Wednesday, June 10, 2020

Why Patients Dislike Rectal Exams

I came across the following article on the National Institutes of Health's PubMed website: Masculinity and the Body: How African-American and White Men Experience Cancer Screening Exams Involving the Rectum

These are the authors:

  • Julie A. Winterich, Ph.D.,
  • Sara A Quandt, Ph.D.
  • Joseph G. Grzywacz, Ph.D.
  • Peter E. Clark, M.D.
  • David P. Miller, M.D.
  • Joshua Acuña, B.A.
  • Thomas A. Arcury, Ph.D.


The purpose was :

"Much of the research on prostate and colorectal cancer beliefs, knowledge, and screening finds that barriers to screening include African-American men’s perceptions that DREs are “embarrassing” and colonoscopies are “offensive,” but none of this literature investigates WHY men report these attitudes."

My first reaction was that that of disbelief. These are well educated people, how could they lack such common sense? But this is the paternalistic problem that medicine has; that just because someone wears a magic white coat or a magic stethoscope, the patient should readily accept what ever indulgences the provider has (no matter how invasive).

Then I looked at this scientifically. The first thing that struck me is the "why." One of my undergrad degrees is a counseling degree. We learned that you never ask "why," but you do ask what the feelings associated with the behavior, incident, object, procedure, etc. Here is a prime example for never asking "why:"

"A financial analyst was convicted Thursday of beating his wife to death with a rock and impaling her heart and lungs on a stake after she complained he had burned their ziti dinner." Source: Associated Press

In this instance, when asked why by a police officer, he said she complained he had burned the ziti again. As a counselor, I know that the complaining was the trigger. Another why is the mass suicide by the Heaven’s Gate,

"They weren’t killing themselves, they thought, but freeing their souls from their so they could ascend to a spacecraft flying in the wake of the Hale-Bopp comet – which at that point was passing by Earth – and were going to be taken to their new home in space." Source: Rolling Stone

The true underlying reasons were cult dynamics at the hands of a mentally ill leader. Why do healthcare providers not accept the reasons of "I just don't want to do that (and it is my RIGHT)" or "I don't like that (and that is just the way that I feel)?" Both are very valid answers, but when pressed, nobody can explain why they feel certain ways, they just know that the feelings are there.

One may not even know what they are feeling (let alone why). All emotions is that they don’t start out as feelings at all but as physiological sensations. So even when a person can’t comprehend their feeling experience, they’re typically aware of what’s happening to them physically. Source: Psychology Today

Emotions are an automatic process in the brain that happens behind conscious thought. We can share emotions with others but not understand what they’re feeling exactly.

When forced to explain something that they cannot, they feel like they are wrong and acquiesce to the provider. This is just one means of forcing compliance from patients. The definitive treatise on coercing patients into compliance with uncomfortable, invasive, or intimate procedures is Behaviour in Private Places: Sustaining Definitions of Reality in Gynecological Examinations by Joan P Emerson.

This summarizes the reasons of asking "why" are futile and fruitless.

It is well established that rectal exams are a barrier to many health screenings, even the annual physical. See: Digital rectal examination is barrier to population-based prostate cancer screening

The results of our study have demonstrated that DRE is a significant barrier to participation in PCa screening.

The invasive, uncomfortable nature of a digital rectal exam (DRE) is well known in healthcare. It is one of the main reasons that men avoid healthcare, especially the annual physical exam. (Reference: ) The DRE increases and reenforces the power differential between the patient and provider and increases the vulnerability of the patient.

Digital rectal exams (DREs) typify much of what’s wrong with our health care system. Men dread going to go get them, they’re unpleasant, they vividly illustrate the physician-patient hierarchy, and — oh, by the way — they apparently don’t actually provide much value. (Source: I Really Wish You Wouldn’t Do That)

The intimate exams are viewed as sexual by many patients despite what medical providers tell them. This again is our feelings and we can NOT tell our minds to simply not feel this way. Our feelings are what they are. See: Rectal exam mistaken for sodomy, a patients personal experience!

When forced upon patients, they see these things as a sexual assault or a rape. See: Rectal exam tried as assault One area that repeated intimate exams have risen to the level of abuse is with intersexed children:

Intersex activist Emi Koyama explains that various routine medical practices and procedures enacted on intersex infants, children, and adolescents constitute “ritualistic sexual abuse of children.” Two examples are the unnecessarily displaying of intersex children’s genitals to numerous other doctors and students, as if their bodies were side-shows to gawk at... Source:

Even the world health Organization (WHO) has deemed this behavior as torture, cruel, inhumane, and degrading. So if repeatedly, these constitute torture, why would they not de disliked?

This statement suggests that he doesn’t seem to fully recognize that the sexual abuse he committed was sexual abuse because it occurred in a medical context. Source: Sexual Assault in Medical Contexts

Indeed saying that this is a medical procedure does not change the feelings of the patient. If the exam is so benign and it is expected that patients willingly accept it, why do medical students no longer practice digital rectal exams on each other?

Policies of medical training institutions state:

"No examination of the breasts, genitals, or anorectal region are permitted between peers. Human patient models will be utilized for training in these aspects of the physical examination."

Concerns that physical exams are not just physically harmful, but also emotionally harmful through embarrassment, coercion or harassment. These concerns do NOT specifically apply to intimate examinations, but to all aspects of physical exams. Intimate exams carry their own additional concerns which medical students strongly oppose. 

All the studies and institutions conclude: "There is no role for peer genital, rectal, or female breast exams in the curriculum."

What about harming real patients? If these exams are so traumatic that medical professionals are unable to conduct on each other to further their education, why are they not traumatic for patients. Even the teachers do not use their bodies to train the students. (This demonstrates there is no existence of medical professionalism.)

The solution has been standardized patients: simulated patients are recruited from the general public to be examined by supervised medical students for teaching purposes in a clinical setting. Not every person can perform the task of enduring intimate exams.

A robotic rectum has been developed to help doctors and nurses detect cancer after only one man registered to allow medical students to examine his prostate. Source: Robotic rectum developed to help doctors get to bottom of prostate cancer

I came up with a modest proposal that would help these researchers find the answer to this question (that to everyone who has ever been a patient, the answer is obvious)...

First, the researchers should procure prostate exam trainer mannequins. The test subjects are instructed by qualified instructors on the proper technique for conducting a digital rectal exam and allowed to practice on the props until they have satisfactorily acquired the skill to properly perform the exam (not necessarily diagnose).

Each study participant will then perform a rectal exam on each of the researchers. Upon completion, the researchers will have gained the knowledge why patients dislike rectal exams.

But that is not going to happen anytime soon. (Maybe it should!)

Perhaps a better question to study is why the profession of medicine believes that patients would happily and readily accept rectal exams? 

Is it the magic white coat or the magic stethoscope?

The profession of medicine believes that patients should accept what ever whims the provider has. It just "ought to be..."

It helps us in determining what we are going to suggest you for treatment. So we can't do away with the physical exam. It's not a painful test, doesn't take a long time and really ought not to be a barrier to screening Source: Shunning Prostate Probe - Fear Of Anal Examination Puts Jamaican Men At Risk

This is paternalismTraditionally, medical practice has been a paternalistic system, with the health care provider telling the patient what to do and making the final decisions regarding screening or treatment. This has been ingrained in the profession of medicine since it began.

There is the fact that the profession of medicine has exempted itself from the norm, expectations, and rules of society and does what it believes what is in the profession's best interest. This was done through the "Social Contract."

One of the most glaring examples of the profession exempting itself from the rules of society was the concept of self-regulation (which was a dismal failure by the profession). Medicine has granted itself absolute power over the patient.

The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions as to their fitness, to influence his attention to them. Source: American Medical Association's (AMA) initial Code of Medical Ethics (1847), under "patient obligations"

Another example of the profession doing what it wants to do and what is in its own best interest is the fact that teaching medical students pelvic examinations on patients under anesthesia without consent still occurs to this day. How can any rational person think that this is acceptable?

But the profession falls back on professionalism and science. But when the science is looked at, it finds that these procedures do very little in diagnosis of disease or to change the management of conditions. (See: Digital Rectal Exams: Worth the Trouble?) These, as other intimate exams that patients dislike, are found to be "more of a ritual than an evidence-based practice" when the data is examined.

Much of medical guidelines and what is recommended for patients is (so called) expert opinions and NOT evidence-based content. Then there is a question of comfort. If we can put a man on the moon (and soon Mars), why can't we find an alternative to digital rectal exams or make them less unpleasant.

We should do everything we can to make unpleasant things, well, less unpleasant: Physicians can’t just focus on reducing patients’ medical complaints but also should seek to reduce other complaints about their care. When patients dread having something done, and often use that as an excuse not to get services, that should be a tip-off that something needs to change. Source: I Really Wish You Wouldn’t Do That

What about teaching patients to do a self examination? (That takes the fun away from the provider to subjugate and humiliate patients.) It is possible, providers are not the only people with a magical power to perform rectal exams. See: Digital Anal Rectal Examination Performed by Patient (International Anal Neoplasia Society Guidelines for the Practice of Digital Anal Rectal Examination
)

Again, this question shows the lack of common sense that medical professionals have both in not knowing why patients dislike rectal exams and why they expect that patients just accept them. What is even more disturbing is why unnecessary voyeurs are brought in to the exam room to oogle and further humiliate the patient. If a provider can not be trusted to perform such an exam, then they should not be practicing.

(The thought) of having another person inserting their finger inside their anus can be very stressing for some men and makes them uncomfortable. Source: Shunning Prostate Probe - Fear Of Anal Examination Puts Jamaican Men At Risk


If one really needs a "why," then read: Reasons Why Patients Reject Digital Rectal Examination When Screening for Prostate Cancer.



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1 comment:

  1. I learned to stand up to doctors when I was 14. I had to physically fight off an overzealous doctor who thought it would be okay to force a genital exam on me. I was verbally abused by him after for refusing to let him legally molest me. If I don't want something done to me, it won't be done.

    mikazuki~

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