Informed Consent is Missing from Male Adolescent and Young Adult Cancer Screening

Consent, particularly informed consent, is the cornerstone of patients’ rights. Consent is based on the inviolability of one’s person. It means that doctors do not have the right to touch or treat a patient without that patient’s approval because the patient is the one who must live with the consequences and deal with any discomfort caused by treatment. A doctor can be held liable for committing a Battery if the doctor touches the patient without first obtaining the patient’s consent. (Source: Farlex Legal Dictionary "Patients’ Bill of Rights" [Redirected from Federal Patients’ Bill of Rights])

Informed consent is missing from many areas of healthcare. With new guidelines released, there has been a focus on informed consent missing for women's annual pelvic exams. Informed consent is missing from from male pelvic cancer screening as well. 

image from: Embarrassing Bodies Testicular Cancer Check

Informed Consent

One of the best resources on informed consent is Temple Health's (Temple University) "A Practical Guide to Informed Consent." It states:

Informed consent is an ethical concept—that all patients should understand and agree to the potential consequences of their care—that has become codified in the law and in daily practice at every medical institution. One of the earliest legal precedents in this area was established in 1914 when a physician removed a tumor from the abdomen of a patient who had consented to only a diagnostic procedure (Schloendorff vs. Society of New York Hospital). The judge in this case ruled that the physician was liable for battery because he violated an “individual’s fundamental right to decide what is being done with his or her body.” [Edwards 1998, Wescott 2005] 

Women's Pelvic Cancer Screening

Doctor Joel Sherman, a cardiologist and an advocate for patient dignity, had written a a November 2009 article, "Informed consent is missing from Pap smears and cervical cancer screening." In the article, he points out that women are rarely given complete information and the choice for cervical cancer screening. Here are some other articles on the topic:

• Time Magazine, "Are Doctors’ Exams a Barrier to Birth Control?"
• Mother Jones, "Holding Birth Control Hostage"
• National Institutes of Health, "Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence."
• National Institutes of Health, "Pelvic Examinations and Access to Oral Hormonal Contraception"

In fact, many women are coerced in to cervical cancer screening. Physicians still require women to submit to cancer screenings and pelvic exams before prescribing or refilling of oral contraceptives, despite guidelines indicating they are unnecessary, research suggesting they can pose a barrier to contraceptive access, and NO laws requiring the invasive and humiliating exams.

One study found that 44% of clinicians who prescribe oral contraceptives admit to requiring the exam. (Source: Over-the-Counter Working Group) In reality, the percentages requiring exams are much higher. In another study, "Nearly all respondents indicated that they would perform the examination in the 55-year-old despite the absence of her ovaries, uterus, and cervix, and over half believed it to be very important for this woman." (Source: American College of Obstetrics and Gynecology "Routine bimanual pelvic examinations: practices and beliefs of US obstetrician-gynecologists")

Male Pelvic Cancer Screening; Lack of Evidence

One group that is not afforded full disclosure to make an informed decision (informed consent) is male adolescents and young adults. These exams are done more as ritual than evidence based medicine. The American Academy of Pediatrics' guideline, "Male Adolescent Sexual and Reproductive Health Care" states:

Despite the lack of evidence-based guidelines supporting routine testicular screening and teaching of testicular self-examination for detection of testicular cancer, a genital examination, including examination of the testicles, represents an important part of a male adolescent's complete physical examination during annual preventive health visits and, specifically, as part of a visit related to a genital complaint. The content of the pediatric/adolescent physical examination required to report preventive health care codes (Current Procedural Terminology [CPT] codes 99382–99384; 99392–99394) depends on age and developmental level and would be expected to include a male genital examination...

Despite the lack of recommendations that support testicular cancer screening, the USPSTF... The American Cancer Society has stated that it "does not have a recommendation on regular testicular self-examinations for all men"... An external anal inspection, a digital rectal examination, and screening for hernia as part of the male adolescent physical examination should be performed on the basis of specific concerns or complaints such as a bulging mass or pain (hernia examination), hemorrhoid or rectal bleeding (digital rectal examination), or risk factors that would warrant an external anal inspection for HPV lesions in a young man who engages in receptive anal intercourse.

Along with the the lack of recommendations that support testicular cancer screening, the USPSTF makes no recommendation for either hernia or pubertal development and other disorders. The Journal of Family Practice states "Insufficient evidence exists to recommend for or against screening genital exams for boys playing sports."

Other Reasons for Screening

The American Academy of Pediatrics' guideline, "Male Adolescent Sexual and Reproductive Health Care" further states:

The content of the pediatric/adolescent physical examination required to report preventive health care [billing] codes (Current Procedural Terminology [CPT] codes 99382–99384; 99392–99394) depends on age and developmental level and would be expected to include a male genital examination. 

Routinely examining the genitals from childhood through adolescence can help the male patient understand the routine nature of this examination component. 

Providers point to another value to doing a genital exam which is the clinician learning what the range of "normal" vs "abnormal" exam findings are and the range and variation present in human genitalia (citation needed). Is that disclosed as part of informed consent?

Respecting Patient Dignity and Autonomy

According to the American Academy of Pediatrics' guideline, "Male Adolescent Sexual and Reproductive Health Care":

Sexual health also requires a positive and respectful approach... People should be able to have pleasurable and safe sexual experiences free of coercion, discrimination, or violence. Men, along with women, have the right to be informed and have access to safe, effective, affordable, and acceptable methods of family planning of their choice and the right of access to appropriate health care services...

Trust and relationship-building are also critical elements of the male adolescent's visit that help him to feel comfortable regardless of a physician's gender and/or background.

Examination in gowns will help prevent missing important physical examination findings, such as gynecomastia or truncal acne. A 

Health care providers might be confronted with male adolescents who refuse a genital examination because of concerns about homophobia, lack of experience with such examinations, fear of getting an erection, or even because of previous abuse. 

Understanding the specific concern can help the health care provider educate the patient about the importance of this examination, determine the priority of such an examination for a particular patient, and negotiate how and when to complete the required components of the examination. Routinely examining the genitals from childhood through adolescence can help the male patient understand the routine nature of this examination component. The use of a chaperone might also be relevant and should be considered during all genital examinations for patient and/or provider comfort regardless of whether the provider and patient are the same gender.

Note: The term "informed consent" does NOT appear anywhere in the above publication.

image from: Embarrassing Bodies Testicular Cancer Check

Here are the problems that I have with genital exams for males:

• True informed consent is not present. 
• Evidence does not support exams
• Exams are rarely OFFERED, that is patient is told that they may decline.
• Gender of provider is ignored.
• Use of a chaperone is usually not a joint decision.
• Gender of the chaperone is ignored. 

Most patients have gender choice in their providers, adolescent and males especially for genital exams. The following studies that confirm patient gender preferences:  

• In a study of children 8 - 13 who needed a suture repair for a laceration. Among the children, 80 percent of girls and 78 percent of boys preferred a woman doctor, and none chose the doctor with the most experience. (Source: AMA Virtual Mentor "Patient Requests for a Male or Female Physician")
• From 901 participants, 83% chose a woman, 59% of whom selected gender or age as the reason. Single and younger patients were more likely to choose female and younger providers, respectively. (Source: American Journal of Obstetrics and Gynecology "Patient choice: comparing criteria for selecting an obstetrician-gynecologist based on image, gender, and professional attributes")
• Athletes (male or female) prefer same gender health care providers. (Source: Science Daily "Locker room talk: How male athletes portray female athletic trainers")

Doctor Sherman goes in to more detail about gender and embarrassment  in "Adolescent Boys and Genital Exams Reducing Embarrassment". This is an excellent piece, I suggest reading it. 

Dismissing the Patient

Too often the solution by providers is to dismiss the patient.

 When the patient's beliefs—religious, cultural, or otherwise—run counter to medical recommendations, the physician is obliged to try to understand clearly the beliefs and the viewpoints of the patient. If the physician cannot carry out the patient's wishes after seriously attempting to resolve differences, the physician should discuss with the patient his or her option to seek care from another physician. (Source: American College of Physicians "ACP Ethics Manual 6th Edition")

Patients are allowed to choose the level of care that they wish to receive. Threatening dismissal is only coercion and the physician NOT trying to earn the trust of the patient.

Psychological and Emotional Trauma

A study in Journal of Reproductive and Infant Psychology Volume 11, Issue 4, 1993, "Post-traumatic stress disorder in women who have undergone obstetric and/or gynecological procedures: A consecutive series of 30 cases of PTSD." highlights the psychological and emotional trauma from intimate exams.

 Forwomenseyesonly ("Gynecological Procedures Can Cause PTSD") highlights the study: 500 women took part in a study about the psychological effects of vaginal exams, pap tests, and other gynecological/obstetric procedures. Of the 500 women who took part in the study, over 100 women reported their experiences as ‘very distressing’ or ‘terrifying’. Of the 100 women who reported distressing experiences, 30 were diagnosed with PTSD. The study highlights the similarities between the after effects of rape and women’s experiences with gynecological procedures.
There is a lack of research related to PTSD following gynecological procedures. The study quoted above was published in 1993, and there does not appear to be any follow-up research specific to gynecological procedure- related PTSD published since that time. There has been some recognition in the literature given to the trauma of pap tests experienced by women with a history of having been sexually assaulted, but the trauma caused by pap tests themselves is generally ignored.
Some of the phrases used by the women who took part in the study to describe their experiences include:

"dehumanizing and painful";
"degrading and distressing";
"my opinions were dismissed as irrelevant";
"hurting and feeling violated";
"very brutal internal was excruciating";
"it felt undeniably like rape".

30 out of 500 is 6%!. Just as OB/gyn procedures can cause PTSD, there are so many other procedures (such as male genital exams) that can do the same. What about the borderline diagnosis? Those who may not have full onset PTSD, but have been traumatized none the less?

Conclusion:

The genitalia are part of the body too. They can become diseased, or give clues to disease in other part of the body. A physician who does not offer to examine the entire body during a routine physical exam is doing a great disservice to the patient. If the patient refuses that is their right, but they need to know that there is a risk of missing something serious as above.

These exams should be "offered" after discussing the associated risk factors unique to each patient while clearly be given the opportunity to decline. If they elect the exam, they should be conducted privately without a chaperon, unless the patient requested one, and then only if the chaperon was the gender the patient was comfortable with.

From the stand point of "Informed Consent," the first conversation needs to be IF the patient is going to allow the exam. After that, then HOW it will be preformed needs to be discussed. 

Thank you for reading.

Eric Garner: a Comedy of Errors...

I have not weighed in on any of the "black men killed by white officers," such as Trayvon Martin, Michael Brown, Tamir Rice,and John Crawford. That is because I see this as people (human beings) killed by police.  White people are killed by police too. I am going to take race out of this equation as I analyze this case.

What caused me to comment on this is police are saying Eric Garner was "complicit in his own death."[Source: The Huffington Post]

In each of the above mentioned cases, the victim is painted as a “thug,” Every time, it seems the bar gets lower to justify the use of deadly force. In Garner’s case, they call it “resisting,” when all he was doing was asking the police to treat him with basic dignity:

Garner was approached by NYPD officers on July 17 because he was allegedly selling “untaxed cigarettes.” Video shows Garner pleading with police to leave him alone and stop harassing him. Garner had previously been arrested and charged with misdemeanor offenses for selling loose cigarettes. He insisted he was not selling anything and was minding his own business. 

As he urges police to let him be, Garner, who was 6-foot-4 and weighed around 400 pounds, is wrestled to the ground by officers including Pantaleo who puts him in an illegal chokehold. Garner is crying out, “I can’t breathe. I can’t breathe,” as Pantaleo pushes his leg into Garner’s head, which is now on the sidewalk. “I can’t breathe,” he cries again. [Source: The Dissenter] 

The medical examiner ruled Garner’s death a homicide and found he had been killed by a chokehold.

The Medical Examiner issued its report on the death of Eric Garner this afternoon and found the "manner of death" to be homicide. It ruled the cause of death to be from "compression of neck (choke hold), compression of chest, and prone positioning during physical restraint by police." In addition, the ME cited contributing conditions as Garner's pre-existing "acute and chronic bronchial asthma, obesity, and hypertensive cardiovascular disease." [Source: NY1.com]

NYPD Chief Bill Bratton, the architect of the “broken windows” policing that likely led officers to aggressively interrogate Garner about whether he was selling loose cigarettes, declared after Garner’s death, “Chokeholds are, in fact, prohibited by the New York City Police Department, as they are, in fact, by most police departments in the United States.” [Source: NY1.com]
Even the EMS workers who responded have been suspended.

The EMS workers, who have not been identified, included two EMTs and two paramedics. The workers are not city employees but work for Richmond University Medical Center, according to the FDNY. They were first placed on modified duty, and then hospital officials announced Monday the workers were being suspended and would not be allowed to work at the hospital or throughout the 911 system...

...A friend of the victim showed NBC 4 New York new cellphone video Monday that showed the response moments later as Garner lay on the ground, not moving: the paramedics, EMTs and police peer over Garner, and none administer CPR. [Source: NBC 4 New York]

Police: Chokehold Victim Eric Garner Complicit In Own Death

"Police officers feel like they are being thrown under the bus," said Patrick Lynch, president of the police union. 

Pantaleo's defenders have included Rep. Peter King, R-N.Y., who argued that the grand jury outcome would have been the same if Garner had been white, and that police were right to ignore his pleas that he couldn't breathe. 

"The fact that he was able to say it meant he could breathe," said King, the son of a police officer. [Source: The Huffington Post]

Rank-and-file New York City police officers and their supporters have been making such arguments even before a grand jury decided against charges in Garner's death, saying the possibility that he contributed to his own demise has been drowned out in the furor over race and law enforcement.

As the video sparked accusations of excessive force, the police unions mounted a counter-narrative: that Garner would still be alive if he had obeyed orders, that his poor health was the main cause of his death and that Pantaleo had used an authorized takedown move - more like a headlock than a chokehold - to subdue him.

Pat Lynch is the president of the Patrolmen’s Benevolent Association, the largest NYPD police union.  At a press conference last night, Lynch made sure to tell everyone that the NYPD doesn’t feel the kind of support they need from De Blasio, Eric Garner is to blame for his own death, and Officer Pantaleo is “literally an Eagle Scout.” [Source: slta_]

A second video shows CPR was not performed by the EMS workers. It does, however, show nearly four minutes of the cops gently shaking Garner as he lies unmoving on the ground. They search his pockets, but do not seem particularly concerned that their suspect hasn’t moved in minutes.  Cops know CPR, and are expected to perform it if necessary.

One officer asks the woman filming to back away and give Garner air, another checks his pulse and a third offers a supportive pat on the back while saying, "C'mon guy, breathe in, breathe out, all right," to the seemingly lifeless Garner. None of the eight cops seen in the video provide him medical help.

An emergency responder, who arrives about four minutes in, takes his pulse and tries to rouse Garner, saying, "Sir, it's EMS. C'mon, we're here to help, all right. We're here to help you. We're getting the stretcher, all right." Afterward, an officer can be heard saying, "He's breathing, he's got a pulse."

Around the 6-minute mark, officers roll Garner onto his back and lift his body onto a stretcher.
"Why nobody do the CPR?" one onlooker asks, as Garner is wheeled away. "Cause he's breathing," an officer responds.

Forearm across trachea = DEATH!!!

How is this NOT manslaughter at the very least?

New York’s statutes on manslaughter are pretty unequivocal. Just going on the plain language of the law, the police officer who killed Garner certainly appears to be guilty of second-degree manslaughter at the very least:

§ 125.15 Manslaughter in the second degree.
A person is guilty of manslaughter in the second degree when:
1. He recklessly causes the death of another person; or
2. He commits upon a female an abortional act which causes her death,
unless such abortional act is justifiable pursuant to subdivision three
of section 125.05; or
3. He intentionally causes or aids another person to commit suicide.
Manslaughter in the second degree is a class C felony. 

Source: State of NY 

The second-degree manslaughter charge requires only two factors: 1) the person charged must have caused the death of the victim, and 2) the perpetrator must have caused the death of the victim via reckless means.

As the video shows, the officer clearly caused the death of Eric Garner, who was alive until the officer put him in a chokehold, a move which is banned by the NYPD for good reason. And why did the police department ban chokeholds? Here’s an article on the subject from 1993, when a previous police chief banned the practice:

The New York City Police Department has issued an order banning the use of choke holds, the restraining maneuvers that cut off the flow of blood and oxygen to the brain and have been blamed in the deaths of suspects here and around the nation.

So an officer used a banned practice that is known to lead to the deaths of people who are subjected to it? That certainly seems to satisfy the second condition of a second-degree manslaughter charge?

We can make a change now!

Please send comments about this draft. 

It can pave the way for ensuring gender choice by patients for  ALL their providers in healthcare.

A friend alerted me to this:

The National Association of Insurance Commissioners has released draft regulations expected to impact the makeup of health plan provider networks on a state and federal level, including on the marketplace exchanges set up under the Affordable Care Act.

NAIC in November released draft updates to its Managed Care Network Adequacy Model Act, [link: http://www.naic.org/documents/committees_b_rftf_namr_sg_exposure_draft_proposed_revisions_mcpna_model_act.pdf] a model law routinely used by state and federal lawmakers when creating insurance laws and regulations, particularly in regards to the creation of health carrier networks and the adequacy and accessibility of services offered under a network plan.

The model Act, which hadn’t been updated since 1996, has been highly anticipated due to the changing insurance landscape under the implementation of the ACA. A controversy over the use of narrow networks on the marketplace exchanges has led the Centers for Medicare and Medicaid Services to investigate the adequacy of provider networks more closely; and the agency said it was waiting for NAIC’s revamped model law before proposing changes to its network adequacy policy for products offered on the 2016 exchanges...

These were my comments:

The reason that gender is a criteria, is because many people exercise their Constitutional rights under Title VII of the Civil Rights Act of 1964 and The Federal Nursing Home Reform Act (“OBRA 87”).

There is a reason that gender is included in directory listings. The problem is that once you get there, nurses, PAs, technicians, etc. who may be necessary for treatment are of the opposite gender of the physician.

There needs to be the additional criteria for the "gender of other personnel" AND "can accommodate request for same gender care."  

What caught my attention was that this paper is being discussed in "narrow networks." By adding the additional criteria of "requiring networks to be broad enough to accommodate request for same gender care," can further the original intent of including the gender criteria originally. 

My friend made the following recommendations:

Include 2 additional criteria for the following in section 8:

Section 8.B(1)(f) Gender of support staff;

Section 8.B(1)(g) Provide same gender care for;

Section 8.B(2)(d) Gender of support staff;

Section 8.B(2)(e) Provide same gender care for;

Section 8.B(3)(e) Gender of support staff;

Section 8.B(3)(f) Provide same gender care for;

Section 8.C(1)(f) Gender of support staff;

Section 8.C(1)(g) Provide same gender care for;

Section 8.C(2)(c) Gender of support staff;

Section 8.C(2)(d) Provide same gender care for;

Section 8.C(3)(e) Gender of support staff;

Section 8.C(3)(f) Provide same gender care for;

Here is an example of the new criteria:

Section 8.B(1)(f) Gender of support staff;

This can be answered: "All Female," "All Male," OR "Both Female and Male."

Section 8.B(1)(g) Provide same gender care for;This can be answered: "Female," "Male," OR "Both Female and Male." This is important due to the situation I mentioned above where the urologist is male, but the rest of the staff is female. The following is possible:

Section 8.B(1) For health care professionals:

(a) Name; Dr. So-and-so
(b) Gender; male

(c) Contact information; (555) 555-1212

(d) Specialty;  urology

(e) Whether accepting new patients. Y

(f)  Gender of support staff: Female

(g)  Provide same gender care for: Male

In this situation, the practice can bring in a male nurse from the affiliated hospital to provide for all male care with advanced notice. This is another trend in today's healthcare. 

I also included references to gender choice in healthcare and modesty issues. 

Here is where to direct comments:

Comments are being requested on this draft by Jan. 12, 2015. The revisions to this draft reflect changes made from the existing model. Comments should be sent only by email to Jolie Matthews at jmatthews@naic.org. 

I am encouraging everyone to comment on this. We can make a difference...

Live like there is no tomorrow....

Abusive Physicians

2014-11-28 -- Doctor’s Sex-Abuse Trial Moved to Frederick -- Dr. William Dando

2014-11-28 -- Myles Bradbury: Cambridge paedophile doctor 'had 170,000 images' AND Victims' Families Weep Over Doctor's Abuse AND Children’s doctor faces prison for sexual abuse of boys he was treating -- Dr. Myles Bradbury -- UK

 

2014-10-26 -- Anchorage doctor arrested on child sex abuse charges -- Dr. Clifford R. Merchant

 

2014-08-25   Mesa doctor arrested after patients allege sexual abuse

2014-06-18 --  EXCLUSIVE: New York City gynecologist charged with sexually abusing patients -- Dr. Robert Hadden

Patient Dignity 20: "It's called sticking your finger in my ass! "

Warning: This post is brutally honest and NSFW (not safe for work).

Physicians and other providers like to correct patients on the terms that we use. It is not a cock, a dick, a willie, mini me, or even Fred, it is a penis.

Does anyone know the reason human beings don’t like to use the words like penis and vagina, but prefer “pussy,” “cock,” “privates,” “wee-wee,” etc.?

Context. Those scientific terms are sterile and devoid of emotion. Those parts of our bodies are very emotional to us all.

This is part of the problem. There is a disconnect between providers and the rest of society. I would attribute it to the way providers are trained. 

What providers may find acceptable, the rest of society does not. Healthcare has granted itself privileges to our bodies that nobody else has. Not even law enforcement. 

Warning: the following example is to illustrate the control over our own bodies. It compares sexual actions to medical actions to illustrate the disconnect. . Although the actions are the same, the intent and purpose are different. 

There are married couples (partners, significant others, etc,) who are adventurous sexually and those who are vanilla. One area that is taboo for many is anal sex. There are many ways to stimulate the anus, but I will use digital stimulation for my example. 

There are people who will not allow this, even for the most important person in their life; their partner. Our partners are more important than healthcare. The species can continue without healthcare. It did for millions of years.

Yet, depending on our age, healthcare imposes an annual DRE on both partners. Imagine the psychological effect this has on people; healthcare imposing something a person would not even grant their spouse.

If a partner were to allow the other to try this stimulation out of love and trust, they have the right to say NO, otherwise it is considered assault (even within a marriage). 

Yet in certain situations (the ED), a healthcare provider can ignore our wishes and it may not legally be assault, but I am sure the patient feel assaulted. 

I am sure we have heard the adage of the American College of Surgeons in their Advanced Trauma Life Support (ATLS) is a training program: Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum. 

There are some spouses who do not like their partners to see them undressed. In certain Jewish sects, intercourse involves a sheet with a hole in it. Again, healthcare expects us to annually undress and place our genitals in the hands of strangers (literally) for a physical exam. 



Going back to my example of "digital rectal penetration," from the point of view of the patient, whether it is a sexual tryst with a partner, or an exam (with appropriate draping and conducted in a professional manner) to make a diagnosis...




 ....it still feels like a finger up my ass!!!

Finally.........


I found this on cancerholocaust.com:

Do you see my point????

Thank you for reading.

Living with ADHD

ADHD is really a super power. If you gave me a pill that would instantly take away the ADHD and make me like everyone else, I would NOT take it. Some days, this is what my train of thought is like...

BTW: I am the guy on the pumpcar ahead of my thoughts....