Sunday, January 29, 2012

Teaching Medical Students about Patient Modesty
by 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.

Tuesday, January 3, 2012

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.


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. <>.

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. <>.

Phoenix Children's Hospital. "VCUG." Phoenix Children's Hospital. Phoenix Children's Hospital. Web. 29 Dec. 2011. <>.

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. <>.

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.