Wednesday, February 23, 2011


It is our pleasure to introduce guest columnist Jan Henderson, PhD. She is a historian of science and medicine who writes about the history of the medical profession and changing attitudes towards health care. You can find more of her writing on her blog, The Health Culture. The following is the second of a two part series.

History of Patient Modesty, Part 2

Convincing patients to disrobe

Guest post by Jan Henderson, PhD

In part one of this post I explained how a new anatomical understanding of disease in the 19th century changed the practice of medicine. Prior to this insight, there was no need to expose the naked body to observation or to touch parts of the body that were normally clothed. In order to apply the anatomical theory of disease, doctors needed to discover what was happening inside the body. This required a new type of physical exam, with much greater exposure and invasion of the body. This was an abrupt and significant change in the tradition of patient privacy and modesty.

Making patients blush

Doctors welcomed both the new understanding of disease and new techniques, such as the stethoscope, that gave them useful information about the interior of the body. Understanding and technique alone did nothing to improve the ability to treat disease, by the way. That came much later. What doctors could do was provide a better prognosis, thus avoiding futile and painful treatment of the terminally ill.

How did patients react to this change in medical practice? Unfortunately, we have very little direct information. Most of the evidence we have comes from doctors, not patients. Doctors tend not to record the routine and taken-for-granted nature of a patient encounter. The private diaries of patients undoubtedly recorded reactions to the more invasive physical exam, but historians of medicine have typically been more interested in uncovering evidence of new medical discoveries than in noting patient experiences.

There is every reason to believe that women found the new physical exam deeply embarrassing. For example, a woman’s diary entry from 1803 reads: “Doctor Williams called and made me undergo a blushing examination.” In 1881, Conan Doyle recorded that a female patient would not let him examine her chest. “Young doctors take such liberties, you know my dear,” she told him.

The indirect evidence we have comes from efforts of the medical profession to convince patients that the new physical exam was necessary and proper. This took two forms: Emphasizing the professionalism of doctors and arguing for the scientific nature of medicine. These 19th century changes in the image of medicine contain the seeds of a new relationship between doctor and patient. They led to a style of medical practice today that increases rather than eases patient concerns about privacy and modesty.

Convincing patients to accept the new exam

The new physical exam was a sudden rupture of conventional modesty and privacy. We can infer the resistance of patients from efforts by the medical profession to create a new image of the doctor in the eyes of the public.

In the 19th century the medical establishment began to emphasize the professionalism of its practitioners. The American Medical Association was established in 1847. It promoted an image of its members as men of integrity with an upright social standing in the community. Doctors were said to have high ethical standards and to observe codes of proper conduct. Simply because they were professionals, they should be held above suspicion. It was this professionalism that entitled doctors to the confidence of their patients.

An apothecary, writing in 1817, expressed the following opinion:

It ought to be fully understood that the education, character and established habits of medical men, entitle them to the confidence of their patients: the most virtuous women unreservedly communicate to them their feelings and complaints, when they would shudder at imparting their disorders to a male of any other profession; or even to their own husbands. Medical science, associated with decorous manners, has generated this confidence, and rendered the practitioner the friend of the afflicted, and the depository of their secrets.

It’s one thing, of course, for women to confide their secrets to a doctor. Venereal disease was quite common at the time and preventing transmission required an honest discussion of sexual partners. But it’s something else to allow direct observation of the unclothed body. Yet this is exactly what doctors were beginning to do.

The comments of an English physician, writing in 1821, reveal the ambivalence of physicians when it came to conducting exams. He remarks on the reluctance of some of his colleagues to observe the unclothed body. When examining his own patients, he often found “plain and obvious disease entirely mistaken and mistreated, for months, — even years, — merely from the practitioner’s neglecting this simple but necessary measure!”

He urged fellow doctors to examine any part of the body where they suspected disease. The patient should be free of “every species of covering that can impede the necessary examination, — always by the hand, and often by the eye; and wherever the case is at all doubtful.” He acknowledges “the repugnance of our patients to the measure.” But he urged doctors to overcome this repugnance, “however great this may be, and however natural and proper we may feel it to be.”

There’s an interesting clue here in the words “always by the hand, and often by the eye.” One can palpate a hernia by slipping a hand underneath a garment. It’s another matter to expose the groin to unobstructed view.

Whether the examination of the vagina was done by the hand or the eye, it was criticized as a threat to decency. The American gynecologist J. Marion Sims, writing in 1868, countered this criticism: “There can be no indecency, and no sacrifice of self-respect in making any necessary physical examination whatever, if it be done with a proper sense of delicacy, and with a dignified, earnest, and conscientious determination to arrive at the truth.”

Justifying medical practice as a science

The medical profession also emphasized the scientific nature of medicine. Biomedical research in particular (bacteriology, the germ theory of disease) was increasingly recognized as scientific by the end of the 19th century. The public’s esteem for science was growing. It was only natural that medical practitioners, who were in a position to apply scientific research, would want to be regarded as scientists themselves.

Medical authorities argued that the physical exam was simply an “imperative of science.” Patients were impressed by diagnostic instruments, which seemed to give doctors a magic not previously available. Medicine’s association with science enhanced the doctor’s image and helped legitimize the physical exam.

The exam was transformed into a scientific ritual. A patient’s visit to a doctor was no longer the interaction of two people with a lifelong relationship. There was a distinct role for the doctor and a different role for the patient. The role of the doctor included special privileges, such as the right to ask intimate questions and to examine intimate parts of the body. The role of the patient was to comply with the doctor’s requests, while admiring his increasingly superior knowledge. Ritualization of the exam made it more abstract and impersonal. In the eyes of doctors, at least, this served to reduce the sense of a violation of patient privacy.

When the power relationship between doctors and patients shifted – when doctors became less dependent on the patient’s account of symptoms — the doctor/patient relationship began to change. The emphasis on the scientific nature of medicine intensified this shift. The objective nature of science required that doctors create an emotional distance from patients.

We see here the origins of the change that evolved into what patients complain about today – the cold, impersonal, and insufficiently attentive nature of modern medicine. Affronts to patient modesty are intensified by this impersonal atmosphere. With the passage of time, patients have come to accept the new lack of privacy. But the sense of embarrassment remains undiminished.

Today’s medicine: Coldness and occasional empathy

When the tools available for a physical exam were limited to the stethoscope, percussion, and visual scopes, doctors obtained the information they needed through direct interaction with their patients. This is much less true today.

The doctor’s time is extremely precious. As medical technology advanced, doctors found they could delegate the collection of medical data to skilled employees who required fewer years of medical education. Much of a patient’s time in the modern health care setting is spent with members of these new occupations, from the receptionist, nurse, and lab technician to the men and women who operate the machinery that views or otherwise records the interior of our bodies. At the beginning of the 20th century, one out of three health care workers was a physician. By 1980, the ratio was one out of thirteen.

Dr. Friedman, the female physician who disclosed her discomfort in anticipation of a colonoscopy (see part one), goes on to describe more of her experience as a patient that day. She compares a reassuring moment of warmth from her doctor with the impersonal treatment she received from the rest of his medical staff.

Of all the … personnel who followed suit, reviewed the data set, and performed medication reviews, vital sign measurements, intravenous catheter insertion, and completion of endless subsets of paperwork, not one asked how I was feeling. None delivered sincere eye contact. All were proper, methodical, pleasant, and yet somehow detached.

She makes a brief visit to the restroom, clutching her skimpy, open-back hospital gown.

Upon return to my slot, I was dismayed to find that Dr. T had arrived during my urologic escapade. Sensitive to the multiple demands on his time and sorry to have caused him delay, I scrambled back onto my gurney so he too could complete his preprocedure process. As I did, Dr. T spontaneously engaged in battle with the curtains to enclose us and ensure my privacy. He bent to cover my exposed legs with a blanket and then looked directly at me to ask how I was doing. With three such simple acts, the man about to see and invade the parts of me about which I am most shy and protective endeared himself and earned my deep gratitude.

The medical profession in the 19th century may have believed that an objective and dispassionate ritual would somehow satisfy the patient’s need to feel comfortable with the more invasive liberties of new physical procedures. The opposite may be the case, however. Not only is it appropriate for a doctor to step outside the dispassionate and objective professional role and take a moment to connect with the patient. It is highly desirable. Treating the patient as an individual human being reduces the stress associated with patient concerns about privacy and modesty.

Patients need respect and compassion from all medical professionals

The sheer number of individuals a patient is exposed to as part of a modern medical encounter – during much of which the patient may be inadequately and awkwardly covered by a hospital gown – has grown exponentially. Any medical professional, from hospital director to hospital orderly, can ease a patient’s concerns for privacy and modesty by treating the patient with courtesy and respect. There’s no difference between the humanity and compassion of doctors and that of any other health care employee. The problem for everyone is that time constraints have made courtesy and respect a vanishing resource.

Dr. Friedman summarizes her colonoscopy experience:

On the one hand, the quality of care was excellent. … On the other hand, sincere caring was lacking. I had predominantly felt more like a product on the fast-moving conveyor belt of a health care factory than a human being. Among all of the processes and gestures that had been so vivid, only Dr. T’s had comforted. Despite whatever other stressors were at play for him that morning, he had personally managed to empathize with me at the center of the surrounding vortex of objectives and deliverables consuming the rest of his team.

Too often it feels like we health care professionals have surrendered our souls in succumbing to demands for increasing efficiency, minimization of time spent at every node along the pathway, and rapid shuttling of patients in and out of facilities. We often strip them of critical remnants of personalization – specifically to meet regulations. Having learned that treating patients like human beings does not facilitate reimbursement, we have capitulated. After all, the delivery of tender loving care (TLC) consumes time and prevents one’s ability to accomplish other competing tasks.

How has the pendulum swung this far? Why do we tolerate an environment in which a reticent but unafraid patient emerges from an uncomplicated encounter feeling dispassionately processed rather than embraced?

In any organization, the values and philosophy of those at the top are communicated – directly and indirectly – to those below. As one moves down the hierarchy of health care industry occupations, there is no logical reason why respect and compassion should be considered inappropriate or unnecessary. In the modern health care climate, however, they are seen as inefficient. When efficiency is the paramount value of an organization, then it’s up to the innate humanity of each employee to assert his or her own values by showing the respect and compassion each patient needs and deserves.


Suzy Furno-Maricle said...

Very interesting part 2. It's easy for readers to understand how the medical field attempted to break down modesty barriers, which was necessary to achieve more accurate care. How to handle this "new idea" of no modesty was certainly experimental, as there were no other coercive techniques existing quite like this one. Perhaps they did the best that they could within this new era of medicine.
As you said, however, "technology is always pushing doctors to new frontiers", and part of that new frontier is the advent of the modern savvy patient. It seems that the past antiquated 'conditioning' is still projected onto patients. Patients who still have respect for a medical provider but not with tha same passive carte-blanc attitude toward each person or every procedure. I would say that it is the medical arena who finds it difficult to keep up with changing patient expectations, therefore: it is easier to ignore it.
It is indeed " always a brave new world". Well said. It encompasses the changes I see in patients willingness to speak up for the respect of their bodies.

I don't know if Dr. Sherman and Doug can speak to this, but I speak with more and more people who drop the anonymous aspect of speaking up for modesty. Conversely, more people who want to make it a non-issue are taking the anonymous seat. This is an important psychological dynamic, as it openly changes the power structure: a move that can not be overstated.
While we may not be becoming vogue, (yet)at least we are more readily accepted.

Your straight forward articles are certainly an important and informative read. I hope advocates and patients come here to review this history.
And thanx for the kind words regarding my blog....


Doug Capra said...

I really don't see this so much as a "male" or "female' modesty issue anymore. Not really. I see it more as a human dignity issue. A patient autonomy issue. A patient-centered philosophy issue. Even if a person isn't modesty at all, he or she could be treated without dignity in terms of unacceptable bodily exposure. I think most people are not either "modest" or "not modest." I think the context is essential. Nude art models can be very modest in different contexts. Male and female strippers can be modest in different situations. Nudists can be easily humiliated or shamed with their own nudity in the correct contexts. For example, even if a nudist doesn't mind parading around the hospital nude, that's not acceptable from several points of view -- if it's allowed, it sets a standard of acceptability. It may offend other patients or staff. Within cultural parameters, there are boundaries, standards. Within the confines of the exam room, doctors and nurse can be more flexible depending upon the patient's comfort (and their own comfort). But the key is the patient comfort. Medical professionals need to learn that "modesty" is a complex and variable concept. If they really care, the most common way they're going to learn about how most patients feel about the issue is to ask and accept that there are preferences depending upon varied contexts. But I don't see that happening unless it's forced due to the nature of the historic and current medical culture. Some caregivers are sensitive to this issues. Others are not. Some don’t consider it an issue. A few are completely oblivious to it. Others have changed and see it better. But money and profit drives medicine today, and time drives money and profit, and expediency and efficiency drives all this. Technology has done tremendously good things to save our lives. But technology has also distanced doctors and nurses from patients as human beings. We as patients have become more like"images" that are read than human beings who are listened to and examined.  Of course there rare exceptions to this generalization. There many good caregivers out there to know this and try to mitigate it.
As to Suzy’s question -- I don’t doubt her observation. As I become more knowledgeable and comfortable debating this topic, I find that when the modesty issue is realistically tied into ethics and human dignity, there really is no argument or debate. Many caregivers know this. They see better than anyone the flaws in the system since they work within it every day. To some, the problems are overwhelming. And the power dynamic within the healthcare hierarchy frightens many of them away from revealing who they are. Depending upon the culture of their workplace, it may not be politically correct (or even considered intellectual) to advocate for patient modesty. Thus, if we argue this issue as a human dignity issue -- not mere modesty -- caregivers don’t have much of an argument. The core values of their institutions, their codes of ethics, their patient rights and responsibilities documents -- all advocate for patient dignity, respect and autonomy.

Jan Henderson said...

Suzy – I’m not as well-informed as you and Doug and Dr. Sherman are about contemporary patient’s attitudes towards modesty and privacy. I remember the first time I came across a discussion of the subject on Dr. Maurices’ Bioethics blog, it was pretty eye-opening.

My sense is that this issue is not brought to the attention of doctors very often (not to mention all the other medical personnel who see patients). That’s based on reading the mainstream medical journals (JAMA, NEJM, The Lancet) and seeing what gets discussed at a site like KevinMD (with the exception of the guest post from this blog). The journals don’t seem to publish any studies on the topic. I wonder if the research is happening elsewhere, like among medical sociologists.

Jan Henderson said...

Doug – That’s a good distinction between not being especially modest, but being justifiably upset when exposed in an unacceptable way.

I think you’re right that it’s no longer a male or female issue. I suspect most women get used to having an annual Pap test, and most ob/gyn’s are now female, which was not the case just decades ago.

The thing that struck me when I first read the Bioethics Discussion blog several years ago was male modesty. It hadn’t occurred to me. I wonder if women assume that men are used to being naked in the locker room and so nudity doesn’t bother them. In reading through the historical data, I didn’t find any references to male modestly. The 19th century complaints from men were about how doctors shouldn’t be examining women.

Doug Capra said...

" I wonder if women assume that men are used to being naked in the locker room and so nudity doesn’t bother them."

Jan -- I could never understand that argument. Yes, my generation of men (and earlier generations) felt quite comfortable being nude with other men in situations like showers. But there were no women present. Many of these kind of events were male bonding rituals, historically. Nudity was part of it.
How men feel when they're in a shower with other men has nothing to do with how some men feel when having no other choice but to be examined or treated intimately by a female caregiver. Male nudity rituals rarely involved women in the past.
Re the research of Havelock Ellis and the writings of Augustine, I think there's an argument that men are more modest than women for reasons Augustine goes into in detail. Men have projected their modesty fears on to women. Women's modesty must be protected because of the affect it has on men, physically. Women's sexuality is dangerous to men.
Jan -- Your thoughts on this?

Joel Sherman MD said...

Jan, as we've discussed elsewhere little is known or studied about male modesty. But I don't think the historical lack of concern about it is due to the fact that men have been used to all male nudity in the past (though no longer). I believe it relates more to the attitude that men 'don't need modesty.' That is to say that men are at much less risk of sexual assault or rape than women. That at least is the theory though its validity can be questioned as the statistics show that boys have been assaulted at a highly significant rate, roughly 50% that of women. Mores are changing and now young men are very aware of increased susceptibility to assault when they are exposed.

Jan Henderson said...

Doug – You’re absolutely right about the difference between an all male locker room and a female urologist. What I’m realizing here is that there were no 19th century modesty complaints from men because there were (virtually) no women doctors. Office (vs. home) visits didn’t start until the early 20th century. There may have been female office staff at that time, but cultural morĂ©s would undoubtedly have sought to protect women from seeing naked men rather than protect men from being seen. There were female nurses in the 19th century, but hospitals were limited to treating the indigent and soldiers injured in battle. So the issue of male modesty came up rarely until … when? Even through the post-WW II era, female doctors were the exception. It strikes me that, since the sixties, there’s been a projection of (not necessarily correct) assumptions about male sexuality (an example at onto assumptions about male modesty. You and Dr. Sherman have a tough job ahead of you in educating the public, but it’s an extremely worthy endeavor.

I appreciate your comment on how men have projected their modesty fears onto women. The idea that women’s modesty must be protected because of the effect it has on men is part of the long history of cultural assumptions about men that you’re up against.

Jan Henderson said...

Dr. Sherman – I didn’t mean to imply that there was a connection between male modesty and male nudity in the past. Merely that women – in the absence of any direct knowledge – might have been making an (incorrect) assumption about male attitudes towards nudity (in an all-male context).

Unfortunately it is sad but true that we now know young men have been victims of sexual abuse.

There are a number of comments on male nudity in Barcan’s book “Nudity.” One is that naked male bodies in public spaces are considered more “dangerous” than naked female bodies. This relates to the cultural assumptions about male sexuality that I mentioned in my reply to Doug.

Barcan repeatedly points out that nudity is associated with sexuality, and in modern times the association has become especially intense due to the use of idealized, partially clothed bodies to sell products and the widespread availability of porn on the Internet. With respect to modesty, she points out that advertising has made people more aware of – and unhappy with – their bodies. As a result there is an increased desire for privacy.

I would wager that close to 100% of what’s been written over the last few decades about attitudes towards our bodies (originating in feminist studies) focuses on women’s bodies. But it makes sense that an increased need for privacy, stimulated by the excess of beautiful bodies we view everyday, should be true for both men and women.

Doug Capra said...

I recently read a book called "The Body Project," about the history of young women and the relationship with their bodies. Very interesting. According to the book, in the 19th century (Victorian) many women had sex clothed and rarely took clothing off for the doctors. A change occurred in the early 20th century, the book said. It doesn't explain the factors that caused the change. But unclothed sex became more common and many women seemed less concerned with nakedness, doctors reported. Of course, we need to consider from what sources the notice of these changes are coming? Are we getting these reports from doctors, women, men?
These are the kinds of trends we need to track, I think, to try to understand attitudes toward modesty. What factors are causing these changes.

Suzy Furno-Maricle said...
This comment has been removed by the author.
Jan Henderson said...

Hi Doug – Yes, that’s a good book. I haven’t finished reading it. I remember reading somewhere about women in the late 19th century who took baths their whole lives with their clothes on. They were never supposed to see their own naked body.

Roy Porter (a great medical historian) writes about the diary of a woman in 1807 who mentions preferring to change her clothes in private. “I like to be alone when I dress and undress.” She comments that this is an exceptional attitude for the time. Both she and her brother were taught to have a high regard for personal modesty. “I like to bathe alone,” she writes.

As you say, there are various trends that should be tracked. And they’re all interesting. I have a book on the history of undergarments. There is the change in attitudes towards bodily functions. There’s the architectural opportunity for more privacy. There are changes in sleeping practices.

There’s a fascinating book called “At Day’s Close: Night in times past.” The author – a historian – spent 20 years reading diaries and legal records for references to what happened at night in pre-industrial times. It used to be quite common to have “bedfellows.” People slept in the same bed, for various reasons – warmth, fear, a lack of beds – they were the most expensive material possession (for those who didn’t sleep on hay on the floor).

Doug Capra said...

Yes, good beds were expensive. And people think Shakespeare cheap for living his wife his second best bed!!
I've read At Day's Close. An excellent book. There's also that five volume series on the history of private life -- have you read it? I'm going through it again to see what I can find about what we're talking about. There's quite a bit there about privacy and bodily functions.

DIY Health said...

It took me a while to read all two posts but it sure was a great read. Even if we have seen the human body for a thousand times, I still want my patients to be at ease with the whole process. Yes, the long line of patients outside and our busy lives strips my patients of their modesty at times. I do hope patients can read this article.

Jan Henderson said...

Doug – I wasn’t aware of “A history of private life.” Turns out my local library has all five volumes available for check out. There’s so much to read!

Dr. Joe – Thanks for reading (I know it’s long), leaving a comment here, and stopping by my website.