Elderly Patients and Modesty by Misty Roberts

In Nursing Homes and Hospitals

The elderly patient presents a unique problem when dealing with the modesty issues they may face.  An elderly patient’s modesty is often compromised because they are unable to speak up on their own behalf, making them vulnerable.  Dementia at any level in an aged patient also poses problems because medical professionals assume that their modesty does not matter if they are not 100% cognizant of what is going on.  

Nursing homes and hospitals have become gender neutral. It is common for male nurses / aides to bathe, perform intimate procedures (changing diapers, urinary catheterizations, shaving their genitals for procedures, etc), and assist with in the bathroom, female patients they have been assigned to. Many families have been shocked and outraged to discover that their family members were bathed by opposite sex nurses or aides without their consent. Nursing homes and hospitals need to work to accommodate elderly patients’ wishes for privacy. 

I personally think it is risky for nursing homes to assign male nurses or assistants to female patients for intimate care tasks (bathing, changing diapers, dressing, cleaning women’s private parts after bowel movements, etc) due to the potential for sexual abuse. Cases of sexual abuse by male nurses and assistants at nursing homes are in the news frequently. The false assumption exists that the elderly do not care about their modesty. This could not be farther from the truth. Many female nursing home residents will not even allow their sons, grandsons, or male relatives help them with intimate care tasks. Why should they have to give up their boundaries about men not helping them with intimate care in nursing home and hospital settings?  I personally believe that male nurses and assistants can certainly work with female patients, but they should have no contact with female patients’ private parts.  This will not only honor their wishes but also help to ensure that sexual abuse does not happen. “Elderly nursing home residents are easy prey for sexual predators, because they are often weak and defenseless. They may also fall victim to sexual abuse because they had a stroke or other medical condition that caused them to lose their speech or motor skills. When a nursing home resident is unable to protect themselves or speak, the likelihood of becoming a victim of sexual abuse increases” according to Sexual Abuse in Nursing Homes – Edgar Synder & Associates.

Nursing homes and hospitals may use this excuse: a male nurse has to assist in bathing some women for the purpose of lifting them and ensuring that they are not dropped. This is not true.  Due to the potential of sexual abuse, this is very risky. It is my opinion that a female nurse or assistant should always bathe a woman. A male nurse or assistant could help to lift a clothed woman in the bathtub if necessary and leave while a female nurse or assistant bathes her. Then the female nurse could call for the male assistant to come back to get her out of the bathtub after the woman has been dressed.  Sponge baths can be given to very frail patients in their beds, requiring no lifting or male assistance whatsoever.

A number of relatives of elderly female nursing home residents have expressed how upset they were to find male nurses / assistants handling their loved ones’ intimate care issues.  Here are a few examples:

1.)    A very painful incident for me involved my mother, who in the advanced stages of Alzheimer’s, was hospitalized with a broken hip. I visited her room one day and found a male nurse cleaning her up after a bowel movement.  She was highly agitated and terrified.  My Dad, who was present, had not protested, so I didn't say anything.  I cannot believe that I was such a coward.  Mother passed away five years ago, and I have not gotten over the regret of not speaking up for her.    Given the opportunity again, I would have insisted on female nurses and aides ONLY!
– Man from South Carolina 

2.)    I have a grandmother in a nursing home that requires assistance in the restroom, help bathing and changing. She is also not completely there in her mind. She can easily be taken advantage of and cared for by a male. The position my grandmother's in is already degrading enough, but to have a male nurse taking care of her and seeing her exposed is wrong in many ways. My family does not want to have a male nurse taking care of her because of the degrading and immoral nature of the situation.”
– A young lady from Durham, NC 

Modesty issues are not reserved for only elderly female patients, elderly male patients also struggle with them.  Years ago, male nurses were very rare. It’s wonderful that we are seeing more male nurses / aides for elderly male patients who are not comfortable with female nurses / assistants. Some nursing homes hardly have any male nurses or aides to help with male patients who are modest. A nurse / aide actually swore at an elderly man who asked her to leave the room for a few minutes so he could use the bathroom. She thought he was crazy for asking her to leave the room.

A pastor shared this with Medical Patient Modesty: A very pleasant, likeable, and religious congregant found himself in the hospital for a prolonged period, prior to his death. His recurring conversation with me, over the course of my many pastoral visits was his resistances to female nurses inserting Foley catheters, giving him complete body baths, and dressing him. Disclosing that he could accept the immense physical pain foisted on him and that he was prepared for death, this sheep of my flock related that the most difficult problem of his entire life was this issue of frontal nudity before strange women! It was foreign to his life experience. "It's not right!" was his plea. His tearful eyes looked to me for counsel. The only consolation this veteran clergy provided him was that if I were in his shoes my feelings would be identical to his own! The female nurses told this suffering, dying patient, "You don't have anything we've never seen before!" "Don't worry about it, we do this all the time!" and "You'll get over it!"

If you have to place a loved one in a nursing home, take time to meet with the nursing home administrator, supervisors and other staff members to discuss how you want the loved one’s modesty to be protected. Ask questions about how they can ensure the protection of your loved one’s modesty.  Make sure that all of your directives are put in writing and be succinct with what you want.  For example, state that no male nurses or aides are allowed to bathe your elderly mother.

Adolescent Boys and Genital Exams Reducing Embarrassment

              by Joel Sherman MD

Here is an unusual post that actually discusses the most embarrassing part of the male physical exam.  Every practitioner who does male genital exams is certainly aware of this problem yet it is rarely discussed.  I quote from this anonymous nurse practitioner's (NP) blog:

It is a hard fact of practice that there will be a time in a clinician's life when he or she will be confronted with an erect penis.  … In newFNP's experience, these awkward moments tend to occur with teenage boys who will pitch a tent upon sensing a sideways glance at the penis. … In general, newFNP really feels sorry for her male patients who have an itchy trigger penis. She knows that they know that they have an erection at an inappropriate time. She knows that they are uncomfortable and assumes that they might like to sink into a crack in the floor. 

I showed this blog to a NP I know who does sports physicals.  She confirmed all the main points:  Yes, this occasionally happens and the boys are generally incredibly embarrassed.  This has been posted about a few times by other practitioners as well although the articles have since been deleted.  I asked the NP whether she was trained to deal with this situation.  The answer was no, the subject was never mentioned in her NP training.  My medical training was decades ago, and that was certainly true then; the subject was never mentioned.  I tried to find out if it is any different now.  A medical educator and physical exam instructor of 2^nd year medical students, Dr. Maurice Bernstein  says that his students are told to reassure men that it is a normal physiologic reaction.  It’s hard to know what else to say, but the response can beg the question.  It is a normal reaction for the practitioner.  -But not for the patient.  Adolescents are not used to having their genitals seen and touched, especially in a non sexual situation, and may respond sexually.  Despite reassurances to the contrary, as seen in the above quote from the blog, the encounter can be a source of amusement to others.    

Standard textbooks on adolescents and physical exams have almost nothing to say about this.  Mosby’s Guide to Physical Examination (4^th edition) was the only text I came across that actually mentioned that young patients especially may be fearful of having erections.  But it doesn’t make any recommendations as to how to avoid the problem or what to do when it occurs.  Two textbooks (Swartz, Textbook of Physical Diagnosis  (6^th ed.) and Bickley, Guide to Physical Examination, (10^th ed.) had brief articles on how to reassure girls for their first pelvic exams.  Incredibly though when it came to the male genital exam, these 2 books only discussed how to reassure the medical student doing them.  The patient’s embarrassment was not mentioned.  Yes the exams are embarrassing for new physicians as well, but concern for the patient should remain primary. Two texts I viewed on adolescents said nothing about the subject.

So it is well recognized by practitioners that genital exams are embarrassing for boys as well as for girls. It is also documented that the gender of the provider is one factor.   (Adolescent Girls and Boys Preferences for Provider Gender & Confidentiality in Their Health Care, Journal of Adolescent Medicine 1999;25:131-142. &  Patient Preferences for Physician Gender in the Male Genital/Rectal Exam, Family Practice Research Journal, Vol 10 No 2, 1990.)   There is evidence for both boys and girls that the exams are more embarrassing when done by opposite gender providers (for further references see link).    The American Academy of Pediatrics (AAP) has published extensive guidelines for both male and female genital exams.  For girls it states: Clinicians should always be sensitive to the possibility of past or current sexual abuse, which can affect the patient's comfort with the examination and her preference regarding the gender of the examiner.  For boys it states:  Trust and relationship-building are also critical elements of the male adolescent's visit that help him to feel comfortable regardless of a physician's gender and/or background.  In other words for girls one should respect their gender preferences for the exam.  For boys it makes no difference if the exam is done properly.  And they don’t appear to recognize that sexual abuse of boys is very common as well, about half the incidence of girls.  The conclusion from the AAP appears to be that girls should be given a gender preference and boys should not.  Given the clear embarrassment that both boys and girls can suffer, there is no justification for the different treatment.  

Likely this difference is a reflection of the varying importance Western society has put on modesty for women vs. men.   And it probably also reflects the genuine difference in the complexity of the exams, a woman’s gynecologic exam taking up to 15-20 minutes with specialized equipment and the patient in an unfamiliar embarrassing position vs. a few minutes for the average male exam with no unusual equipment or positions needed.   But clearly the embarrassment that boys feel during these exams can be comparable to what girls go thru, especially if an erection develops.  Indeed many men as well as adolescents can’t help but feel that someone handling their genitals is a sexual experience, usually more intense with an opposite gender provider.

Adolescents in particular deserve utmost sensitivity for genital exams, especially for their first thorough one.  While this is recognized for girls, it is rarely mentioned for boys even though every practitioner must be aware of boys’ embarrassment.  Parents will often accede to their daughters wishes for gender preference and will prepare their daughters for what to expect; boys are rarely accorded the same consideration which is now much more of a problem than it was years ago when female pediatricians were a small minority.  It is easy to find texts and manuals as to how to handle pelvic exams in the least stressful and embarrassing way possible.  For boys a similar discussion is rare.   Most practitioners must know how to reduce embarrassment by keeping the boys covered as much as possible and keeping tactile stimulation to a minimum through brief exams and the use of gloves.  It is time that medical teaching and parents caught up with the fact both boys and girls need equal consideration including offering them a preference for the gender for the provider.

Privacy Rights in PrisonNew Regulations Increase Rights to Prevent Prison Rape

By Joel Sherman MD

A California Prison

A recent directive of the Dept. of Justice (DOJ) to prevent rape in prisons has gotten very little general publicity, but it represents a major change in prison standards, one which increases privacy rights.  These rights in prison are not directly related to privacy in general or medical privacy, but still and all there are ramifications that echo throughout society.  The courts have long held that prisoners have restricted privacy rights and that security in the prisons is paramount.  But over the last 40+ years, equal employment rights have often also been held to trump prisoners’ privacy rights.  Thus women guards are common in men’s prisons and men have always been present in women’s prisons.   Over the years there have been innumerable lawsuits over this with conflicting results.   Rules vary from state to state and prison to prison with separate rules governing federal prisons.   As a general rule, women prisoners are afforded more privacy from male guards than vice versa.   For both cross gender strip searches are generally only permitted in emergencies, though the interpretation of what’s an emergency can be very liberal.   But cross gender viewing in showers, bathrooms and cells is very common with once again women afforded more protection.  However the release on May 16, 2012 of new federal rules from the DOJ to prevent rape in prisons may change all of this.  These regulations immediately take effect in federal prisons, but can only be enforced in state and local lockups through loss of federal grants.  So these changes will take many years to percolate down through the nation.

The federal government has documented that there is an epidemic of rape in prisons.  One in ten prisoners have been raped, usually the weak, disabled, gay, lesbian or transgendered.   Half of prison rapes are prisoner on prisoner, but nearly half involve guards and prisoners.  Surprisingly more of the guard on prisoner rapes involve women guards and male prisoners.   For juveniles an astounding 95% of sexual encounters were with female guards;  40% of encounters were considered forced by the juveniles.  For adults nearly 75% of guard on prisoner sexual encounters were rated consensual by the prisoners, though legally they are all classified as assaults.  Consensual or not, all guard prisoner encounters are destructive to jail discipline.  The lengthy new federal regulations are primarily concerned with what administrative changes can be made to prevent rape with special protections needed for juveniles and the LGBT population.  Most pertinent to this blog are the recommendations they made that directly affect the privacy rights afforded prisoners:   

“Cross-Gender Searches and Viewing. In a change from the proposed standards, the final standards include a phased-in ban on cross-gender pat-down searches of female inmates in adult prisons, jails, and community confinement facilities absent exigent circumstances—which is currently the policy in most State prison systems. However, female inmates’ access to programming and out-of-cell opportunities must not be restricted to comply with this provision.

For juvenile facilities, however, the final standards, like the proposed standards, prohibit cross-gender pat-down searches of both female and male residents. And for all facilities, the standards prohibit cross-gender strip searches and visual body cavity searches except in exigent circumstances or when performed by medical practitioners, in which case the searches must be documented.

The standards also require facilities to implement policies and procedures that enable inmates to shower, perform bodily functions, and change clothing without nonmedical staff of the opposite gender viewing their breasts, buttocks, or genitalia, except in exigent circumstances or when such viewing is incidental to routine cell checks. (Emphasis added)  In addition, facilities must require staff of the opposite gender to announce their presence when entering an inmate housing unit.”

Note that the only double standard now permitted, in a change from their preliminary guidelines put up for commentary, are that  cross gender pat downs searches (that is searches done through the prisoners clothing) are permitted for adult men but not for women.  I believe this change was done for practicality only, not because it wouldn’t afford men more protection.  There are so many women guards, in some jails, such as in the men’s city prison of New York where they are over half, that they’d have to fire women guards and hire more men.  All cross gender strip searches are forbidden except in emergencies.  What this tells us is that the Commission believed that cross gender intimate contact of all types greatly increased the risk of sexual assaults, whether consensual or not.

What is the relevance of all this to society in general, and healthcare in particular?  A new standard has been set that reverses over 30 years of preponderant court decisions in the US.  Up to now the courts have generally given preference to equal employment rights over privacy rights.  This applies to institutions other than prison such as healthcare.  There are exceptions (BFOQ, bona fide occupational qualifications) to the rules but they are applied sporadically without any uniformity creating lots of work for attorneys.  The new regulations adopted by the DOJ recognizes for the first time that unfettered equal employment rights can put people at risk of abuse.  To my mind, this is an important new precedent.

Unfortunately the federal government is a multi headed hydra.  I note that in recent news the Office of Civil Rights, part of the US Dept of Health and Human Services has asked to file a brief in support of women guards in Ohio in a case they claimed was employment discrimination.   The Ohio prison defended their employment policies saying they could not use women guards in areas of men’s prisons where they needed to witness strip searches and showering.  That would seem to accord fully with DOJ regulations.  I don’t know how this will all play out; an accommodation could potentially be made to increase female employment in non sensitive areas.  I think our prisons would be safer for all though if no opposite gender guards were permitted in sensitive areas which are the majority of most prisons.  The US is the only country in the world which insists that male guards be in women’s prisons because of equal employment rights; it violates United Nation law.

To summarize, privacy rights are more than just a nice legal theory but are also important for safety.  The right to same gender intimate care and monitoring, both in prisons and throughout society should not be held hostage to equal employment rights.

Medical Students Learn About HIPAA Guest post by Estelle Schumann

Medical Students Learn about Patients’ Right to Confidentiality

Patient health information and privacy has been protected since 2003 under the Health Insurance Portability and Accountability Act, or HIPAA although it is something that both current and aspiring health care professionals  have always been aware of. Congress enacted HIPAA in 1996 as part of a broad health care reform effort. Initially, the emphasis was on promoting personal health insurance portability, but the emphasis changed to standardizing the process of sharing insurance claims with medical insurers.

Congress recognized a great potential for abuse of electronic health data, so they placed strict controls on its movement and care. Doctors and hospitals must comply with HIPAA regulations, and so must academic medical centers. Like all other staff of hospitals and medical centers, medical students must complete HIPAA training. Every health care facility must provide documentation of this training for everyone who has access to patients or patient data.

Protected Health Information (PHI) which is stored, transmitted, accessed, or received electronically is called ePHI. Under HIPAA, PHI means any information “that identifies an individual and relates to at least one of the following:

• The individuals past, present or future physical or mental health.
• The provision of health care to the individual.
• The past, present or future payment for health care.

Information is said to identify an individual if it includes the individuals name or any other information that could be used to determine the individuals identity.

To know the specifics of how to protect patient data, entering medical students must complete HIPAA training, which is generally administered online. HIPAA is site specific, and entering students, for example, at the University of Washington must complete training both for UW HIPAA and the Veteran’s Administration Hospital’s HIPAA prior to Orientation. The course for UW Medicine is web-based and takes approximately two hours. Students will receive a user ID, password, and web address for the training in an email, the summer before they enter medical school. Upon completion, they will receive a compliance certificate, one copy of which they must email to the school in PDF format, and one copy they may be asked to provide at clinical sites or to participate in research that includes patient data.

Some general HIPAA guidelines, according to the Medical College of Wisconsin Affiliated Hospitals, Inc., are:

• Access patient information only if you need that information to do your work.
• Share or discuss patient information only if it is necessary to do your work.
• Never share your identification number or password with anyone.
• Follow the hospital’s or healthcare provider’s policies on confidentiality and privacy.
• Log off your computer session when you are not by your workstation.
• Ensure confidentiality when you handle protected healthcare information.

In addition, MCWAH trainees are required to sign a confidentiality form.

Yale University is required to notify individuals within 60 days if the security of their PHI has been compromised. They must also notify the Department of Health and Human Services, and, if more than 500 individuals are involved, they must notify the media. Civil monetary penalties and criminal penalties have been established by HIPAA for knowing use or disclosure of identifiable PHI. An individuals own access to his or her health information is somewhat restricted under HIPAA, but generally the law protects the individuals right to privacy.

Doctors, medical students, and healthcare personnel, are trained and certified to follow HIPAA guidelines. It is an important piece of legislation that is vital to protecting patient privacy.

Estelle Schumann blogs at  http://www.healthscience.net/

The Mass Media & Men's Health by Joel Sherman MD

This article was chosen for reposting on KevinMD.

CBS Cares - About my prostate !

The mass media has a long history of covering medical dramas and rarely doing so with any realism.  We’ve gone from Marcus Welby MD to a host of shows dedicated to portraying medical personnel in the most salacious ways possible.  But at least with all these dramas it is understood that they are fictional.  There are now though a host of shows which pretend to show real life medical stories which are even more perverse. 

Some of the most egregious examples come from Untold Stories of the ER, a Discovery Health Channel production which is sporadically rebroadcast on The Learning Channel.  A prime example from this show is episode 4 from season 5, ‘Grandma’s Back.’  This episode can be downloaded from Amazon .    One of the incidents portrayed is that of a young man entering with priapism, an erection which won’t subside spontaneously.  This is a relatively rare occurrence as a side effect of Viagra.  But can also be associated with serious underlying clotting disorders and malignancies.  After an episode of priapism men are frequently left impotent.   In short, the condition is a serious one and anything but a joke.  It’s about as intrinsically funny as female infertility. 

The vignette portrays a young man coming in the ER with a prominent bulge in his pants accompanied by his mistress.  His wife later shows up and the two women fight as neither was apparently aware of the other.  The patient is portrayed as being in great pain and whining for relief while trying to fend off the two women who turn against him.   The whole episode is one of comic relief in contrast to the other 2 episodes in this hour show.  The other two tales in this episode concern critically ill women, one young and attractive, the other elderly but well preserved, both of whom ultimately do well.   Needless to say, both are treated sensitively as if a miracle had taken place without a hint of mockery.

The doctor in the priapism story is identified and I was able to call him.  He said the season was filmed in Vancouver, in a defunct medical clinic, which the network rented out for the month.   Of course all the patients and likely most of the staff are actors, but the identified physicians are real.  The priapism tale is one the physician suggested based on a real experience from his residency.  In commenting on the filming, the doctor said that ‘sex sells.’

A further episode portrays a man who came in with testicular pain.  A testicular ultrasound is ordered, but a mix-up occurs and an orthopedic patient is sent instead.  The patient who underwent the mistaken testicular ultrasound by a woman technician of course is later shown to have thoroughly enjoyed the exam.   Two other episodes make a point of showing men being embarrassed to be treated by female physicians or nurses.  Needless to say, I’ve seen no episodes ( though I haven’t seen them all) where women are portrayed in such a mocking disrespectful way.

The attitude taken on this show towards male health problems is reflected throughout society.  It is routine on TV and in movies for the portrayal of men being hit in the groin to be used as a comic event despite the fact that serious injuries occur.  The media treatment  of the John Wayne Bobbitt case is an extreme example.  There are many sites devoted to jokes about the incident.  It’s inconceivable that mutilation of a woman could be treated similarly by the media.

Men’s reluctance to obtain routine health care is also routinely treated as a joke.  Even physicians have done this.  An example quoted before on these blogs' is Dr Sharon Orrange’s article  on the 10 reasons men don’t go to the doctor including “you are afraid we will put our finger in your butt” and “you are afraid we will examine your balls.”   This same physician has never treated woman’s issues with levity. 
 

Even when the motives are unquestioned, the media frequently uses humor and sex to try and encourage men to receive medical care.   CBS has run a series of public service announcements to entice men to receive prostate exams.  Some are directed to women rather than men, a common strategy.  Some of these ads use a young alluring woman to give the message with a smile (pictured above).   Can you imagine an ad to promote Pap smears using a young handsome man?  I don’t think you’ll ever see one.   Why not use an ad from a former athlete who may have had prostate cancer himself?  There are lots of them.  Johns Hopkins was featured in an ABC TV series in 2008 purportedly to show real life situations in medicine.   One episode featured a female urologist coaxing a minimally reluctant  older man to submit to an exam.  He is shown from the back lowering his pants for her.  There was no point to this episode except to introduce some sex and male embarrassment into the show.  There are many thousands of women physicians in this country who do thousands of exams on men every day.  Why feature men for embarrassment?  Women get just as embarrassed,  but that’s never a matter for humor.  That’s treated as a serious concern.  On an opposite but analogous theme, a play called, ‘Midlife Crisis, the Musical’ has one scene showing men sitting reluctantly in a doctor’s office waiting for their appointment.  But they are then told that the provider has been changed to a young pretty female physician, and the men now jump up with eagerness to get their exam.  So men are either reluctant to have an exam or eager, depending on what seems more humorous in the setting.

In short, the media has always portrayed medical situations in sitcoms and dramas in a way to sexualize and dramatize the entire episode.  It is highly variable whether any pains are taken to get medical facts correct; often they are totally inaccurate.    But at least it’s apparent that these dramas are fiction.  The so called reality shows are worse in that viewers are more likely to believe that they are actually witnessing valid portrayals of modern medicine.  Male patients are usually not shown as being capable of making intelligent choices about their health care.  They either need their wives to push them into it or the medical encounter needs a pretty provider to attract them.  Frequently they are embarrassed to seek help.  Now these characterizations do fit some segment of the male population, but why are they the only segment shown?  No humor is portrayed when women  need to be pushed into obtaining needed medical care.   The majority of men who need chronic health care, predominately middle aged and older men, would be better served by intelligent and factual reminders of what is needed.  Some professional organizations like the American Cancer Society do provide this, and there are serious health segments, especially on cable news, but in general the popular mass media fails miserably.  I see no organized protest about this.  Groups such as the AMA could improve the situation if they tried.

Modesty: Medical vs Societal Standards Guest post by Carolyn Knight

Medical Carte Blanche

If you go through security at an airport and are selected for a pat down, they will make sure that a TSA agent that shares your gender pats you down.  If you get arrested and receive a pat down before entering a squad car and an officer of your gender is not present, one will be called to the scene.  But, if you are in need of a urinary catheter at a hospital, you get no say in the matter whatsoever.  Oftentimes they are not even going to perform the insertion behind closed doors. 

Awaiting a prostate procedure

In today’s medical facilities, statistically speaking, catheter insertion is more likely to be performed by a female nurse. In fact, according to the U.S. Department of Health and Human Services, only around 6% of the nurses in the U.S. are men. Since some patients do not wish to be examined by a medical practitioner of the opposite sex due to cultural, moral, and modesty standards, this is a problem.

Some people believe that there is a general attitude in the medical profession that what gets in the way of a medical objective must be crushed and swept out of the way.  When it is cancer, then by all means, crush it and sweep it out of the way, but when it is human dignity people must advocate their rights. 

Dying female patients that are admitted to the emergency room that must have their clothes cut off and their breasts exposed for a chest tube or worse might not be too concerned about their modesty, but sometimes modesty is violated over matters of convenience and not collapsing lungs. 

People that enter the medical profession may not have the inherent tendencies to violate patient privacy. However, a total lack of modesty in training in school from LPN programs all the way to medical school and you have many practitioners that no longer have any boundaries. 

According to ABC news, men are less likely to visit the doctor than women because of factors such as modesty and a desire to not appear helpless. The price men pay for not seeking medical attention is tremendous. If those in the medical profession work to respect the privacy and modesty of their male patients, they would likely see a spike in men seeking help for their medical conditions. Men should, at the very least, be able to choose the gender of their doctors and nurses in the emergency room when they are seeking help for conditions that require extensive physical examination.

Of course, modesty and privacy concerns don’t just affect men. According to the American Medical Association, only around 40% of practicing OB/GYNs are women. And, according to the Canadian Medical Association Journal, around 50% of women prefer to seek help from a female doctor when it comes to childbirth and gynecological issues. So, women who desire to see a female gynecologist in the emergency room have less than a 50% chance of being able to do so. Women can, of course, choose the doctor that gives them a pap smear. However, they rarely have a say when it comes to which doctor sees them in an emergency room.

Male patients have a right to a male medical professional whenever exposure or contact with genitalia is a factor as much as female patients have the same right to be treated or handled by a female.  The lack of consideration for this right to privacy is not healthy for the trust of the patient in the practitioner, or for the aspects of truth, compliancy and giving forth of information and compliancy that is necessary for optimal treatment. 

As the accused have fought for the rights to be searched by the same gender, shouldn’t the same level of courtesy be given to those made vulnerable by their need for medical attention?

Author’s Bio: Carolyn is a guest blogger who writes about career advancement, LPN programs, and higher education.

Same Gender Maternity Care by Misty Roberts

Many people falsely assume that women don’t care about their modesty during childbirth because they are in too much pain, but that is simply not true. There are many women who feel that their modesty during childbirth is extremely important. Some women and husbands don’t want a male obstetrician / gynecologist (ob/gyn) or any other male medical professional to be present for the birth of their baby. All too often families have their wishes for modesty violated as they gave birth. The birth of your child should be a joyful time and it is tragic how violations of modesty have made birth experiences traumatic. Even female ob/gyns can be insensitive. 

Some female doctors have ignored women's wishes for privacy and allow medical students to be present for all parts of birth even when asked otherwise. At some hospitals, medical students strive to do as many pelvic exams as they can for their requirements and many women are taken off guard because they have medical students coming into their room uninvited doing these invasive exams and other procedures without asking.

A number of hospitals in the United States, especially rural areas, have mostly male ob/gyns and few or no female ob/gyns. This is a very serious problem because many women don’t want a male gynecologist to deliver their baby. Far too many hospitals cannot assure families that their desires for modesty will be met. All hospitals should offer this choice for women, to be able to birth with a woman. There are a number of wonderful all female ob/gyn practices in the United States that work hard to accommodate patients’ wishes for an all female team. Unfortunately, it is hard to find an all female ob/gyn practice in small towns so women who reside in those areas have limited choices unless they are willing to drive to a bigger city. Before 1990, there were not many all female ob/gyn practices so women's choices were very limited. About 80-90% of current ob/gyn residents are female so there will be an increase of hospitals that can guarantee a woman a female OB/GYN for the birth of her baby in the years to come. 

Home or birthing center births with a midwife attending is an excellent choice for healthy women with low risk pregnancies. You choose who is there with you – family, friends, or neighbors. There are no externally-imposed visiting hours in your home, before, during, or after the birth. Women's wishes for modesty in hospital settings are disregarded routinely unless they have worked out arrangements with the hospital to ensure that their wishes are honored.  Unnecessary medical interventions are common. The list is huge, but a few examples are: too many pelvic examinations, episiotomies and unnecessary C-sections. Midwives do fewer pelvic exams and always ask first. With respect for you as a laboring woman, you will reduce your chance of having these unnecessary interventions. 

If you choose an out-of-hospital birth, look for an appropriate back-up plan, preferably with an all female ob/gyn practice to deliver your baby. Always be prepared for complications that could happen that would require you to be transported to the hospital from a birthing center or your home so it is very crucial that you prepare a backup plan ahead of time. Make it clear to your midwife that you don't want a male gynecologist. Many midwives even do breast examinations, pap smears, gynecological examinations, and even some procedures for women who are not pregnant. 

For a planned hospital birth, (or unplanned as in the case of a transport from home or birth center), if a birthing mother wishes for an all female team and maintain that her husband is the only man present, she will need to choose an all-female ob/gyn practice that doesn't rotate with other practices of male doctors. Keep in mind that all doctors in a practice rotate. There are many wonderful female ob/gyns in mixed practices, but you usually cannot be guaranteed a female ob/gyn in a mixed practice. If you use a practice that has two female doctors and two male doctors, you have a 50% chance of having a male doctor deliver your baby unless you have a scheduled C-Section with one of the female doctors. 

Discuss with your ob/gyn your desires for an all female medical team for the birth of your baby. You should also visit the hospital and meet the nurses especially the nursing supervisor to let them know your desires. Remember that the team may consist of the female ob/gyn doctor, nurses, anesthesiologist and/or nurse anesthetists, and surgical scrub technician. If you need an epidural, you will need an anesthesiologist. It's best if your team consists of all females, a female anesthesiologist or nurse anesthetist. Many hospitals employ at least a few nurse anesthetists. Nurse anesthetists are often able to administer anesthesia without an anesthesiologist. If it isn't possible, speak to the doctor and nurses and request that they keep your private parts covered while the anesthesiologist or anesthetist is present to protect your dignity and modesty. If you must have a Cesarean Section, you will be required to have a catheter inserted. You should ask that the male anesthesiologist or anesthetist stay out of the room until all of the prepping for surgery including insertion of the urinary catheter has been done. 

Important Tips For Pregnant Women Concerned About Modesty During Childbirth: 

1.) Choose an all female ob/gyn practice that doesn't rotate with other practices that have male doctors. 

2.) Visit the hospital that the practice delivers at and ask to speak to the nursing supervisor or the manager for the Labor & Delivery unit. Discuss your wishes about who you want to be present and how the nurses can protect your modesty in case a male anesthesiologist or pediatrician is required to be there for some parts of the birth. Make sure you indicate if you don't wish for even female medical students to be there. Some women who want an all female team are open to female medical students observing them giving birth.

3.) Request that the amount of vaginal exams be kept to a minimum. Vaginal exams cannot tell you exactly how close you are to giving birth. They can increase the risks of infection even when done carefully and with sterile gloves. 

4.) Speak up immediately if you feel your wishes are not being honored. 

5.) Create a birth plan. Make sure that you include who you want to have present. If you don't want medical students or male medical professionals to be present, indicate that on your birth plan. Make sure you come up with a plan in case the unexpected happens. One web site that offers a good example of a birth plan is: BirthPlan.com. 

6.) Consider hiring a doula to provide support during your labor. She is an advocate who can help you to speak up for your wishes about modesty if you are birthing in the hospital.

Misty Roberts is the founder of Medical Patient Modesty (http://www.patientmodesty.org), a non-profit organization that promotes stronger patient modesty.

Teaching Medical Students about Patient Modestyby Maurice Bernstein MD

  

I teach first and second year medical students how to take a medical history from a patient and how to perform a physical examination.  I have been at this task for the past 25 years.  When asked by Dr. Joel Sherman  to write here a commentary about how patient modesty is taught in medical education,  I replied that though medical school instructors teach students about patient modesty concerns  in general, such instruction is a background topic since most of the teaching time is spent with detailing the mechanisms of the physical examination in terms of developing productive information which will help to rule in or rule out suspected diagnoses.  It is not that we have knowingly diminished a concern for patient modesty but after presenting the general instructions to attend to modesty which generally deal with draping or undraping the patient, touching the patient and using the proper professional words, there is generally no further didactic activity on this topic. What remains is for the instructor to simply monitor the students for following the instructions.  Uniformly, we find they do. 

If you would like to know why first and second year medical students are so tuned to the concern for patient modesty leading to reluctance and caution in having the patient's body exposed is because virtually uniformly they show evidence of their own physical modesty concerns.  The student's personal modesty is apparent as they become patient subjects for their classmates to examine.  In my experience, I have never found a naturist medical student.  And this modesty is not student gender specific although as expected examination of the exposed breasts are uniformly permitted by males but not females.  Nevertheless, examination of their groins is seemingly a restricted area by both genders.  Some students will only allow same gender students to be their examiners. Students do not examine each other regarding genital or rectal learning though they do so with teacher-subjects.  

So, what do we teach? Undressing and dressing of a patient should be performed by the patient themselves in private if the patient has the capacity to do so. Otherwise, if unable, then the student would help but with the patient's permission.  We teach that draping of a patient of both genders  is important  both to prevent chilling and also for patient physical modesty.  We teach that removal of draping for examination of a specific area of the body should be performed  best by the patient him/herself and only at the time that area is to be examined. Afterwards, the area is re-covered.  We stress the importance of communicating with the patient prior to examination of each area of the body with regard to what the student intends to do.  We have followed the advice of our dermatology professors to instruct students that a full body skin examination for skin lesions should be  performed with the patient not standing in the nude but  covered and serially undraped in small segmental anatomic areas.  This technique not only supports modesty but also has been shown to improve physician detection of small lesions.

Draping and undraping patients and positioning them for genital and rectal exams is, as previously mentioned, taught by skilled teacher-subjects and with also particular attention to professional touching routines and appropriate verbal communication with patients during these examinations.  Male genitalia exams for an ambulatory patient is done standing and rectal examination with the patient bending over a table. Female pelvic and rectal exams are  performed with the patient draped but lying on her back on a table in the so-called lithotomy position.

What we haven't instructed our students is the need to specifically bring up the topic of that patient's physical modesty concerns prior to the start of the examination.  Prior to reading 6 1/2 years of visitor discussions on my bioethics blog "Patient Modesty" thread,  what we haven't taught the students is that there will be some patients who would sacrifice their health and lives in order to preserve their physical modesty and that healthcare provider gender selection and the provider's  environment and behavior are of great concern to some, if not many, patients.  It is my impression that  the gender selection issue and how it is satisfied by the medical system particularly with regard to the requests by male patients is really not a discussed issue in medical education amongst teachers and with students.  The concept that physical modesty will ever trump diagnosis and treatment of disease as a decision by a patient is also, I believe, one patient decision that all in medical  teaching or practitioners of medicine are unaware.   It will take specific education along with changes in the systems, not just of medical students, but also the physicians, nurses, technicians and all of those who run medical schools, nursing schools, hospitals and clinics, so that they can be made aware that all the undressing, draping techniques, positioning, touching and standard communication with patients are still inadequate to meet the emotional needs and demands of some patients with regard to their patient modesty.  

Dr. Bernstein has been teaching medical students for decades at the Keck School of Medicine of USC.  His bioethics blogs are well known.  He has had a discussion on his blogs concerning patient modesty for many years.

Young children and modesty by Holly Goodwin

Pediatric modesty is not a subject that is discussed often but certainly must be addressed. Recall experiences with your own children or your own childhood; at what age did the “good touch, bad touch” discussion happen? Healthy children will likely never have to have invasive pelvic procedures done to them and so it is likely not many people have experienced what it’s like to be a child who is forced into one of these examinations and procedures, but for those of us who were it can be a life altering event.

By the age of 5 I knew what a bad touch was. To my mind, it was anyone who wasn’t my parents touching my genitals. I was always told to say “no” if I felt uncomfortable with anything and I would be in the right. I suppose my parents didn’t expect me to begin having pelvic problems at such an early age.

My first episode with Interstitial Cystitis, a painful, incurable bladder disease, was when I was five. It was nap time and about time to go home when I felt the urge to urinate so I asked my teacher if I could go to the bathroom. After urinating I still had the feeling that I really needed to urinate bad but nothing would come out. I stayed on the toilet straining and confused for a long time before I got up and went to my teacher crying and saying it felt like I had to urinate but nothing would come out. Like most people, she assumed I had a UTI and let me go call home.

I cannot remember if I actually had an infection or not when I had to do the pee-in-the-cup test. I’m not sure if this was in the same visit or not, but I know that eventually it was discovered there was no bacteria in my urine anymore (if there even had been any) and the doctor wanted to perform a pelvic exam on me. I was already afraid of doctors from a series of treatments for my lazy eye which eventually ended up being a painful surgery that left me blind for what felt like days.

When I was asked to take off my pants and panties I was confused. I said I didn’t want to because my doctor was a boy. I expected a girl to come in because I was always taught not to let boys touch me there if I was uncomfortable, and of course I was uncomfortable given the setting. With my mom’s aid, they forced my clothing off me while I was screaming and crying for a female doctor. That useless argument that we women always hear came up, but most heart-breakingly, from my own mother – that “He’s seen so many it’s not a big deal” speech. Regardless, I had been told to say no if I didn’t want to be touched there, and I did say no. I screamed no. Despite my struggling, I was too little to fight them off. The doctor didn’t penetrate me with anything but he looked at my urethra and inside my vagina and said he thought I may have a yeast infection causing the problems. He brought a cream out and slathered it all over my genitals and it burned. 

After I put my panties back on all I could feel was that cream slurping around in my privates and making me feel very humiliated, as though I had wet myself. My mom kept making me use the cream at home despite it burning and not helping, but because the doctor said so she made me do it. As to why the doctor insisted on putting the cream on me himself inside the office instead of allowing my mom to do it there or later at home with the prescription I have no idea, but it made me realize I truly had no say-so or autonomy when it came to matters with my body and doctors regardless of everything I’d been taught during my 5 years of life. I was ashamed and depressed, but didn’t know how to express these feelings in words. In the end the cream did nothing. I had Interstitial Cystitis, not a yeast infection. In fact, the irritation of the cream likely made it worse. After that experience I stopped telling my mom when I hurt and lost a lot of trust in her.

A study done by Child Abuse & Neglect: The International Journal says that a child’s ability to recognize a bad or good touch depends mainly on age and if they were educated. Before being educated in the study, 5-year old children were most likely able to distinguish a bad touch from a person of authority, who was usually considered “good,” than 4- or 3-year olds. After being educated over 90% of both 4- and 5-year olds were able to determine a bad touch regardless of its source (Maureen and Wurtele). To me, what had happened had been a “bad” touch despite the position of authority he held since I was old enough to recognize that I was uncomfortable with the idea of a man I hardly knew touching me there. This study shows that children as young as 4, and even some at the age of 3 can have a sense of genital autonomy and social taboos about it as well as knowing about saying “no” to bad touch. To a child, a burning cream forced onto him or her could definitely count as a “bad touch.” A child’s sense of personal autonomy over his or her own body during the years of preschool and elementary school is very strong. They are often modest, have a strong sense of ownership in regard to their bodies, and often may insist on privacy, even from their own parents. The ability to maintain comfortable boundaries is important for a child’s dignity, self-esteem, and a healthy sexual development later on in their lives (Popovich, 12). Children are very vulnerable to psychological disorders caused by the helplessness of hospitalization or invasive procedures (Popovich, 12).

Despite my own experience with the lack of care towards a child’s modesty preferences I had it lucky. If I actually did have an infection then I could have experienced the VCUG [voiding cystourethrogram] . A VCUG is performed to test for kidney reflux in children 5 and younger. The procedure is that the child must disrobe, lay on a table with a gown, have catheter placed through his or her urethra and have dye pumped into the bladder. The child is then forced to urinate on the table while pictures are taken while voiding. Not only is this exam invasive to privacy, it includes painful penetration, and as an act of losing all dignity, the child must pee on themselves in front of a medical team during an age where most have just proudly became fully potty trained. The pamphlets given to parents absolutely do not prepare either the child or the parent for what occurs during the exam (Phoenix Children's Hospital). It mentions discomfort, not pain, and describes the catheter as a “soft like a spaghetti noodle.” Anyone who’s been cathed will likely disagree with this statement. The first step to patient modesty is telling them the truth, especially to parents. Because of the child’s developmental issues at such an age, their feelings of shame or guilt are intensified when he or she is forced to expose the body and experience hurtful, invasive procedures. Children are also very frightened when doctors or other personnel focus on their bodies in ways only their parents have done. Preschool-age children react to this through regressive actions such as crying or thumb sucking. Even worse is for cases when parents are not allowed in the room; children may feel they are “bad” for allowing themselves to be touched, prodded, and probed (Popovich, 13). 

There are pediatric nurses trained for such cases, but evidence suggests that they hardly practice what they were taught due to personal attitudes or a tendency to be reactive instead of proactive. With little research there are few cases to cite, but in 2000 Popovich found that pediatric nurses had knowledge of a child’s physical needs but lacked knowledge in needs relating to psychological growth and emotions (13).

Many studies have concluded that the levels of anxiety experienced by children in a medical setting is unknown, but regressive behaviors like anger, sleep disturbance, and bed wetting is considered “normal” by nurses and doctors while a child is in the hospital. There is no published research on hospitalized children’s need for privacy, modesty, and self-esteem (Popovich, 14). 

The most hurtful thing for me to read are the stories written by mothers about the treatment of their children during the VCUG. Obviously, a good advocating parent will ask for treatment for the pain the child will feel, assuming they researched online rather than just using the hospital’s pamphlets, but nurses and doctors often try to talk parents out of using anesthetics like Versed. General anesthesia cannot be used evidently because the child must pee on him or herself for the test to be complete. As to why anesthetics like Propofol cannot be used I have no idea since it is an extremely short lasting form of general anesthesia commonly used for outpatient procedures like colonoscopies. 

Some grown adults can’t even handle this procedure, me included. Now imagine being a 4-year old child being prepped for this procedure, but you don’t really understand why they need to do this to you. Your parents likely told you what they read on the hospital’s pamphlet about it being “slightly uncomfortable” because it’s the only information they were given, and once you felt you were ready to cope with the embarrassment you find out how agonizing a catheter really is. At this point you may start to fight, but will be held down even as you scream, certainly not giving consent to be touched “there.”

The following are posts from parents I’ve come across during researching pediatric modesty, and especially about the VCUG which not only destroys a child’s privacy, but is actively penetrating their urogenital area and causing severe pain:


"Update: I'm still a little agitated after yesterday's experience and

trying to figure out how I feel about the way things went, so forgive
me if I ramble a little, and vent a bit. But, first of all --
everything's fine. My daughter's tests showed perfectly normal
kidney/bladder function; that's a big relief.

The ultrasound went well-no problems there. However. When the
office staff went to send back the orders for the VCUG, they
found that the ped's office had sent the script without sedation.
Not what we, including our daughter, were prepared for. They
could not get through to the doctor's office (8:30am), and the
voice mailbox was full. Great. I got out my cellphone [sic] and
hit the lobby...within 20 minutes (mostly spent on hold), I had the
office staff faxing the correct prescription. In fact, by the time I
got back to the Radiology waiting room, I was getting the thumbs
up from the office staff. Good.

Then, once in the room, the "intervention" nurses talked us out of
sedation. I believe at first they thought she was going under general
anesthesia, but even when told it was oral Versed, she persisted in
trying to persuade us that the risks were not worth the benefits --
that the catheter would be easily done and that the testing would be
simple. Ok, fine. We're all for less risk.

However, the catheritization [sic] was not simple. Not pain free. Not
un-traumatic. It took 4 nurses/techs to hold her down and get the
catheter in (after 3 tries), and this is with DH and I at her head
talking to her and holding her arms. NOONE [sic], and I mean
NOONE [sic] prepared us or her for the fact that she was going
to be asked to pee on the table. She's 3. She's recently
potty-trained. She doesn't pee on the table. Meanwhile, the
Radiologist is being a screaming cheerleader, which is pumping
up her anxiety level and he WON'T SHUT UP.

Egads. It was really quite the experience. I'd probably feel really
differently if we'd found out something was really wrong, and I
know I'd feel differently if we'd done sedation and something
had gone terribly wrong, but man...I just am so torn about the
process. I'm so pissed that they didn't give us all the
information we needed BEFOREHAND, despite my persistant
[sic] and detailed questioning. It's the things you don't anticipate
that get you.

We've tried to use the experience to continue teaching the ever so
important lesson that it's ok to object to people doing things to your
genitals that you don't like. That it's ok to say no. That it's ok to
scream and yell and put up a fuss if someone is trying to hurt you,
all the while reinforcing that this was a necessary medical procedure.
Such a fine balance. She was so offended, and so hurt that we didn't
do more to protect and defend her. Breaks my heart (Garden_of_darwin)."

Another commenter replied:

"My just turned three year old dd [sic] is going to have to
do the ultra sound and the VCUG. I had reflux from age 2 to age
10 and outgrew just before surgery was going to be ordered. I
had the VCUG procedure done no less than five times
WITHOUT sedation. At age 35, I am still traumatized and
would choose child birth over the procedure any moment of
any day. I INSIST that my dd [sic] has sedation and I think
that the nurses that guilted you out of it are no less than
monsters for doing so. Our pediatrician wants sedation,
which surprised me as I thought I was going to have to
sell her on it, but she insists as well. It is like an ancient
torture method without, believe me. I am soooo [sic]
sorry it happened that way for you and for your daughter.
We all do the best we can and as parents, of course we
don't want to risk our children. However, oral sedation
is not as dangerous as IV/general anasthesia [sic] and I
don't think they must have even had good motives in
scaring you out of it."

On another forum I read that the mother's girl was screaming to get it out of her. How this doesn't qualify as medical rape, I have no idea. I just know that only having a male doctor look at my privates against my will still haunts me and those paper gowns just make me want to die. It's like they take the last defense mechanism you have and toss it away, giving them complete power over you. There needs to be a major overhaul with how children are treated by medical professionals.

Propovich suggests the following enhancements to pediatric care:

· Preschool and early-school-age children are quite vulnerable to feelings of shame. Help them avoid such feelings by providing children with physical and psychological privacy, preparing them appropriately for procedures, and asking permission to look, listen, and touch. Providing for their privacy and respecting their sense of modesty convey to children a recognition of their inherent worth.

· Perform baths, assessments, and procedures with curtains drawn and doors closed.

· Use treatment rooms when appropriate to ensure protection of the pediatric patient’s self-esteem and self-concept.

· Spend time talking to children and walking them through procedures and stressful events in advance.

· Since children of this age group usually do not want to be seen crying, nurses can assist them by encouraging them to express their feelings, taking care not to deny or negate their expressions of fear and shame, and not criticizing out-of-control behavior.

Likewise Rosen-Carole, a helpful family practitioner, wrote about how she deals with pediatric modesty. Last year a pediatrician was charged with 471 counts of sexual abuse towards minors. Delaware Attorney General Beau Biden said, "These were crimes committed against the most vulnerable among us—those without voices (Quinn)." Rosen-Carole says that we have to rethink what we teach our kids in regards to “good touch, bad touch” as doctors are usually seen as being the “good” and parents may mention them as the exception, but from the study posted at the very top of the page it takes education to give a child the power to truly tell the difference. She shared her method of reinforcing the “good touch, bad touch” in Contemporary Pediatrics:

“As I listened to the news reports, I thought back on my own practices and realized that the following clinical pearl might be useful to others. Any time I examine a child more than about the age of 3 (and less than, say, 13) below their underpants, before I pull down their underpants, I point at them and say, "So, who is normally allowed to look down here?" The child will sometimes point at a parent, sometimes shrug, look blank, or even point at me. I look to the caregiver for guidance here and say, "Is that right? Only mommy/daddy/grandma (etc), right?" Then I ask the child, "Can doctor look?" and mostly get yes as an answer. I then answer myself, "NO! Only if mommy or daddy is in the room, right? If mommy or daddy went outside, I couldn't look anymore, right?" I wait for acknowledgement from caregivers and children at this and generally get it. Sometimes, if the child or family doesn't appear to understand yet, I go further and say, "What if someone tries when mommy or daddy isn't around? You say no and kick and shout and run away and tell mommy or daddy, right?" The caregivers look sometimes surprised, but mostly relieved. I think the relief might be that I have brought up a sensitive topic and have shown them how they can bring it up with their kids, too.” Rosen-Carole also mentions how the parents are surprised when once she asks their child the question they seem to not know the answer regardless if they have talked about it or not (Rosen-Carole).

Fellow Interstitial patients have also mentioned experiences with such procedures, stating that they held off diagnosis for years out of the terror that remained since their childhood after having these procedures done without any pain-killers (Interstitial Cystitis Network). I myself held off diagnoses for 3 years simply because of how violated I felt as a child anytime I went to the doctor. Even at age 12 I recall my doctor, who was female, not ask or say nothing to me before grabbing my shirt and looking down the neck hole of my shirt to examine my breasts. I was so shocked I couldn’t say a thing and my mother made no comment. I felt extremely violated as I was very sensitive about the changes happening to my body at the time.

I now struggle every year when it’s time for my annual pap smear. Just knowing that I have to have it done to get birth control turns my mind into a wreck at having my bodily autonomy once again taken from me through this “carrot on a stick method.” I have a wonderful, caring doctor now that I had to seek out for myself but I cannot get rid of those feelings of complete helplessness and bodily violations, especially with the current birth control policies most clinics have.

Preventing iatrophobia, the fear of doctors, starts at childhood. I plead to anyone with children to advocate for them and never leave the room. Listen to their gender preferences if they need to disrobe, and always research beyond what pamphlets the doctors hand out about pediatric procedures. There are many support groups online who will tell it like it is without any sugar coating from the medical community. Research, research, research, and if the doctor or hospital will not provide adequate emotional or physical pain relief then walk out and find one who will focus on what’s best for the child. In the end, it is you who must make the decision. Doctors can only recommend and perform procedures, not tell you what is best for your child and family. They are trying to look after themselves when the issue of pain relief comes up just as you are trying to look after your child’s well being, emotional and physical. Research if their methods are standard and get a second opinion, and even if their method is standard and you disagree, there will always be another doctor who will have a different view on how to diagnose, dispense medication, and treat conditions.

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Works Cited

Garden_of_darwin. "Vcug Renal Us for 3 Year Old: Seeking Information (long) - Kitchens Forum - GardenWeb." That Home Site! Forums - GardenWeb. 7 Feb. 2006. Web. 29 Dec. 2011. <http://ths.gardenweb.com/forums/load/kitchbath/con0212390014095.html?27>.

Kenny, Maureen C., and Sandy K. Wurtele. "Children's Abilities To Recognize A "Good" Person As A Potential Perpetrator Of Childhood Sexual Abuse." Child Abuse & Neglect: The International Journal 34.7 (2010): 490-495. ERIC. Web. 17 Dec. 2011.

Laura. "Interstitial Cystitis Network : Patient Stories : Della." Interstitial Cystitis & Overactive Bladder Network - Overactive Bladder, Bladder Pain Syndrome, Painful Bladder Syndrome, Hypersensitive Bladder Syndrome Information & Support For Patients & Providers. Interstitial Cystitis Network, 29 Apr. 2005. Web. 29 Dec. 2011. <http://www.ic-network.com/patientstories/laura.html>.

Phoenix Children's Hospital. "VCUG." Phoenix Children's Hospital. Phoenix Children's Hospital. Web. 29 Dec. 2011. <http://www.phoenixchildrens.com/PDFs/patients-visitors/VCUG-1.pdf>.

Quinn, Rob. "Pediatrician Earl Bradley Indicted on 471 Counts of Child Sex Abuse." Newser | Headline News Summaries, World News, and Breaking News. Newser, 23 Feb. 2010. Web. 29 Dec. 2011. <http://www.newser.com/story/81556/pediatrician-indicted-on-471-counts-of-sex-abuse.html>.

Rosen-Carole, C. "Good Touch, Bad Touch: Teaching Your Patients Whom To Trust Can Keep Them Safe." Contemporary Pediatrics 27.7 (2010): 66. CINAHL Plus with Full Text. Web. 17 Dec. 2011.

Holly Goodwin is a student who blogs about her personal experiences with interstitial cystitis.