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