Wednesday, July 20, 2011

Medical Education & Modesty Concerns
A former medical student's troubled path

Moderator's note:  This blog does not usually publish anonymous posts but because of the highly personal nature of this contribution, we have agreed to anonymity.  The article is an important contribution to a rarely acknowledged subject.

by  'Stressed Student'

I was a University of Illinois at Chicago (UIC) medical student. Like many teenagers and young adults, I had never visited a gynecologist or proctologist. I did not come from a medical family either. And because pelvic and prostate exams are not mentioned in the premedical curriculum nor explained to medical school applicants and incoming UIC students, I did not know about these exams when I first moved to Chicago to begin my medical education.

My faculty did not bother to explain what bimanual exams were my entire first year of medical school. I only learned about them from classmates cracking jokes, and from receiving e-mails from students selling T-shirts that compared the exams to sexual activities, making light of the way we must complete the exam once on an actor as part of our Essentials in Clinical Medicine (ECM) physical exam course in our second year.

I immediately had problems with pelvic and rectal exams. I found them violating in concept. I believed it had to be wrong for my school not to explain to applicants beforehand that there was more to examining men than testicular exams and more to examining women than breast exams and catching babies. I thought that training students to lubricate and insert their fingers into male and female sexual organs was much more taboo than what many young students would creatively imagine on their own before matriculating. I thought it was not right to assume that every student must agree with digitally penetrative exams just because they are widely accepted as valid medical procedures, at least in this country. After describing these exams to my younger sister and a few friends from college, I was confident I was not the only human being who viewed these exams as more than just a little uncomfortable, but also violating.

There was ample support at my school for students with academic problems regarding written exams. But there was nobody to speak with for students who had personal, cultural, or ethical conflicts regarding clinical procedures. I did speak with a school psychologist who specialized in stress management because she gave students her contact information during orientation week, but all she did was invalidate my perspective by repeating "There is nothing sexual or violating about these exams." Realizing that a broken-record psychologist could not alleviate my stress, I decided to complete the first year curriculum and resolve my issues over the summertime.

I entered the program at UIC to prepare for a career in translational services between medicine and investigational science. I wanted to focus on pathologies of the brain and nervous system. So I was looking to develop into the capacity of a pathologist or maybe a neurologist who conducted translational research on that organ system. I was not aspiring for a career in a field like family medicine, emergency medicine, internal medicine, and obviously gynecology. And so when I learned about these invasive genital exams, I found them violating enough to refuse. Realizing they were not part of my future responsibilities, I thought the most professional and honest approach would be to discuss all of this with faculty

Over the summer, I confided in faculty that even though I understood many people saw these exams as being just another part of the physical exam, I saw pelvic and rectal exams as being violating procedures, and that unless I went through some psychological change where I could perform them without feeling violated, I would decline to perform them, especially in non-emergency scenarios such as practicing on an actor in an artificial environment, and especially since it was not listed as a graduation competency to students beforehand (or even at all anywhere). What happened when I said this is they withdrew my scholarship, and shunned me for asking for "special privileges". I withstood so much abuse when I brought the topic up with faculty, ridiculing me with "What? We have to tell students that doctors touch people?", guilt-tripping me with "If you cared about patients, you would do the exam", and victim-blaming me with "You knew all about these exams before you got here, you just repressed it."


Over the summer, the first person I contacted was an instructor of ECM (the physical exam class where we must complete these exams). I vaguely told him I had "concerns" about the ECM course for second-year students. He offered to meet with me, but said most students speak with other ECM instructors first, and then with him if things are not resolved. So I spoke with all the other course instructors, and by then he knew what my issues were, and was no longer interested in meeting with me. I did learn a lot of unacceptable facts about the ECM class from the other course instructors though.

I was appalled and frustrated to realize my school has watched students suffer personal conflicts like me for decades:

1) Every single year, the instructors watch a "few" students resist these exams. One instructor told me these students say "I just can't do this" and "I don't want to do this". Some students abruptly walk out of the exam room, and some postpone their dates, all the way until summertime when they must complete it once to advance to third year.

2) Students have fainted during the exams.

3) Students have cried during the exams. The worst was a recent student who said she was a rape-survivor and had problems with the male rectal exam. My instructors still forced her to do it, and she left the room sobbing in front of the actor and instructors.

4) The instructors have a rule that one female must be in the room for the male rectal exam. The rule was established to mitigate any "homophobia" among male students, and apparently my school thinks the presence of a female neutralizes any viewpoints students might possess that the exam is a "gay thing". I thought this "rule" reeked with discrimination and hypocrisy. It seemed to me this "rule" was conjured up decades ago by the primarily male heterosexual faculty who empathized with problems male heterosexual students as a selective group would face, and made it easier for them to at least graduate, when many male students never even asked for it. The most disturbing part about this "rule" though is that the faculty EXPECT a few young students to be unable to desexualize the prostate exam when it is introduced to them. To then force students to complete the exam, knowing that some cannot desexualize it, must be sexual abuse. But not wanting to "scare students away", these instructors deliberately keep students in the dark until they have invested too much time and money into school. Because at that point, students who find these exams unacceptable must choose between getting sexually abused or crawling away with a mountain of debt as a medical school dropout. The instructor who told me about this "rule" said it was handed down to her when she took the position in 1982. In other words, this "rule" is over three decades old!

What do you think of these four points? I think they unfold like rape scenes. A self-proclaimed rape-survivor leaving the exam room sobbing? Students crying and fainting while doing "intimate exams" that were not explicitly explained beforehand? Students "resisting" and "postponing" the exams for months? One instructor assured me that I was not out of place, and said he always sees students "make horrified faces". Unfortunately, his comments did not make me feel better, they made me feel angry that my school failed to question why this is the case. It disgusted me that nobody advocated for the rape-survivor. I believe they raped a rape-survivor. And it outraged me that this student cried in front of her peers, and then felt she needed to reveal personal information about herself too. There is no justification for the fact that they did absolutely nothing after that for future students.

I was sickened by the degree instructors deny they are hurting a few students each year. They assured me "I always ask those kids who keep postponing the exam how it turned out, and they say it was not as bad as they thought." What else can these students say when their own abusers fish for an agreeable response like that? The instructors even told me matter-of-factly "Students faint during the pelvic exam because they did not eat a big breakfast." They cannot possibly be keeping tabs on 200 students breakfast schedules. It irritated me they never considered why nobody fainted during the ear exam. As of now, their "solution" to the fainting episodes is to remind students earlier in the week when they explain the pelvic exam workshop to eat a big breakfast on the morning of the workshop.


I read a book "Public Privates" by Terri Kapsalis. When I learned halfway through the book the author was a pelvic exam actor at UIC, I was shocked to discover she wrote an entire chapter about UIC students having problems with pelvic exams. This book was published 20 years ago, and nothing at my school has changed. Here are some quotes from her book about my school:

1) [The author discusses a paper by a physician named Buchwald] "Students seem to find it very difficult to consider female genital display and manipulation in the medical context as entirely separate from sexual acts and their accompanying fears. Buchwald's lists of fears makes explicit the perceived connection between a pelvic examination and a sexual act. "A fear of the inability to recognize pathology" also reflects a fear of contracting a sexually transmitted disease, an actual worry expressed by some of Buchwald's student doctors. Likewise, "a fear of sexual arousal" makes explicit the connection between the pelvic exam and various sexual acts. Buchwald notes that both men and women are subject to this fear of sexual arousal. "A fear of being judged inept" signals a kind of "performance anxiety," a feeling common in both inexperienced and experienced clinical and sexual performers. "A fear of disturbance of the doctor-patient relationship" recognized the existence of a type of "incest taboo" within the pelvic exam scenario."

... "Buchwald's work deviates from most publications dealing with the topic of medical students and pelvic exams. Largely, any acknowledgment of the precarious relationship between pelvic exams and sex acts is relatively private and informal, taking place in conversations between students, residents, and doctors, sometimes leaking into private patient interactions. For example, as a student in the 1960s, a male physician was told by the male OB/GYN resident in charge, 'During your first 70 pelvic exams, the only anatomy you'll feel is your own." Cultural attitudes about women and their bodies are not checked at the hospital door."

... "In his article about medical students' six fears of pelvic exams, Buchwald accepted student fear without either questioning why young physicians-to-be would have such fears or searching for the cultural attitudes underlying them."

2) [The author discusses that schools hired prostitutes to teach the exam] "In a sense, the patriarchal medical establishment took the position of a rich uncle, paying for his nephew, the medical student, to have his first sexual experience with a prostitute. This gendered suggestion assumes that female medical students are structurally positioned as masculinized "nephew" subjects as well."

3) [The author quotes a fellow pelvic exam actor] "I think the students are afraid it's sexual. They're afraid about how they're going to react, whether they're going to be aroused, but it's so clinical."

4) "Only with the use of GTAs [pelvic exam actors] have medical schools attempted to incorporate women patients' thoughts, feelings, and ideas into pelvic exam teaching. And yet, as these feminist teachers pointed out decades ago and as my experiences have occasionally confirmed, it may be impossible to educate students properly within the medical institution given unacknowledged cultural attitudes about female bodies and female sexuality."

The author of this book is correct: There is no validation from faculty at UIC that some students suffer problems regarding these exams, and there is no effort to investigate why this is the case. I also agree there is no search for "cultural attitudes" that could underlie students perceiving these exams differently. In fact, although I have American citizenship, I was raised overseas from age four and returned to America for college at age nineteen. I retrospectively learned that in many developed nations, the thought of asymptomatic women paying strangers in white-coats to routinely penetrate their vaginas is the exception rather than the norm. In Korea, for instance, some women use vaginal swabs in the privacy of their homes. In Japan, screening for cervical cancer at all is not commonplace. In other developed countries, there are self-pap tests that some women use because they find the traditional gynecological exam to be inappropriate in the absence of symptoms. In addition, the developers of the CSA blood test cite "cultural taboos" as being a primary motivation for them inventing a non-invasive alternative to check for cervical cancer. So I think my school is very ethnocentric to believe all incoming students automatically agree not only with these exams, but also with practicing them on asymptomatic actors. It is undeniable some students discover personal clashes that might derive from cultural upbringings while learning about the most taboo aspects of physical exam for both sexes, and I find it unethical that schools would not inform students about these potential problems before they move to new cities and matriculate.

At the same time, the author conveys similar beliefs as the instructors I met at UIC, hastily diagnosing students as having "anxieties" and "fears" that they can "cure" us of via "education". I think the quote the author provided from a fellow pelvic exam instructor ("Students are afraid it's sexual") is nauseatingly narrow-minded. How does this woman believe she can tell all adults that an exam, mechanically the same as digital sex, is not sexual? Why does she think she can speak her mind for all adults about human sexuality in medicine by resorting to empty buzzwords like "professional" and "clinical" to do so? In fact, she cannot define what is and is not sexual (or sexually violating) for any other adult.

This reminds me of one instructor who concluded I had an "irrational phobia". Do you think it was fair for this instructor to tell me I had a "phobia" of being forced to have digital sex with an actor without my consent? Because you could easily make the reverse argument: Students who do not want to do these exams when introduced to them (as this apparently happens each year), but still complete them have "phobias" about disobeying orders from faculty, or have "phobias" about standing up for themselves, or have "phobias" about what instructors will think of them if they admit they see a medical exam as being sexual. The same with patients too: I have seen peer-reviewed papers written by gynecologists investigating why some women have "fears" about getting exams. But the counterargument here is that women who dread the thought of being humiliated and penetrated by strangers, but force themselves to suck it up, have hypochondriac "fears" about developing a rare cancer and benefiting from a notoriously inaccurate exam. Depending on their lifestyles, some women are more likely to be harmed than benefited from the outdated pap smear, and the World Health Organization does not recommend ovarian cancer screening via bimanual exams. For these reasons, I believe smart and responsible women can decide to never submit to these exams while asymptomatic, without being diagnosed by pushy and one-sided doctors as having "curable fears".

It is too easy for instructors to label and ostracize students as having "fears". These instructors told a rape-survivor she was being irrational to "fear" the prostate exam. What is particularly evil is they knew this teenage girl or young woman likely did not know about taboo old men healthcare to decide for herself before starting school whether or not she found completing a prostate exam to be acceptable. In any case, her "fear" turned out to be a rational one because the experience did cause pain, as she expected, seeing that she left the room crying. These instructors pride themselves on walking over students and their problems, and believe that with their supremely rational minds, they can triumph over anything, when in fact they have not proven any strength unless they have all been raped themselves. So who are they to judge a rape-survivor student with long-term effects of depression? And then to boast that they gave this student such a valuable educational experience, just because they cannot relate to her suffering from traumatic life events? I thought that was just plain childish.

I do not think my instructors are very intelligent. There is more to intelligence than exercising the rational mind. The author refers to these exams as being a "first sexual experience" for many students. If it is indeed true (that medical exams can be sexual experiences), then forcing teenagers and young adults to perform them without consent using shame and blackmail, when it causes problems for a few of them each year, is institutionally-sanctioned serial sexual abuse and rape. At least that is how my intellect - both rational and emotional - sees it.


After I spoke with all physical exam instructors, they sent me to an OBGYN faculty involved with curriculum planning. I met with him twice, and our second conversation bothered me.

He told me he was "ignorant" medical students had problems. But really, he was anything but "ignorant" since he works with the same instructors who watch students cry and faint.

I asked him if I could bring in "evidence" that students have problems. So the second time we met, I brought detailed information about UIC students having problems, as well as news articles about students across the nation being "known to faint, cry, vomit, become hysterical and sweat" over these exams

I also brought one article about teenagers and women getting unwanted pregnancies because they could not obtain birth control from gynecologists when they refused pelvic exams. I brought this last article because I empathized and related to the female patients, as I would also refuse the exam if I were in their positions. The article was pointing out that because the medical community does not respect and accommodate these women and their opposition to pelvic exams, it leads to bigger problems like unwanted pregnancies. And I felt that was a similar message to what I was trying to voice to my school: I think a small number of medical students can find out they disagree with exams, and they should no longer be marginalized and ignored for it because that only leads to bigger problems.

When I handed him the paper, his demeanor changed from the previous meeting, and he suddenly raised his voice at me (even though I never raised my voice at him). He actually balled up his fist like he was holding pills and growled at me "If I have something a patient needs, I withhold it until they get the exam!" He was steaming with anger, even though I never thought to question his practice at all. I had read about why it was unethical to require pelvic exams for birth control
, but I assumed the doctors who abused their power in this manner were working in private clinics out in the boonies. It never even crossed my mind that an OBYGN faculty of a medical school would fit that profile.

Shocked and creeped out, because I saw his true color, I asked "Shouldn't doctors at least tell patients they could go elsewhere and get birth control without a pelvic exam?" I thought it would be lacking informed consent not to do so. He just sneered at my comment. It was very clear to me this person went into gynecology for all the wrong reasons one might expect. It infuriated me he could not even pretend to empathize with the girls and women in the article who found pelvic exams to be intolerable, just as he could not empathize with his own students who have felt the same way for years. Any gynecologist, especially one who is training the next generation of gynecologists, should understand and respect how various patients feel about their reproductive rights and healthcare. Hurdles should never be imposed for women seeking contraception. In my opinion, this has nothing to do with health care, and everything to do with power, control, and making money.

His thinking and practice is outrageously sexist: When he was a teenager who needed a condom, he did not need to confront an old woman in a white coat who withheld what he needed until he had digital sex with her first. He presents himself as someone who cares so much for women, but then dupes them into accepting pelvic exams for birth control, even though the World Health Organization and numerous medical associations have consistently stated that the only recommendation is a blood pressure check, since hormonal contraceptives are as hazardous as Aspirin. Medically speaking, there is no greater logic to requiring pelvic exams for women who want birth control than there would be for requiring prostate exams for men who want Viagra.

You can only imagine some terrible scenarios he has exploited: An adolescent patient from a poor family shows up for birth control but does not want a pelvic exam, and does not know beforehand that she will be pressured to accept one. Once in the office, she might view doctors as authoritative figures whom she cannot question. She might be time-pressured for immediate access to birth control. She might be too scared to challenge a doctor. She might find it more embarrassing to try to resist the exam. She might be fooled that the pill will harm her body if she does not accept the exam. She might be intimidated by the medical setting, and maybe cannot speak fluent English. At that point, she can either run away from the exam room (and get undesirably pregnant), or reluctantly submit to the exam (and suffer rape-like symptoms). And I am not just speculating here, I have read about female patients who realize they were mistreated after being coerced into something they adamantly did not want but ultimately accepted because of false guidelines presented to them. I have also read about women feeling "raped" from this practice, and driving for miles to find a doctor who actually follows the law.

I wonder why no students speak up when they see him mistreat patients? Maybe their voices have no impact. Maybe they worry they are out of line to defend patients. It agitates me because I know his misogynistic attitudes have an exponentially poisonous impact, seeing that his peers actually respect his philosophies enough to bestow him the responsibility of training future gynecologists at the largest public medical school in the country.

When I was about to leave the room, I recalled a discussion I had with a kind-hearted classmate who recently drove me home. I told him I had problems with these exams, and he urged me to speak with faculty and resolve the issue. Then he told me although he did not have problems performing the exams, he did have problems the way some instructors handled them: He said he shadowed an ECM instructor, and watched him reprimand each female patient who asked for a female to do her pelvic exam. Evidently, the instructor believes such requests are backwards and bigoted.

So when the OBGYN faculty asked me if I had anything else to add, I said I was concerned about an ECM instructor teaching students to reprimand patients when they prefer one sex over another for intimate care. The OBGYn faculty scolded me, and said he applauded that ECM instructor. He believed it was sexist for me to assist these patients and their wishes. He asked me "Would you ask a black person to leave the room? Would you ask a Jewish person to leave the room? Would you ask a short person to leave the room? Probably. Because you would ask a man to leave the room!"

I thought his analogy here was meager and self-serving. Funny how he was offended by modesty in medicine to vilify it as condoning sexism, when he is the one who abuses his position of power to do such despicably sexist things as withholding birth control from girls and women who refuse pelvic exams.

Patients requesting same-or-opposite-sex care for intimate exams was legalized under the Bona Fide Occupational Qualification (BFOQ) by humanitarians who advocated for patient rights to preserve cultural and personal beliefs about sexuality and bodily modesty. There are scenarios where patients know they will experience the exam as being less sexual because of their sexual history and preferences. For instance, a heterosexual man who has only had sex with women might prefer a male to do his exams because he might experience that as being less sexual. But another heterosexual man who has only had sex with women might prefer a female to do his exams because he might experience that as being more natural. And yet another might have no preference. So really, all individuals have unique sexualities both in and out of medicine. For these reasons, I believe my instructors are the ones who pass judgments on their patients and their sexual values and identities.

Some patients might find it more logical to speak with a provider who has experienced physical problems, like a female patient talking about cramps. And some patients might prefer same or opposite intimate care to protect the intimacy between their partners and spouses. How can a health provider admonish a patient and his or her relationship values?

In all honesty, I do not believe that a woman asking for another woman to do her pelvic exam is sexist. Many women perceive the act of getting naked and spreading into the lithotomy position as being sexually vulnerable and submissive. Even if a woman consciously believes that male and female doctors are equivalent caregivers, her natural instincts might strongly prefer a female examiner because she could not get impregnated by a strange female, as opposed to a strange male, between her naked legs strapped in stirrups. The consistent prevalence then of females requesting female intimate caregivers must have instinctive and deeply emotional roots, and must be accommodated by doctors without judgment or ridicule. Because when these women are demonized for making reasonable requests, doctors are punishing them for protecting themselves at a primitive and instinctual level. Hence, these doctors are docking points off patients for being human, known as dehumanization.

I have to say I find it troubling that these male providers harass female patients for requesting same-sex care. The power differential is too unfair. Most (American) female patients are very young when they have their first pelvic exams and are too often pressured by biased propaganda and brainwashed mothers to get them without the opportunity to judge for themselves whether it is really necessary or whether they are candidates for less invasive alternatives routinely offered in other developed countries. The pelvic exam is also longer in duration and so much more visually exposing than the prostate exam. Women also face additional hurdles since our society is still a very patriarchal one, where women are sexually abused by men at much higher rates than any other combination of sexes. Even if a woman has not been directly sexually abused, she has certainly been emotionally abused from a very young age, knowing female friends who have been sexually abused (often by men), reading newspaper articles about women being raped (often by men), reading history books about villages of women being raped (often by men), receiving catcalls and verbal sexual abuses (often by men), and knowing about pornography and prostitution and late night clubs where women are sexually belittled (often by men). She has been surrounded with evidence her whole life that some men might view sexual parts of female bodies differently. Unfortunately, OBGYN is not much different than these phenomena anyway, as it is a field that has abused the sexual organs of women for decades and was created primarily by male minds. And so when a female patient requests same-sex care, it may be because she has read books such as "Women and Doctors" by John M. Smith, MD, which revealed frightening statistics such as how much more likely it is for male gynecologists to recommended unnecessary hysterectomies, and how much more prevalent it is for male gynecologists to be reported as sexually abusive.

So how can this OBGYN faculty, who holds birth control hostage from girls and women until they submit to stirrups, relate to patients who ask for modesty accommodations anyway? Any physician or nurse, male or female, should be open-minded and accommodating with all patients and their valid and legal requests for same or opposite intimate health care, as well as their legal right to refuse degrading exams for contraception. Unfortunately, instead of accepting his patients as human beings with modesty concerns, he exploits their situations to elevate his own status as the heroic physician who is educating students to end what he conveniently believes to be sexual discrimination in medicine.

Even if these instructors are so black-and-white in their thinking to believe they are being discriminated against, they still hold responsibility to follow the law and teach students to do so as well. If they dislike the law, they can always orchestrate their own rallies to advocate for fewer patient rights. But I wonder how honest and humanistic they would feel about their pursuits. All they would be doing is transferring the alleged target of discrimination to the group of people who are in the much more vulnerable position, the patients.


The OBGYN faculty said he did not support my conflicts with the curriculum, and sent me to a Dean who is also involved with curriculum. This Dean gave me an unhelpful psychotherapeutic session the moment I walked into his room. Before I could explain in my own words what I came to speak about, he asked me "Do you remember anything happening to you that would make you see an ear exam differently than a pelvic exam?"

I thought it was unprofessional for him to ask me personal details about my life, but I told him I have never been sexually abused. I told him some students might find the exam itself to be violating if they are not told about it beforehand. He shook his head like I was a child trying to convince him Santa Claus was real, and told me the only explanation for a person to feel angry over medical exams was if he or she had been abused. Even when I reiterated this was not my case, he told me to seek help from a psychiatrist and "connect the dots" to my abusive upbringing. He went so far to ask if I had siblings, and suggested they also seek help.

I did not think this Dean seemed like an intelligent person to preach about sexual abuse inside or outside of medicine, seeing that he gave no exemption to the student who did admit to an abusive past, and maybe even believed the prostate exam granted her the ability to stop overreacting to whatever caused her to cry.

When searching for criticism of modern gynecology, I came across a popular book "(Male)Practice" by Dr. Robert Mendehlson, who was a pediatrician at UIC. The author stated:

"I will never forget a student of mine who wanted to specialize in obstetrics but couldn't swallow all of the ridiculous obstetrical intervention that he was being taught. He began to ask questions of the obstetricians: Why were the mothers' feet up in stirrups? Why were they giving the women analgesia and anesthesia? Why were they inducing labor at such an early stage? Why were they performing Caesarean sections when there was no clear indication of need? Did he get answers? No, but he got action. He was referred by the chairman of the department for a psychiatric examination, because any student who asks a hostile question in medical school is presumed to be 'disturbed.'"

This book was written in 1982, and still thirty years later at the same school, when students disagree with sensitive medical procedures, the Deans immediately send them in for psychological evaluation. I whole-heartedly concur with the author: Instructors at UIC stubbornly maintain there is something wrong with individual students each year, and never with the system itself.

Even worse, this Dean promotes a philosophy to his students that as long as nudity, touching, and penetration occur in the medical setting, then no sane person could possibly feel violated. This is far from the truth, and patients are beginning to speak up about their rights to refuse, request accommodations, and seek alternatives for "intimate" procedures.

For instance, I read the term "birth rape" has been coined. While I understand the term may be legally problematic, I find it conceivable that some women can only describe it this way after what was done to their bodies without permission. And I do not think these women are upset having life-saving C-sections, instead of natural dreamy births. They are upset having unnecessary and aggressive interventions without consent. Can it really be true that so many women must have their labor induced (a known risk factor for pelvic floor damage, perineal tears, epidurals, and C-sections)? Do so many women need episiotomies, when there is no evidence that artificial tears are safer than natural tears, which are rare anyway? Large studies of home births with trained birth attendants show that the majority of women can give birth without interventions, with less injury to mothers and babies, and no increased risk of mortality to either.

There is an unfair rule from doctors that all women automatically accept fingers and instruments in their vaginas if they wish to deliver a baby, even when births are proceeding smoothly. Doctors have an obsession with "checking progress" and recording numbers, with no respect for women who feel the procedures are barbaric. Some insurance providers cash in $250 per bimanual exam, which generates big bucks when doctors perform multiple "cervical checks". There are less demeaning maneuvers that cause less vaginal infections, but these alternatives are never offered. Instead, women who decline pelvic exams and episiotomies receive them against their wills! The baby needs an emotionally healthy mother, and that does not happen when she leaves the experience with so much trauma to call it "birth rape".

As for cancer screening, women are kept in the dark about less intrusive methods to test for cervical cancer (CSA blood tests, urine tests, vaginal swabs, and self-pap tests). Unlike this Dean, I strongly believe patients could feel mistreated by undergoing traditional pap smears should they discover that alternatives, which could have preserved their dignities, were not fairly discussed with them, or should they discover they were not even candidates for cervical testing in the first place.

A report released by Dr. Angela Raffles (cervical cancer screening expert from the UK) demystifies pap smear risks - 1000 women need to be annually tested for 35 years to save one woman from cervical cancer. Meanwhile, 95% of them (950) will require one or more biopsies that can be harmful (emotional stress, sexual problems, cervical stenosis, pregnancy complications, and even infertility). Another article by pathologist Dr. Richard DeMay "Should we abandon pap smear testing?" exposes the fact that cervical cancer mortality was trending downward before the application of pap smear testing, and that when malpractice suits led to higher false-positive rates (and hence more biopsies) cervical cancer mortality actually increased. Hence, the widely proclaimed association between the introduction of the pap smear and decline of cervical cancer might be more casual than causal.

Most doctors do not tell women that "the best kept secret of cervical cancer prevention" is through practicing safe sex and avoiding smoking, not through pap smears. Some women have microscopically slim chances of benefiting from the pap smear, such as virgins, women who only have sex with women, and long-term monogamous women. The same is true with ovarian cancer screening via pelvic exams: The American Cancer Society recommends against it. Why should doctors keep sticking their fingers in places they do not belong when there are no proven benefits?

It is clear to me that dishonesty surrounds much of these "preventative" gynecological exams. Doctors established these tests (money or fear of being sued), and the individual was disregarded. It became: Every Woman must have these exams with No Alternatives.

I can say with confidence that medical students are trained to think this way. In fact, in our first year of medical school, all students practiced interviewing patients with a standardized list of important questions. We asked ALL women: "When was your last pap smear?". But we asked NO men: "When was your last prostate exam?" It would almost make more sense to assume all older men are candidates for prostate exams, than to assume all women are candidates for pap smears since cervical cancer is an STD and so some women are not eligible. Also, the incidence and death rates of prostate cancer are much higher than those of cervical cancer, so it must not be about the numbers. In addition, cervical screening can be a more vulnerable process than prostate screening, because men often have the option of the PSA test (while the CSA test is never offered to women). So really, our first lesson was that female patients do not mind being humiliated in the medical setting, and that we should assume all women accept traditional gynecological exams, even the ones who could only be harmed by them in the first place!

The tunneled vision that this Dean holds (that doctors and nurses are above human modesty) will lead to suboptimal care for many patients outside of gynecology as well. I respect Dr. Joel Sherman and Dr. Maurice Bernstein, and the medical modesty issues for which they are raising awareness for male patients as well. In many ways, it can be a world more difficult for male patients to request and receive modesty accommodations because it is an overlooked topic without enough attention to draw any intelligent conclusions. In addition, people often view modesty as an unmanly characteristic, which might contribute to the ignorance about men having modesty, as well as the silence that fuels this ignorance because when they know to expect ridicule, men do not want to voice their modesty concerns. And I feel very sorry when I read comments from boys and men who have been traumatized by icy nurses and doctors who stereotype males as having no modesty. Unfortunately, I worry this stereotype will die hard, unless male modesty rightfully becomes a component of medical training and education.

I believe most of this ignorance stems from the way doctors are trained. When medical students learn to take sexual histories, we are trained to ask: "Do you have sex with men, women, or both?" (As a side note, I always thought the question should also include "or none" to represent all patients). Before the gay rights movement, this question was systematically swept under the rug to favor the heterosexual population, and hence made gay and bisexual patients less comfortable to openly discuss their sexual histories. Doctors now know not to assume all patients only have straight sex, and this is something that was strongly enforced at my school. I cannot imagine any of my classmates forgetting this simple question, because we are trained and repetitively graded to ask it verbatim from the very beginning. I think many medical students would feel confident to question one of their superiors if they did notice he or she was discriminating against sexual minorities this way, since it is a highly-valued aspect of our training.

On the other hand, when medical students conduct intimate physical exams, we are not trained to ask: "Do you prefer intimate care from a male or female provider, or do you have no preference?" Currently, this question is sidetracked to favor time-pressed doctors and patients who have no preferences, despite it being a legal request unknown to some patients. Obviously this setup makes patients feel ashamed if they do hold strong preferences and values whether a man or woman does their intimate exams. Perhaps then there needs to be a patient modesty movement that might be as successful as the gay patient rights movement by training and grading students to exercise the sexual rights of their patients in this manner as well.

Unfortunately, medical students know they will be shunned if they advocate for patients this way, since sex preference for intimate exams is not an official part of the curriculum. Not only that, but as I mentioned earlier, the instructors at my school reprimand students who bring the topic up for discussion. Therefore, I think dishonesty and silence are fostered in medical school, because I suspect some medical students make their own requests when they are in the vulnerable position as patients. And so they must empathize with patients, but at the same time they must sell their integrity by not questioning their superiors and fitting into what is expected of them, which is to work toward becoming competent physicians who possess minds too perfectly rational to see anything sexual about the exams, and hence too rational to understand why patients might seek modesty accommodations. In other words, doctors pretend not to "see an ear exam differently than a pelvic exam" since they fear admitting so would be a transgression of their medical conduct, and unfortunately this means distancing themselves from patients who do have modesty concerns about exams due to their sexual nature.

I think many medical students sacrifice their integrity subtly at first, and then succumb to the Domino Effect. At first, maybe a student knows he cannot desexualize the pelvic exam, but fearing how his instructors will react, he says nothing, and performs it poorly at the expense of the patient. Next, he might watch an instructor reprimand a female patient when she admits she is not comfortable surrounded by male medical students for her pelvic exam, and he does not stand up for her even though he believes she should not be reprimanded for her request. Now that he has grown more desensitized and dependent on fitting into what instructors expect of him, he might watch an instructor misinform a patient (out of conflict of interest) that pelvic exams are always necessary to obtain birth control, and even though the patient seems weary about the procedure, he does not question the ethics of his instructor. After all, he cannot express his concerns without implying that the instructor is sexually abusing his patient, which would certainly label him as a whistle-blower.

After that, an instructor tells the student that if he admits he is a medical student, then no patients will not allow him to practice sensitive exams on them, and so he follows the advice to flat-out lie to patients about already being a doctor. Ultimately, he agrees to practice pelvic exams on anesthetized patients who have not consented to it, because his instructor tells him these women would have adamantly refused students using their bodies for didactic purposes, and so it is a great opportunity for them to practice their exam skills on unconscious bodies that cannot protect themselves. The student believes the most important skill with a pelvic exam is to obtain informed consent. He sees this "educational" setup as being no different than gang rape. But he has already jeopardized his ethics so many times in the past in relation to sensitive exams. So he does what apparently many medical students do in this country, and gang rapes his own patients.

Gang raping anesthetized patients is apparently a "time-honored tradition" in medical schools, an ethical problem that has garnered media attention for decades, but has never provoked enough frenzy to encourage change. I never witnessed this practice as a first-year student, but I bet my life it is something I would have encountered had I graduated from UIC. I strongly suspect this because when I was sent to the OBGYN faculty, he cautioned that I would face additional dilemmas if I refused to perform pelvic and rectal exams during clinical rotations, and said "You might also have a hard time with... Never mind, we do consent all our patients here." It was patronizing he thought I was gullible enough to believe in his statement when he had to "correct" himself. In any case, I already knew this person was not sincere because he had already lied to me earlier in the conversation. (One of the news articles I brought was about Muslim male medical students refusing certain exams on female patients. When I handed it to him, he casually commented "Oh yes, I have read about this before," when the very reason I brought him articles was because he had told me in our first meeting he was "ignorant" students had problems with aspects of physical exam).

The way he corrected himself mid-sentence told me that in fact UIC has not enforced any policy to end the gang rape of patients, which according to the press, still routinely occurs in most medical schools. This is a topic that was never officially discussed at my school, and I only learned about it through my own research. Hence, students at my school are not prepared to challenge medical gang rape because they will be branded as trouble-makers for suggesting their instructors are gang rapists. This is why I believe most medical students trade in their ethical tenets to complete school, because otherwise repulsively unethical practices like gang raping patients would have died long ago had students followed their hearts, refused to participate, and reported their instructors for legal action.

Two other quotes from Dr. Robert Mendehlson, the pediatrician at UIC:

"The tragedy of this dogmatic approach to medical education is not only that it screens out the most thoughtful, intelligent, and ethical students, or that is perpetrates traditional idiocies, but also that it virtually forestalls the application of creative noninterventionist approaches to medical practice. Dr. Roger J. Williams put it well in his book, Nutrition Against Disease: Medical schools in this country are standardized (if not homogenized). A strong orthodoxy has developed that has without a doubt put a damper on the generation of challenging ideas. Since we all have one kind of medicine now - established medicine - all medical schools teach essentially the same things. The curricula are so full of supposedly necessary things that there is too little time or inclination to explore new approaches. It then becomes easy to drift into the convention that what is accepted is really and unalterably true. When science become orthodoxy, it ceases to be science. It ceases to search for the truth. It also becomes liable to error."

"My colleagues who head the nation's medical schools boast that this process of "survival of the fittest" assures Americans of the finest medical care in the world. My observation is that doctors are taught to provide a lot of medical and surgical intervention, but I don't see evidence of very much 'care.' The fittest do survive, but what are they fit for? They are the survivors of a heartless system that too often weeds out the best and the bravest - the students with compassion, integrity, intelligence, creativity, and the courage to resist the destruction of their own moral and ethical codes."


When they withdrew my scholarship, faculty told me they "firmly believed" future doctors must competently perform these exams. But this obviously is not the case at all, otherwise they would not graduate students who did not complete the exams objectively. All the students who cry and faint and make horrified faces certainly are not demonstrating objective behavior. Moreover, the school does not even give all students the opportunity to prove they have desexualized any type of medical exam, since they enforce their "rule" that one female must be present during the male rectal exam. When problems like this are marginalized, it inevitably translates to a small number of students advancing to clinical rotations ready to hurt patients expecting adequate exams, since these students feel too much pressure to act competent as future doctors, they cannot admit the exam is something they never desexualized (and they cannot admit they might faint or cry on a real patient, like they did on the actors). Students like this avoid pelvic exams as much as possible, and write "pelvic deferred" in patient charts, because they cannot be honest enough about their shortcomings to ask another provider who feels more comfortable to perform the exams instead (Article: "Managing Emotions in Medical School").

So by trivializing something important, like the inevitable cultural and personal attitudes and barriers about human sexuality in medicine, my school is hurting patients by exposing them to students who are too busy hiding their inadequacies. I thought I was more professional than these students to admit I had visceral problems over these exams, than to not admit so and make an already unpleasant exam even more unpleasant for patients. It is blatant that the only thing faculty "firmly believed" was that students never stand up for themselves if they cannot find peace with a small component of the curriculum.

Before I left, I recommended to several faculty members to start screening students. It is unprofessional and unethical to not explain these taboo exams to students before matriculation. When I suggested this to the OBGYN faculty, he nonchalantly replied that they "might consider it." He said this in a very condescending and indifferent tone of voice, even though as a physician, he should respect and practice full informed consent. The only person who ever got back to me was one of the ECM instructors who sent me an e-mail saying she would voice my concerns for future students but she "can't promise that there will be a change."


I am not angry I did not graduate from medical school: I do not want to work in such a hostile and uninspiring environment. But I am angry I moved to a new city to start school without knowing that the same problems that mistreated students in the past would mistreat me because my school will not clean up their system. I am angry I had to arrange so many embarrassing conversations with faculty, only to be told I was "too immature", "too sheltered", "too squeamish", and sexually abused as a child. I am angry my school ostracizes a minority of students each year over something personal like their sexualities, and believes they should all have to change their views to assimilate to those of the majority. That is something that has always bothered me.

I hope Dr. Sherman and Dr. Bernstein continue to raise awareness for patients to know and exercise their options and legal rights regarding sensitive medical exams. And as a woman, I hope American girls and women start to explore alternative practices and philosophies about their bodies and reproductive healthcare outside of the rigid setup traditional modern gynecology has to offer. I could never accept non-emergency care from OBGYNs now that I know how they are trained. If I ever wish to have a baby, I will not think twice about home-birthing with midwives because I do not want to be a woman who receives demeaning and dangerous interventions when unnecessary and often harmful to both her and her baby. And I am ecstatic to see that American women are becoming more informed about their birthing options, thanks to documentaries like "The Business of Being Born" by Ricki Lake.

Much of what I wrote here ties into various medical modesty and ethical concerns discussed on Dr. Bernstein's Blog. That is why I agreed to publicize all of it here on his Blog. I also do not mind publicizing this story further anywhere else if it might prompt a change in some of the problems I detailed.

I wanted to end by saying that I believe there should be a requirement at the national level that students are explicitly told about these exams when they apply to medical schools, which should not be laborious to implement because students all use the same application website. I contacted several individuals last fall, told them my story, provided them with news articles about students fainting and crying, and none of them took me seriously. Some of the people I contacted included the "Senior Director of Student Affairs and Student Programs at AAMC" and the "LCME Assistant Secretary". These people told me they thought most students knew about these exams beforehand. First, I have never believed that "most" is ever enough; it does not validate the fact that the system currently tramples over a minority of young students. Second, I do not know where they got their flimsy statistic that "most" know about these exams anyway, since most students have never visited the proctologist, and at least half have never visited the gynecologist. These people also told me different students face different "challenges", and so they cannot cater to one "challenge" over another. I do not believe these intimate exams are "challenges". I believe any exam that could be construed as sexual (and sexually violating) must be fully explained and consented. Otherwise, it could be serial sexual abuse and rape.

I also want to report the OBGYN faculty for not following the law that women can get birth control without pelvic exams, as well as report both him and one of the ECM instructors for not properly educating students about the BFOQ patient modesty law. These individuals are teaching and encouraging hundreds of future physicians each year how to be insensitive about sensitive exams, and I want to do something about that. The problem is I do not know how to report these authoritative figures, unless there are freelance lawyers any readers out there might know about who advocate for patient rights.

I look forward to reading any comments and suggestions from readers.


Anonymous said...

As this person is allowed to be anonymous, and yet make such strong allegations against an identified medical school, and probably identifiable persons, I hope that the medical school will be contacted and given the opportunity to respond - that seems only fair.
Including such allegations as "told me that in fact UIC has not enforced any policy to end the gang rape of patients" - stating things as "fact" while admitting that she has never seen them is possibly libel, and certainly unfair in my opinion. While this person has a possibly legitamate complaint, this article seems irresponsible. While the issue may be legitimate, the way this is written reminds me a bit of a child who did not get her way.

Joel Sherman MD said...

I agree that many of the allegations are very strong. Because of that I asked stressed student to remove specific titles so that individuals cannot be positively identified. I do not agree with the tone of some of the article. You are free to draw your own conclusions as to how impartial and unbiased the article is. It is not written by a disinterested observer. I will be happy to post any rebuttal from the college of medicine who by the way certainly would recognize the author.
Nonetheless the article is unique and valuable and needs to be aired. The main issues she raises need to be brought out in the open. This blog is dedicated to raising awareness of these issues. The college of medicine needs to see itself from others perspectives.

Anonymous said...

I agree that the issues are certainly worth considering. If possible, I would encourage you to not only welcome and allow comment from the medical school, but to actively solicit it. I think hearing their response (or lack of response) might provide some additional insight into the medical school atmosphere and practices.

Joel Sherman MD said...

The College of Medicine has been invited to comment.

SS said...

To Anonymous:

Thanks for your comments.

1) To clarify, I am not anonymous at all. I will copy and paste my comments from Dr. Bernstein's Blog (

"I am willing to publish the story with as many or as little details as deemed necessary by any publisher (with the exception of directly publishing personal names - both my own and faculty). When Dr. Sherman asked me to publish my story with the school name without job titles, I agreed to that format and still believe it is a terrific opportunity to tell the story to his audience in whatever way works best for his Blog.

In terms of my own anonymity, that is something that is not in the least bit protected in my writings. One could easily look between Blogs, and know the author is an MD-PhD female who entered "my school" in 2009 (There are only four people who fit that description, and the three others are still in school). With this information alone, any student or faculty from "my school" who reads these Blogs can unequivocally identify me.

Furthermore, any Blog reader can find a two-year old "Welcome New MD-PhD Students 2009" website from "my school", and compare it to the current online roster from "my school", and deduct that the missing name belongs to the author of this publication. My article also reveals that I grew up overseas between ages 4 and 19, have a younger sister, left UIC in summer 2010, and was interested in brain pathology. Not only my classmates and faculty, but any coworkers or family or friends who read these articles will know all the more that I am the author and can hence know my personal and embarrassing reasons for leaving school - as well as the fact that I actually had my scholarship withdrawn against my choice, something I do not readily tell many others.

I did not include my full name as author, not because I am ashamed of my beliefs (otherwise I would not have spoken face-to-face with dozens of faculty, a few trustworthy classmates, my sister, my college friends, and school psychologist) but because I do not need my name key-linked to sensitive material on the Internet. I cannot be widely proclaimed as a "whistle-blower" on the Internet as it will damage my future career applications and ambitions. (Although I welcome readers to determine my real name with the aid of Google if they are for some reason interested). Likewise, I did not include the full name of my instructors and key-link them to sensitive material on the Internet.

Both me and my instructors are all semi-anonymous on the same ground (i.e. A few clicks away on Google, but without direct key-linked name identification)."

SS said...

To Anonymous:

2) I am worried maybe my sentence was confusing: "The way he corrected himself mid-sentence told me that in fact [My Medical School] has not enforced any policy to end the gang rape of patients, which according to the press, still routinely occurs in most medical schools."

You are right, I stated I never saw this at my school. I would never falsify something that horrific. I clarified this in several recent comments on Dr. Bernstein's Blog:

"As I stated in the article, I never directly witnessed this horror at my school since I never reached clinical rotations. However, I know it most likely occurs at my school. Terri Kapsalis, the pelvic exam actor at my school, wrote in her book about the practice of gang raping anesthetized women in medical school. And the OBGYN "Associate Dean for Curriculum" inadvertently raised my suspicion that lack of consent routinely occurs at my school when he corrected himself mid-sentence. In addition, before I left the city, I had dinner with a friend who shadowed an OBGYN as a first-year student. She told me her mentor introduced her as a "doctor" to practice a pelvic exam on a patient. She said she felt like she was "just fingering" the patient because she was had never performed the exam before (There is a rule - obviously not followed - that students cannot perform genital exams on patients until third year). The OBGYN taught my friend that informed consent can slide, and that medical students can have the arrogance to believe their right to learn takes precedence over the right of the patient to know the truth. What if this patient did not want her body used for pedagogical purposes without consent? Or have a pelvic exam done by someone with zero experience without consent? Deceive patients so you can get in their pants - I thought that was a creepy lesson for my friend. If faculty at my school lie to practice pelvic exams, then they might abuse and rape to practice pelvic and rectal exams."

"Again, I never witnessed "gang rape" of patients at my school, but I believe that since old habits die hard (especially in medicine), and if it does continue at any of the many hospitals near my school, rotating students will not be prepared to defend the patient or report the incident because the practice is not officially recognized as being appropriate for students to fight against in the "formal curriculum" at my school."

SS said...

To Anonymous:

3) I am sorry you believe I sound like a child. To be honest, I think this is a harsh statement for you to make with an anonymous voice when I am not anonymous.

I wrote about my writing style on Dr. Bernstein's Blog:

"I am writing a personal account on my medical school experience, and my writings present my own viewpoints and values. I never said to speak for any faculty, students, and patients. I wrote what I witnessed in medical school and related that to patient modesty issues with my own subjective eyes, hoping it could contribute to something more positive for the future. As the title suggests, the article is about my individual "concerns", and hence I allowed my anger and disbelief to naturally come out in my writing. Otherwise, to artificially tweak my writing to sound distant and professional would introduce an element of dishonesty because I am writing from the heart about "my concerns".

SS said...

To Anonymous:

4) Thank you for suggesting to contact my school more directly. I did direct Dr. Bernstein's Blog to one UIC psychologist (because she mistreated me and I wanted her to read the article so she does not mistreat similar students in the future). Whether you are this person or anyone else affiliated with UIC I will never know.

But I agree I should contact more people at UIC and offer them a chance to express their own viewpoints:

"When I originally left on a "Leave of Absence", my OSA (Office of Student Affairs) advisor told me I needed to type my reasons for this to be read by a "review committee" consisting of students and faculty. I e-mailed her today, and attached a more thorough reason for withdrawing from the school to be reviewed by the same "review committee." Of course my full name is revealed to all these committee members. In my typed reason, I included the links to both Dr. Sherman and Dr. Bernstein Blogs, and invited all faculty and students of the "review committee" to contribute their thoughts to the Blogs. I also attached an alteration of the article, which included the full names of all faculty members I discuss in the article, in case the individuals in the article wish to respond to my statements.

I am very happy to have invited my school (and specific faculty members) to contribute to the Blog with their own comments. I believe an open discussion like this is very much needed, both to benefit my own beliefs that I was personally abused by their system, and also to benefit their own system in the many ways it dismisses medical modesty issues (faculty not screening students, faculty teaching students to withhold BC from patients, faculty teaching students to not respect BFOQ laws, faculty allowing students to lie and introduce themselves as "doctors" to get in patient pants). These things do not change until somebody makes a fuss."

Doug Capra said...

I want to reference three articles connected to this discussion -- articles I have discussed in several past posts on this and Dr. Bernstein's blog.
-- "Not Just Bodies: Strategies for Desexualizing the Physical Examination of Patients" by Ptti A.Giuffre and Christine L. Williams. Published in Gender and Society (2000) 14:457.
It discusses various strategies doctor use to desexualize physical exams. Assumed in this entire study is that there is a need for a significant number of doctors to desexualize these exams. As I've pointed out, these strategies are not necessarily healthy strategies -- just strategies that work for the doctor. Though they may work for the doctor, that doesn't mean they work for the patient. This study is very relevant to what "stressed student" writes about.
-- "Managing Emotions in Medical School: Students' Contacts with the Living and the Dead" by Allen C. Smith, III and Sherryl Kleinman. A few quotes:
"As several sociologists have shown, both doctor and patient use dramaturgical strategies to act "as if" the situation is neutral." Implied here is that the some of these intimate situations are not really "neutral" by we pretend that they are in order to get the job done. Patients and doctors use these strategies, but these techniques are not necessarily in sync.
"Clothed in multiple meanings and connected to important rituals and norms, the body demands a culturally defined respect and provokes deep feelings. Even a seemingly routine physical exam calls for a physical intimacy that would evoke strong feelings in a personal context, feelings which are unacceptable in medicine."
The issues brought up by "stressed student" are not insignificant, and have been known and addressed by medical professionals for years. This doesn't mean they have necessary been addressed successfully.
"The ideology of affective neutrality is strong in medicine; yet no courses in the medical curriculum deal directly with emotion management, specifically learning to change or eliminate inappropriate feelings."
Embedded in this statement is that inappropriate feelings are a significant issue in medicine and that medical schools do not deal with this sufficiently.
-- "The management of embarrassment and sexuality in health care" by Liz Meerabeau. Journa of Advanced Nursing, 1999, 29)6), 1507-1513.
Note "management." These feeling do exist and cause problems. From my research, the focus is more on management strategies that work -- not on whether these are healthy strategies or how they affect the patient.

Joel Sherman MD said...

I think it likely that FERPA (a HIPAA like law that covers schools) will prevent the college from responding, though they could contact the author directly in private. Multiple people from the college have now viewed the article, though none have made an identifiable response.

There are so many areas for discussion in these articles that it's hard to know where to begin. One small item, the policy to require a woman to watch every male rectal exam is bizarre. I take it that the purpose is to make the medical student doing the exam more comfortable. But as SS points out, that would hardly be a problem for most students. I don't know if this policy refers only to initial rectal exams done by students on 'actors.' If that policy was applied to real patients, it is a gross violation of privacy and ethics. Some men do consider rectal penetration to be gay, and might even prefer it to be done by a woman, but the worst possible scenario would be for it to be done by a male with a woman watching the patient's embarrassment.

Doug Capra said...


" I take it that the purpose is to make the medical student doing the exam more comfortable."
And this seems to be the trust of policies like this --to make the medical professional feel more comfortable. Now, I can see that. Few patients want a doctor who doesn't feel comfortable treating them doing so. But, as you suggest, there seems to be little concern about how this will affect the patient's comfort.
Also, although I see the value of standardized patients for these kinds of exams -- I think they can give medical students a false impression of how real patients will feel and react to such exams. I can see medical students becoming over confident after dealing with a few of these standardized patients who are quite comfortable themselves with the proeedures.

Joel Sherman MD said...

As a physician who trained decades ago, I don't fully recall my reaction to the first pelvic exams I had to do. In contrast our school barely taught us anything about male exams, perhaps thinking that they were so comparatively simple that reading our text book was sufficient. As was the usual custom in those days, the first bimanual exams were done on clinic patients. I have no idea anymore whether they were told we were students practicing or not. Although all students have anxieties about these exams, I don't remember any students not being able to cope with them. That part of SS's story is a surprise to me. Still and all her examples are persuasive and it is clear that it is a recognized problem that is indeed kept hidden by schools. As described by SS, her treatment by the school was poor. You would think some compromise could be made for a student who was clear that her career path would take her into other areas. As a cardiologist I have not done an intimate exam in decades. Probably 30-50% of physicians in this country can say the same.
I have ordered the book mentioned in the article, Public Privates by Terri Kapsalis and hope to get a better perspective.

Anonymous said...

This is the original anonymous. I am not associated with UIC, nor any medical school. In fact, I am not in the medical profession at all. Just wanted to clear that up.

Joel Sherman MD said...

I feel I should respond to the doubts raised on Bernstein as to the existence of SS.
First I routinely refuse to publish any comment which I believe is fiction or fetish. I receive them only occasionally, but they do happen. A comment published on Bernstein within the last month or so was one I had previously gotten and strongly believed was fetish. I refused to publish the story.
We do not in general publish anonymous articles but I believe Dr Bernstein and I are both convinced that SS's experience is very real and worth retelling. I would have preferred that SS make her real identity known at least to us (in confidence) but did not insist upon it. She does have some valid reasons for staying anonymous on these blogs. She did however give me the full identity of the professors and instructors she complains about. I will not publish those names, especially as long as SS is anonymous herself. Another point is that UIC (U of IL in Chicago) has viewed her article many times here and has not commented. FERPA ( a federal HIPAA like law) likely prevents them from saying anything, but that would not apply if the story were fiction.

Anonymous said...

Dr Sherman:
Some of the comments on other blogs were that "SS" does not actually exist. I have to wonder what they believe would be the motive for such a charade? Beyond time consuming, it sounds like a rather dangerous game that I can not imagine you, Doug, or Dr. Bernstein participating in.
These few blogs continue to exist because of trust in the modertors' integrity.
I, for one, am astounded.


Jan Henderson said...

In addition to the hugely important value of raising these issues for discussion, I especially appreciate the author’s references to other sources of information on this subject – and also to the sources cited by Doug Capra and Dr. Sherman. I’ve been researching an incident from 1850 when a medical school allowed students to observe a live birth for the first time in the US. It created a huge scandal and a lawsuit. I’m especially interested in how medicine managed to accomplish such an apparently complete attitude change towards modesty on the part of practitioners between then and now.

This post and many of the references provide evidence that the 19th century attitude towards modesty is still prevalent, but is ignored and suppressed. Also, that practitioners still struggle with the issue. I believe the change in attitude that occurred (and that is used in medical schools to justify the criticisms the author of this post was subjected to) has to do with medicine becoming a science in the late 19th century, which legitimated the objectification of the patient. Something was definitely lost from medicine when that happened. We may regard that loss as a trade-off we’re willing to accept in return for the wonders of modern medicine. But the truth is, we rarely stop to notice or question what we’ve lost, unless prompted to by a post such as this. Thanks for publishing this post.

I’ve been thinking recently about some ideas in a book by Charles Rosenberg (Our Present Complaint: American Medicine Then and Now) that I find encouraging. Biomedicine is not a unique and necessary institutional expression of scientific knowledge and technical capacity; part of the power of our biomedical culture is that its contingency is ordinarily invisible to those who dwell within it; and because we ignore this largely invisible contingency, we fail to see that medicine need not be what it currently and temporarily is.

Joel Sherman MD said...

Doctor Bernstein raised the question of the advertised curriculum for the UIC College of Medicine. Now there may be more detailed outlines given to prospective students, but the online description does not per se mention intimate exams. So it is certainly feasible that a student who had no experience with these exams could be taken by surprise.
This is unlike the curriculuum descriptions at Dr B's school (Keck) and at mine, the University of Chicago (unrelated to UIC).

Maurice Bernstein, M.D. said...

I clicked on the school's Student Handbook link to see if the intimate physical exam learning experience for the 2nd year students was described. Unfortunately, at this time, the page is not available for undescribed reason. ..Maurice

SS said...

Dr. Sherman:

"I have ordered the book mentioned in the article, Public Privates by Terri Kapsalis and hope to get a better perspective."

The book is bold to relate these exams to private sex acts. I appreciate the author's candid criticism of UIC ignoring how some students react to these exams each year. Having grown up overseas, I related to her arguments that cultural background can strongly influence values surrounding these exams.

Because UIC does not practice informed consent, some incoming UIC students do not understand that full examination of a female patient (at least in America) means inserting their own lubricated bodies into her vagina and rectum. And so I think it is unprofessional for UIC to believe they can "educate students properly" when really students should have the fair opportunity to think for themselves about these exams before matriculating.

One objection though: I found it unfair for the author to pen an entire book chapter on the subject without seeking input from UIC students who do disagree with these exams under certain conditions, especially as she is analyzing the problem from her own slanted lens as someone who supports hundreds of strangers practicing the same exams on her body when not medically necessary. And so she had narrow perspectives to mitigate any adverse reaction on the part of students as "fears", especially because her wording here contradicts her more thoughtful statements regarding the need to recognize and respect personal and cultural values of human sexuality both in and out of medicine. And even worse, forcing these exams on uninformed students who show negative reactions can be sexual abuse and even rape, much worse than little "fears".

I also did not understand why the author referred to herself as a "feminist teacher." She supported ECM at UIC, a course that convinces students it is ethical to give pap smears to all female patients without screening out the ones who will only be harmed by it (women who only have sex with women, monogamous women, and especially virgins). I thought then this UIC ECM course promoted sexual abuse and rape of female patients who cannot really "consent" to allowing speculums and fingers into their vaginas. As a humanitarian (and hence a feminist), I did not understand how the author could also be one when she supported the UIC ECM course that way without any fuss about it in her novel.

SS said...


"Some of the comments on other blogs were that "SS" does not actually exist."

All doubts come from the same person.

I am currently living overseas and do not have any official UIC documentation with me.

But I was informed by UIC they will review my reason for withdrawing, and that I should soon receive a letter confirming my request to withdraw was granted. The letter will be mailed to my younger sister, who lives in the States. So I can ask her to fax me a copy to forward to Dr. Bernstein and Dr. Sherman as proof that I was a UIC medical student.

SS said...

Dr. Sherman and Dr. Bernstein:

Thank you for searching about informed consent at UIC. None of the many faculty I spoke with seemed to even care about screening UIC students, and none of them could show me a single source that guaranteed all UIC students explicitly understand these aspects of training.

Here are the two UIC ECM websites where we learn these exams on actors. Nothing explicitly mentioned of course:

SS said...


"In addition to the hugely important value of raising these issues for discussion, I especially appreciate the author’s references to other sources of information on this subject – and also to the sources cited by Doug Capra and Dr. Sherman."

Thank you Jan, I think these issues need to be discussed as well. What disturbed me the most was the lack of informed consent of both incoming students and patients. On a personal note, it did not matter my efforts to bring better change for future students, as far as I know, UIC still does not screen incoming students.

"This post and many of the references provide evidence that the 19th century attitude towards modesty is still prevalent, but is ignored and suppressed. Also, that practitioners still struggle with the issue. I believe the change in attitude that occurred (and that is used in medical schools to justify the criticisms the author of this post was subjected to) has to do with medicine becoming a science in the late 19th century, which legitimated the objectification of the patient."

As a student who was taught by faculty that it is acceptable to insert speculums into vaginas when unnecessary (even on virgins) to collect cervix samples from the body, I was shocked to read your guest post about how physicians used to deem it inappropriate to place their ears on the breasts of patients to collect heart sounds from the body. And that this level of concern for patient modesty actually in part inspired the invention of the stethoscope!

I agree some of these changes occurred when medicine became a science in the 19th century. Doug recently wrote that fascinating article about 19th century medical students bringing back new philosophies from their training in Paris: Even though they brought back positive and "progressive" medical techniques (and attitudes that women and minorities can practice medicine successfully), they also brought back less positive attitudes that patient modesty is nothing but an old-fashioned hindrance to the advancement of science.

Some of the issues raised in his article (that patient modesty came to be seen as "anti-progressive") paralleled what I witnessed at UIC.

One example is a UIC ECM instructor who teaches students to reprimand females who ask for female providers to do their pelvic exams. I actually attended an elective seminar with a small number of students organized by this same instructor that covered gay and lesbian and other sexual minority patient advocacy. We had a transsexual patient talk to us about her hassles in the clinical context when she must ask for prostate exams instead of pap smears, much to the confusion of providers, since her internal organs remained unchanged after sex reassignment surgery. Of course it must be awkward for patients like her to have to correct providers, and she advised students to provide forms in clinics that allow patients to indicate these scenarios before meeting face to face with providers.

What I am saying is this instructor is a big advocate for reshaping clinics to allow patients to have their intimate medical needs met without derision and disbelief. But at the same time, he teaches students to scold a female who makes her legal request to have another female do her pelvic exam, even though this request could be deeply related to her own sexual identity and values and maybe even previous sexual abuse that needs to be tolerated by practitioners without shame and ridicule. Why then does he not advocate for but actually shun a similar cause? My guess is that advocating for transsexual patients seems "progressive" to him, while advocating for patients who strongly prefer either same or opposite sex health care seems "backwards" to him.

Joel Sherman MD said...

SS, I note this line in the second reference you give above:

Understand how personal beliefs may affect the care and treatment of patients;

UIC doesn't seem to understand that line very well. They should read their own online information. Maybe they don't realize that the statement applies both to physicians and patients.

Doug Capra said...

"Understand how personal beliefs may affect the care and treatment of patients;"

Joel and SS

I'm learning that many hospitals have lost contact with their wonderful core values. There seems to be a huge disconnect in some cases -- an abyss that sometimes separates their everyday behaviors, esp. regarding modesty, and what they say they believe in.
I'm also learning that they just don't seem to want to talk about this issue, that they don't want to put in place protocols or policies about this because then they'll have to accommodate.
Too bad.

SS said...

Doug and Dr. Sherman:

"I'm learning that many hospitals have lost contact with their wonderful core values."

One UIC ECM instructor holds a three-hour mandatory seminar for first year students. He has the entire class (200 students) participate in a drill in which he reads true or false statements "I grew up on a farm", "English is my second language", etc. and students stand up in front of the rest of the class for each statement that holds true to them. He adds some sensitive questions into the mix "I am gay, lesbian, or bisexual", "I have a mentally ill family member", etc.

The moral of the lesson is that medical students should never "assume" things about patients, classmates, and coworkers, and it sinks in because most students learn sensitive information about classmates they might never have guessed otherwise. He also finishes the seminar with student representatives from different cultures speaking about medical values. Several speakers affirm that some cultures influence patients to routinely seek same sex intimate care.

Puzzling then how my classmate told me this same instructor scolded a female patient who made a legal request to have a female do her pelvic exam, instead of him and his entourage of male students. He seems to be "assuming" quite a bit about this patient. He "assumes" regardless of her cultural, personal, spousal and relationship sexual values, and regardless of whether or not she has survived sexual abuse in the past, that he somehow has the right to ridicule how she feels about an exam he has never even undergone himself, and then tries to strip her of her legal rights. He also "assumes" he is instilling valuable lessons for the students shadowing him, encouraging them to intimidate and degrade a vulnerable patient for no legitimate reason.

Not to mention, this same instructor "assumes" that when a rape survivor student cries in his course to do invasive genital exams that such painful scenarios could never happen again. He "assumes" that whether or not he has been raped himself, that he is clearly doing a good thing to force her to complete the exam. He "assumes" he is correct to trample over students who inevitably have issues over these exams each year just because they are a minority who cannot speak up about an embarrassing and taboo topic. He "assumes" students from different cultures might never see these exams differently than himself. And then he "assumes" that when a student tries to speak up and request consent for future incoming students, that the most effective thing to do is to ignore her, and somehow this will fix the problem.

SS said...

Doug, Dr. Sherman, and "Anonymous":

"I'm also learning that they just don't seem to want to talk about this issue."

I think this is unfortunately very true.

After "Anonymous" suggested that my article be presented to UIC for comment, I sent the full article (and links to the Blogs) to my academic counselor on July 21, and requested that my full reason for withdrawing from UIC be disclosed to the "review committee" consisting of students and faculty, which was supposed to take place on August 16.

On August 12, I received an e-mail from a student affairs staff asking for my mailing address because if the school approved of my reason for withdrawing, I would receive an official letter in the mail. I asked him to verify that my full reason had been forwarded to the committee. Somehow I doubted. And this was his verbatim response "I don't believe I have received your full explanation? I received a short (two to three sentence email from [Name of My Academic Counselor]), but there wasn't an explanation attached. Your previous request will suffice to process your withdrawal from the College of Medicine."

I sent to him directly the full reason and asked that it be included. But I never heard back.

Last summer, I was told I could write as much as I wanted in my request for withdrawing. And at least my article stands up for future students and exposes some of the corrupt teaching and practices maintained by some UIC instructors.

So to "Anonymous" who said "I think hearing their response (or lack of response) might provide some additional insight into the medical school atmosphere and practices." I hope the lack of response provides you with the additional insight you sought.

Joel Sherman MD said...

SS, yes from your description it does seem that many of the faculty of UIC are very insensitive to personal beliefs and problems despite giving lip service to it. Hard to understand how a faculty member could give an entire seminar to raise consciousness and then totally ignore it in his own practice. Maybe your posts and communications have raised their consciousness, but it may take more than one student (or patient) complaining to change anything.

One point you have made several times though I disagree with. You have said that patients have a right to same gender care, but that overstates the law. Patients have a right to request same gender care, but providers are under no legal obligation to provide same gender care unless they specifically promise it in their written statements. BFOQ does not apply here; that applies only to employers hiring practices and not to individual patient encounters. In other words as long as an institution hires both men and women, they are legally in the clear. In general though they can still use gender to assign individual tasks and patient encounters to satisfy patient preferences.

Doug Capra said...

"SS, yes from your description it does seem that many of the faculty of UIC are very insensitive to personal beliefs and problems despite giving lip service to it. Hard to understand how a faculty member could give an entire seminar to raise consciousness and then totally ignore it in his own practice."

Actually, Joel, although it disappoints me, I'm not especially surprised. It's a completely human tendency -- not walking the talk. It's easy for our species to put blinders on, to proclaim certain ideals and then not see how we're not practicing them. I'm not excusing it in this or any case. I'm just saying that it often takes someone or something from the "outside" of our personal world view to wake us up to what we are really doing and how it does or doesn't fit into our core values.
I cases like this one, the individual has so much power within his institution that few if any people will actually force him to engage in a debate or discussion about this. If he could be confronted with the double standard with a rational argument, he might, perhaps, begin to at least examine his point of view. But that's the probleme with power. What do they sometimes say: "Never tell the truth to power." Unless one is willing to pay a steep price.

Joel Sherman MD said...

Here's is a link on KevinMD on how to address the mistreatment of medical students. It is written by a medical student.
It's obviously more common than I was aware of.

Knitted_in_the_Womb said...
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