Monday, November 16, 2015

Trump Needs to Call Carson Out...


Dr. Ben Carson has thrown his hat in the ring as one of the 2016 Republican Presidential candidates. He had made his share of gaffs. 
He’s compared Obamacare to slavery. He was for gun control – especially assault weapons – before he was against it. He compared homosexuality to bestiality and child abuse. He said fashion models looked like Auschwitz prisoners. (Source: Blue Nation Review)
I do not believe that he can be a candidate unless he answers for the shameful practices of medical schools, AND promises an end to them. I speak of pelvic exams and other intimate exams of patients, while under anesthesia, by medical students, WITHOUT explicit consent. 

Here are links to PubMed articles (National Institutes of Health) on the subject

The issue was brought to light in 2003. The practice was rampant especially in the 1970’s and 1980’s (Carson graduated medical school in 1977). I am sure that Dr. Ben Carson had learned to to pelvic exams in this manner. A 2003 survey of Philadelphia medical students found that 90 percent reported being asked to perform pelvic exams on women who had not explicitly consented to the procedure. (Source: PubMed, "Don't ask, don't tell: a change in medical student attitudes after obstetrics/gynecology clerkships toward seeking consent for pelvic examinations on an anesthetized patient.” )

This act of rape under the guise of medical care is still happening today. See the 2012 PubMed article, Practicing pelvic examinations by medical students on women under anesthesia: why not ask first? 
As a medical student, Dr. Shawn Barnes had an experience that he says left him feeling ashamed and conflicted. During his rotation through the obstetrics and gynecology ward of a teaching hospital in Hawaii, Barnes performed pelvic exams on women under anesthesia without the women's explicit consent to the procedure… 
"For three weeks, four to five times a day, I was asked to, and did, perform pelvic examinations on anesthetized women," Barnes wrote in an editorial published in the October issue of the journal Obstetrics and Gynecology… 
But Barnes says the exams are done without explicit consent more often than these doctors indicate. A 2003 survey of Philadelphia medical students found that 90 percent reported being asked to perform pelvic exams on women who had not explicitly consented to the procedure. (Source: Live Science)
It is not only women at risk for this, but men are at risk too. (Source: ABC News, "Students Perform Pelvic Exams Without Consent”) In fact, male modesty and consent is often overlooked more than female modesty and consent. (Reference: Patient gender preferences for medical care)

Donald Trump needs to call Dr. Ben Carson out on the issue of how he learned to do pelvic exams and other intimate exams. Has he ever owned up to what he did? Has he ever apologized for what he has done. This does not only happen to women, but to men as well (although it is not as publicized). 

Donald Trump has been hard on all candidates, asking the tough questions. Now he needs to get tough on Carson. 

The problem stems from physicians and medical students believing that patients are obligated to be teaching subjects, hence reducing patients to warm cadavers. This had become such an issue, that ethical research was done to show physicians and students that patients do NOT have an obligation to participate in medical training. (See: PubMed, "Refuting patients' obligations to clinical training: a critical analysis of the arguments for an obligation of patients to participate in the clinical education of medical students”) 

Even in 2015, physicians and medical students believe that patients are obligated to be teaching subjects and insufficient respect for patients’ autonomy. (Source: PubMed, “Medical Students’ and Physicians’ Attitudes toward Patients’ Consent to Participate in Clinical Training”) 

Please note that I do not have any direct proof that Dr. Ben Carson was trained in this manner,BUT if you look at the 2003 PubMed article cited above, 90% of medical students admitted to being asked to perform pelvic exams on women who had not explicitly consented. When you take in to account a certain number of students may have been ashamed of doing this and lied, the number is higher. 

Further, being a medical student and a person of color in the 1970’s and 1980’s, there was a perception that the medical student was not the most qualified candidate (reference: Black Man in a White Coat: A Doctor's Reflections on Race and MedicineTaking My Place in Medicine: A Guide for Minority Medical Students, and The Atlantic), hence not the best doctor. 

Couple that perception with the racism of the time (racism is still a problem today), AND being male, Dr. Carson would probably have had very few opportunities to perform pelvic exams as a medical student. (reference: Black Man in a White Coat: A Doctor's Reflections on Race and Medicine, and Taking My Place in Medicine: A Guide for Minority Medical Students

None of this is meant to degrade Dr. Carson, in fact it does just the opposite. There’s no doubt that Ben Carson is a brilliant neurosurgeon, although now retired from his illustrious career as a neurosurgeon, Dr. Carson holds 67 honorary doctorates, is a member of Alpha Omega Alpha (AOA) Honor Medical Society and sits on the board of directors of several leading organizations.  

What just as disturbing, is Dr. Ben Carson’s anti-gay views and comments are paramount to a racism of sexual or gender identity. Dr. Carson compared gays who support marriage equality to pedophiles and practitioners of bestiality during a March 27 interview on Fox News' Hannity. (Reference: Media Matters

Patients should feel safe at a physician’s office, and physicians expect patients to be honest and tell them the most intimate details of their lives. According to new research, your doctor may biased against LGBT patients. New findings from research conducted by the University of Washington show that health care providers may in fact harbor biases against patients of opposing sexual orientations.

According to the abstract of the study published online Thursday by the American Journal of Public Health, “implicit preferences for heterosexual people versus lesbian and gay people are pervasive among heterosexual health care providers.” This maltreatment amounts to torture. 
A federal court in Minnesota issued a preliminary ruling in a case concluding that discrimination against an individual because of his gender identity is prohibited under the Affordable Care Act… 
The lawsuit, known as Rumble v. Fairview Health Services, was filed in June 2014 by the Minnesota-based advocacy group Gender Justice. In addition to making claims on the basis of the Affordable Care Act, the lawsuit also alleges the hospital violated the Minnesota Human Rights Act. The court also allows the litigation to move forward on the basis of alleged discrimination under this statute. (Source: Washington Blade)
There can be no free pass for Dr. Ben Carson. Donald Trump talks about getting tough. It is time that he needs to get tough on Ben Carson. He needs to ask him about learning PEs and his views on LGBT individuals.

Thank you for reading. 

Friday, June 26, 2015

Patient Chaperones: A Practice that is Useless and Abusive

First reported by Courthouse News Service, "Unconscious Patient Says Doctors Mocked Him," plaintiff D.B. sued Safe Sedation LLC and Safe Sedation Management in Fairfax County Court, alleging defamation and infliction of emotional distress. He allegedly captured audio on his cellphone of doctors mocking him as an unconscious colonoscopy patient,  joking that he has syphilis and talking about firing a gun up his rectum. Drs. Tiffany Ingham and Soloman Shah, who are not named as defendants, mocked him from the moment he was unconscious.
"A medical assistant at GMA touched plaintiff's penis during the colonoscopy," the complaint states. "Although plaintiff's penis is not involved in a colonoscopy, the medical assistant noted there was not 'much of a penile rash.' Tiffany Ingham, M.D. responded, 'No, you'll accidentally rub up against it. Some syphilis on your arm or something.' Solomon Shah, M.D. responded, 'That would be bad. That would be real bad.'" (Source:
Courthouse News Service)
Now The Washington Post has reported that a court has has ruled in his lawsuit against two doctors and their practices for defamation and medical malpractice and, last week, after a three-day trial, a Fairfax County jury ordered the anesthesiologist and her practice to pay him $500,000.

The jury awarded the man $100,000 for defamation — $50,000 each for the comments about the man having syphilis and tuberculosis — and $200,000 for medical malpractice, as well as the $200,000 in punitive damages.

Abuses such as these happen in the presence of other doctors, nurses, medical assistants, techs, etc. Rarely are they ever reported. I have previously mentioned Dr. Twana Sparks, who gave patients genital exams for over 10 years, and in one case slapped the head of an unconscious patient's penis.

It has been alleged that it was commonly known that she did this for over 10 years and was the topic of jokes among hospital staff.

The Certified Registered Nurse Anesthetist, Alison Garner, who was providing anesthesia for the case, found Dr. Sparks’ conduct to be so unprofessional that she reported it to the administration at Gila Regional Medical Center (New Mexico) and eventually to the New Mexico Medical Board. Reporting Dr. Sparks may not have been the best professional move for Garner. Sparks is a money maker for the hospital who will generate an estimated 20 million dollars in revenue over the next 10 years. She is also the only ENT surgeon residing within 100 miles of Gila Regional.

As a show of their appreciation, the Gila Regional Medical Center revoked Alison Garner's privliges there and NO action was taken against Twana Sparks. (Source: Outpatient Surgery MagazineGarner claims she personally delivered her first complaint on Sparks’ conduct to Gila Regional’s Director of Anesthesia, Mark Donnell, M.D. According to Garner, Donnell laughed and said, “Oh, wait, is Twana doing one of her exams again?”

SILVER CITY -- Dr. Twana Sparks, who was accused of performing non-authorized genital exams on male patients without their consent while they were under anesthesia, will not lose her medical license and has signed an agreement with the New Mexico Medical Board that allows her to continue to practice, but with numerous restrictions.
The Medical Board had issued a notice of contemplated action against Sparks, a board-certified otolaryngologist (ear, nose and throat surgeon) who is on staff at Gila Regional Medical Center, in April that alleged: 
"(A) For many years, up to and including at least July 17, 2007, Respondent performed genital exams on many of her Ear, Nose and Throat patients while they were under anesthesia without obtaining prior written, informed consent from the patients and did not refer to the exams in the patients' hospital records."
"(B) For many years while she was performing Ear, Nose and Throat surgeries at the Gila Regional Medical Center, Respondent wrote messages and created artistic images on the bodies of many of her patients while they were under anesthesia without obtaining the patients' prior written informed consent."
Sparks had the right to request a hearing before the Medical Board, but instead signed an agreed order with the board, dated Nov. 17, denying any wrongdoing but acknowledging that the board could present evidence in support of the allegations if the matter were to proceed to a hearing.
The agreed order outlines numerous terms and conditions that Sparks must comply with in order to continue practicing. Those terms are:

  • All interactions with patients, whether in an office setting or in surgery, be done in the presence of a chaperone who is over the age of 18
  • Only diagnose and or treat ear, nose and throat conditions of her patients.
  • Not perform any genital, rectal or breast exams for any reason.
  • Inform patients that they need to be seen by other providers for any other conditions that they have.
  • Participate in the Resource Center for Health Professionals under the direction of Connie Merrell-McDonald and comply with all requirements.
  • Waive any rights to confidentiality with respect to information gathered by the Resource Center for Health Professionals, with regard to her participation in, compliance with the order and benefit from treatment and rehabilitation activities. The waiver extends six months beyond the end of her participation, and Sparks is responsible for having RCHP submit quarterly reports to the Board assessing her participation.
  • Participate in regular individual therapy sessions with an RCHP approved psychotherapist and waive confidentiality rights with respect to information gathered by the psychotherapist regarding her participation and benefit from treatment, and have that therapist submit quarterly reports beginning Feb. 1.
  • Go to the Professional Research Center in Kansas for further therapy if recommended and waive confidentiality with regard to the New Mexico Medical Board's access to that information.
  • Undergo polygraph exams every four months that would ask specific questions regarding similar conduct outlined in the notice of the contemplated action.
  • Obtain a worksite monitor at each facility where she performs surgery and have that person provide quarterly reports to the medical board regarding any behavioral concerns beginning Feb. 1.
  • Submit quarterly reports to the New Mexico Medical Board.
  • Appear before the medical board quarterly or upon request.
If the board has reasonable cause to believe Sparks has violated any of the terms it may suspend her license immediately. The Agreed Order also states that its terms and conditions will be reported to the National Practitioners Data Bank and the Healthcare Integrity and Protection Data Bank.
Calls for comment to Sparks' office and her attorney, Deborah Solove, were not returned.
In a previous statement, citing the confidentiality of the Medical Practice Act, J.J. Walker, spokesperson for the board, would not confirm if the allegations against Sparks involved more than one patient, the age of the individuals, why the complaint dates back to 2007, or if Sparks has had other complaints lodged against her.
Walker did say that anyone can file a complaint about a physician with the board and that all complaints are reviewed by a committee, which then makes a recommendation to the board. Every complaint is investigated, but not every complaint results in action by the board. If the Board votes to close the case with no action taken, then no documents would be filed.
Following her earlier signing of an agreed interim order, Sparks requested leave from the hospital, beginning Aug. 14, said Gila Regional Medical Center spokesperson Holley Hudgins. She has since returned from that leave.
Hudgins released this statement via e-mail:
"Gila Regional Medical Center conducted a full investigation. We cannot comment on our findings or actions taken as such are protected in accordance with the New Mexico Review Organization Immunity Act. We are aware of the New Mexico Medical Board's investigation and recommendations and that we trust they have acted in the manner they feel is best."
A medical professional from Gila Regional Medical Center, who spoke on condition of anonymity for fear of retaliation, said the hospital's risk management attorney, Carrie Young, informed nurses and other operating room staff in two separate meetings that Sparks could only see patients with a chaperone who was over the age of 18, and the chaperone would have to record that information somewhere in the nurse's notes. The source said medical personnel were not informed if they would be paid extra for chaperoning Sparks and they were not given a time frame of how long the chaperoning would have to continue.
The medical professional also said the hospital had the name of one of the patients who was examined without his knowledge or consent but was not aware if the hospital had contacted that patient with that information.
Hudgins declined to answer questions as to whether the hospital informed or had plans to inform the patients who allegedly had their genitals examined under anesthesia without their consent or knowledge. Hudgins also refused to confirm the date Sparks returned to the hospital following her leave in August.
The medical professional said Sparks returned to work at the hospital sometime in October. (Source: Silver City Sun News)

In Front of Others...

It is obvious that chaperones offer NO protection. According to a paper written by nurse and researcher, Joan Emerson, having more people in the room, is a way to "force" compliance from a patient.
 In fact, one of the main functions of her presence is to provide a team member for the doctor in those occasional instances where the patient threatens to get out of line. Team members can create a more convincing reality than one person alone. Doctor and nurse may collude against an uncooperative pa- tient, as by giving each other significant looks. If things reach the point of staff collusion, however, it may mean that only by excluding the patient can the definition of re- ality be reaffirmed. A more drastic form of solidifying the definition by excluding recalcitrant participants is to cast the patient into the role of an "emotionally disturbed per- son." Whatever an "emotionally disturbed person" may think or do does not count against the reality the rest of us acknowledge.
This advocates bullying in the healthcare setting.

Dr. Joel Sherman has written a very good article on his blog: Chaperones Do They Reassure or Disturb Patients? The consensus is that chaperones are primarily for the protection of the healthcare provider, and do offer some comfort to some patients. Here are some other articles that discuss the issue (as Dr. Sherman notes, much is written about it in US as well as British literature):

It’s clear however that many patients aren’t comfortable with the presence of chaperones for a variety of reasons.  Surprisingly nearly 50% of women don’t want chaperones present even when male physicians do a pelvic exam.  For men, the figure is 80 to over 90% refuse chaperones when given a choice in most studies.

With the Supreme Court's recent ruling that gay , with transgender actress Laverne Cox being the first openly transgender person to be nominated for a Primetime Emmy Award in the acting category, and Caitlyn Jenner's public transition, there are new issues being raised, there are new questions about chaperones. Edwin Leap discusses the potential new complexities of "Medical Chaperones in a  Brave New World."

Chaperones do NOT protect patients!
Use of a chaperones should always be a mutual decision between the doctor and patient.

Tuesday, April 28, 2015

Patient Dignity: But it is Sexual... Redux

In one of my first posts, Patient Dignity 02: But it is Sexual..., I show how touching the genitals (whether it be for pleasure, therapeutic reasons, as a demonstration of power, for procreation, etc., IS a sexual act. 

If two men, a man and his countryman, are struggling together, and the wife of one comes near to deliver her husband from the hand of the one who is striking him, and puts out her hand and seizes his genitals, then you shall cut off her hand; you shall not show pity.” (Deuteronomy 25:11-12)

Despite what doctors tell patients, the manipulation of one's genitals feels sexual. Now I have research to back my assertion. 

By the very nature of the physical exam it is a sexual experience for both the doctor and patient.[1]

Patients (especially children) perceive genital exposure and the physical examination of the genitals may be experienced subjectively as nosocomial sexual abuse.[2] [3] Many patients suffer lasting physical and psychological effects similar to those who have been the victims of sexual abuse as a result of repeated genital examinations in childhood.[4] [5]

Repeated examination of the genitalia, including medical photography, may be experienced as deeply shaming. [...] Medical interventions and negative sexual experiences may have fostered symptoms of posttraumatic stress disorder and referral to a qualified mental health professional may be indicated.[6]

For patients, genital exams (GEs) or genital procedures, to be viewed or touched by another individual was difficult to dissociate from the sexualized situations in which this behavior ‘normally’ occurred.[7] GEs are characterized as a potentially sexualized (as opposed to a strictly clinical) experience.[8] [9] In particular, the genital exam represented a vulnerable and highly sexualized situation.[10]

Gender choice can also affect the degree that a procedure involving the genitals is sexualized.[11] Patients’ preferences for physicians' gender is well documented. [12]

While providers (doctors, nurses, etc.) have training to neutralize these situations, patients do NOT. Clearly, the exposure of one’s genitalia – or the ‘nude body’– is never rendered neutral or stripped of cultural value.[13]

These strategies include objectifying patients, looking professional, threatening the patients, using chaperone, telling jokes about jokes and empathizing with the patients.[14]

Data illustrate how male-female social/sexual relations, even within clinical encounters with female service providers (e.g. genital exams), remain ‘dangerously feminized,’[15] thus retaining a “sexualization” about it.

Many organizations put out guidelines, that have NO SCIENTIFIC BASIS, that claim that, “Routine examination of the external genitalia as part of a well-child physical normalizes the examination for the child and helps to inform the physician about the large variations in normal genitals.[16] Evidenced-based research has shown that genital exams are NEVER routine.[17] [18] [19]

The “normalization” process that happens when performing genital exams routinely (as per the guidelines[20]) is the same process that normalizes sexual contact in victims of abuse.[21] [22] [23] [24] Normalization is the process by which an idea or behavior goes from clearly problematic to an accepted part of societal culture.[25]

Normalizing is a tactic used to desensitize an individual to abusive, coercive or inappropriate behaviors. In essence, normalizing is the manipulation of another human being to get them to agree to, or accept something that is in conflict with the law, social norms or their own basic code of behavior.

Aggressors often work to make their victims feel less sensitive to, or more accepting of offensive behavior by minimizing, down playing or mocking any negative reaction to inappropriate acts.  In turn, victims often normalize bad behavior (the other person's and their own) by buying into the aggressor's logic and lowering their own standards. They learn to accept as normal what they once believed to be unacceptable, wrong, or dangerous.  Normalizing is achieved when the victim no longer questions a behavior as inappropriate and starts to accept the perpetrator’s assertions that a questionable behavior is, in fact, normal and “healthy.” [26]

The reason that doctors do not know that genital exams are abusive is because the power imbalance of the doctor–patient relationship prevents the patient from voicing concerns and research indicates that the closer the victim is to the abuser, the less likely he or she will disclose the abuse.[27] The patient is pressured to identify with the [abusing] doctor in a positive way by family, the doctor, and other healthcare providers, which is psychologically identified as “Stockholm Syndrome”.[28]

The long-term emotional consequences for the patient of being sexually “touched” by a doctor have been likened to rape or incest.[29] Doctors unconsciously manipulate the situation so that the discussion never comes up; “exploitation can nevertheless be argued if the fiduciary has acquired information about the client's vulnerabilities that otherwise would remain concealed”.[30]

Doctors never explicitly tell a patient that they can refuse a genital exam although ALL guidelines state a “Patient has the right to refuse any or all parts of the exam at any time”.[31] [32] [33] [34] [35] [36]

Providers themselves are prone to sexualizing the patient and the encounter.[37] The following is an extract from the publication “Learning about sexual boundaries between healthcare professionals and patients: a report on education and training” (2008), published by The Council For Health Care Regulatory Excellence (CHRE) of the United Kingdom.[38] It clearly acknowledges that medical students, doctors, and healthcare professionals are not different from any other human beings when it comes to sexual attraction.

Medical students must be taught that there is nothing unusual or abnormal about having sexualized feelings towards certain patients, but that failing to identify these feelings and acting on them is likely to result in serious consequences for their patients and themselves. Students and healthcare professionals should be made aware that while it is not unusual to find patients or their carers sexually attractive, it is the healthcare professional’s duty never to act on these feelings and to ensure appropriate action is taken to avoid a breach of sexual boundaries. If a healthcare professional is sexually attracted to a patient and is concerned that it may affect their professional relationship with them, they should ask for help and advice from a colleague or appropriate body in order to decide on the most professional course of action to take. Developing awareness about the Dynamic of Patient-Doctor relationship is the duty not only of healthcare professionals, but also of patients: It is in fact essential to timely recognize, and prevent sexual exploitation from the doctor. The key point is that the CHRE establishes that dealing with this situation is always the healthcare professional’s responsibility. For this reason, any denial of the fact that both patients and doctors are, due to their own human nature, potentially susceptible to experience sexual attraction, arousal and even feelings during intimate examinations, is not on only very unscientific, and very intellectually dishonest, but it is a severe offense of the supreme value of their human dignity: Neither the patients stop being human and become a simple combination of tissues, nerves and bones when they enter a medical room, nor the medical doctors get magically transformed into robots and lose their human nature when they wear their white coat. Unfortunately many doctors fail to keep up with the standards and the rules of their profession. Those who are in denial and who are not able to recognized and deal with their sexual feelings or their patients' sexual feelings.

Doctors defend these exams as being necessary or routine. What they fail to realize that many of these guidelines have been written by sexual predators. What providers consider a "necessary, normal exam" can be an act of RAPE.

The nurses conducted their exams over the protests of the children, with some crying for their mothers. Still others, intimidated and filled with fear, even attempted to resist physically. Their parents did not know that the exams were scheduled and had not given their consent. So there was no way they could have known the terror their children were enduring during their school day.
The nurses stretched the children out on a floor mat, on top of a school desk, and forcibly removed their clothes. Although the nurses were not even wearing hygienic gloves, they pressed and probed the children's genitals and took blood samples. The exams were conducted en masse--the children endured these humiliations in front of one other, amidst the panic, crying and fear.
When confronted about the situation, the Head Start director responsible for the exams said that he didn't think there was anything strange or unusual about the physicals. The tragic thing is that the director may be partially right--horror trips like this may become less and less unusual. A similar situation has already occurred to middle school girls at a public school in Pennsylvania. (Source: The Rutherford Institute

Image courtesy of William H Ayres Watch Blog

Convicted pedophile psychiatrist Dr. William Ayres, was president of the American Academy of Child and Adolescent Psychiatry and co-author of "Practice Parameters for the Forensic Evaluation of Children and Adolescents Who May Have Been Physically or Sexually Abused" which is now an accepted guideline. [39] Many of the egregious acts he used to groom the victims, give him access to their bodies, and allowed him to molest he had written into those guidelines. This has turned abuse into medical procedures. 

The genital examinations of patients of William Ayres appeared to have "very specific” reasons and follow the general consensus of researchers who not only approve of but encourage such methods, a psychotherapist with a medical degree told jurors yesterday.
...Dr. Gilbert Kliman, who belongs to the American Academy of Child and Adolescent Psychiatry [Ayres once was president], differed from prosecution witness, Dr. Lynn Ponton, who told jurors there was little if any reason for the genital exams described by 10 former patients who testified.
…Kliman disagreed. He called one patient’s file a "delightful psychotherapeutic interaction” and praised Ayres’ methods. …the wider realm of psychiatry which allows — and sometimes proactively supports — the idea of physical and genital exams performed in conjunction with treatment.
Some researchers believe physical exams provide more comprehensive care and "increase rapport” between doctor and patient, Kliman said.
 Kliman conceded he’d likely seek parental consent before performing a physical and genital exam on a minor patient but that it isn’t an industry standard. [40] 
Ayres also said there is nothing inappropriate about a psychiatrist giving physical exams. He said every full pediatric exam should include an inspection of the genitals.  [41] Yet when common sense prevails, it is denounced because it goes against guidelines: 
"My training was very strict on that," said Hugh Wilson Ridlehuber, a retired child psychiatrist who said he was present for Ayres' presentation and once worked out of the same group practice as Ayres. "Even if it's done innocently, there is a very high risk of a patient sexualizing it and affecting your relationship with the patient." [42]

Clearly we can see why PTSD can result from genital exams when preformed professionally and according to recommended guidelines.[43] Doctors and other healthcare providers have committed malpractice for failure to recognize that PTSD, other physical, and psychological side effects can result from the sexual nature of genital exams.

[5] Leserman J. Sexual abuse history: prevalence, health effects, mediators, and psychological treatment. Psychosom Med 2005;67:906-15.
[11] Holland, J., Ramazanoglu, C., Sharpe, S. and Thomson, S. (1998) The Male in the Head: Young People, Heterosexuality and Power. London: The Tufnell Press.
[13] Barcan, R. (2004) Nudity: a Cultural Anatomy. Oxford: Berg Publishers.
[15] Flood, M. (2008) Men, sex, and homosociality: how bonds between men shape their sexual relations with women, Men and Masculinities, 10, 3, 339–59.
[17] Rey-Stocker I : Principes généraux d’examen gyné- cologique; in Salomon-Bernard Y, Thibaud E, Rappaport R (eds): Traité médico-chirurgical de gynécologie de l’enfant et de l’adolescente. Paris, Doin, 1992.
[18] Beyth Y, Hardoff D, Rom E, Ziv A: A simulated patient-based program for training gynecologists in communication with adolescent girls presenting with gynecological problems. J Pediatr Adolesc Gynecol 2009;22:79–84.
[19] Barcan, R. (2004) Nudity: a Cultural Anatomy. Oxford: Berg Publishers.
[30] Feldman-Summers S. Sexual contact in fiduciary relationships. In Gabbard GO. Sexual Exploitation in Professional Relationships. Washington (DC): American Psychiatric Press, 1989: 193–209