Peter Ubel, M.D., author of Critical Decisions and Free Market, and a post he made on Psychology Today:
I felt a woman’s uterus without her permission. How this happened, and why I thought I had done the right thing at the time, tells us something important about medical education and shows us why doctor/patient interactions often play out like conversations between earthlings and aliens.  
To understand my inappropriate actions, you need to know something about the physical exams that we physicians conduct on our patients. More specifically, about the pelvic exams we perform to assess whether a woman’s uterus or ovaries are potentially diseased... 
...But we know that we must overcome our nerves and practice. I certainly knew of my need to practice when I walked into the operating room that day, in 1987, gowned and gloved and prepared to assist the surgeon in any way possible... 
“Student, come over here right now,” the surgeon said. “We need to start the operation, but you need to examine the patient first.”  
“Come over and feel her uterus,” she told me. “She has a large uterine mass. You need to know how to recognize this kind of mass on a pelvic exam.”
“Don’t worry,” the surgeon continued. “She’s anesthetized and won’t feel a thing. Plus, her muscles are totally relaxed from the anesthetics, so you will have a much easier time feeling the anatomy.” 
I inserted two fingers from my right hand into her vagina, pressed gently on her abdomen with my left, her uterus now squeezed between my two hands. Yep.  Definite mass. My physical examination skills were now inching towards expertise. My surgical supervisor had helped me develop as a physician. 
But of course, she’d also shaped my moral development. I had examined the woman, after all, without her permission. How could the surgeon and I have thought that it was acceptable to do this?  I could only speak for myself. To begin with, I was frantically obsessed with learning my new trade.  In addition, I wanted to impress the surgeon and get a good grade on the rotation. So when I stood there in the O.R. that day, presumably facing a moral dilemma, I barely gave the situation a second thought. 
The result of that was that I began thinking that this kind of action was ok. The surgeon, after all, was a wonderful person, committed to medical education and patient care. And I knew that I had nothing but good intentions in examining this patient. There was nothing prurient in my behavior.  I simply wanted to become a better clinician. 
But I’m sure if we had woken up that woman and told her what happened, she would have been horrified. The women I have surveyed on this topic say that, while they’d be willing to give permission for medical students to practice pelvic examinations on them, they would feel violated if such practice occurred without their permission.  
Moral attitudes are often a function more of our experience than of our training. When some colleagues and I surveyed medical students and asked them how important it was to ask permission before conducting a pelvic exam on an anesthetized woman, brand new medical students almost universally stated that permission was vital but by the time the students finished their OB/GYN rotations three years later, they didn’t see permission as being important anymore (see paper here). 
Despite the lectures they’d received about “informed consent” during the first two years of medical school, six weeks of an OB/GYN rotation was enough to change their moral attitudes.

 Are you Medical or a Monster??? 
What would your patients say?

How do you know???