Advocating for informed consent and patient autonomy in gynecological care

Transcript below:

A woman once woke up after her hysterectomy with an unsettling feeling that something was wrong. She couldn't quite identify what had happened, but the unease persisted. Days later, when she spoke with her surgeon about unusual sensations in her pelvis, he casually mentioned that the medical students learning how to perform pelvic exams had been "very gentle with her."

She was shocked. No one had informed her that medical students would be performing pelvic exams while she was unconscious.

If you're surprised by this story, you're not alone. This scenario highlights a critical gap in women's healthcare: the need for transparent informed consent, especially regarding procedures performed under anesthesia. As advocates for women's health, we believe every woman deserves to know exactly what will happen to her body during medical procedures—and to have the power to consent or decline.

Understanding Pelvic Exams Under Anesthesia

The difference between being violated under anesthesia and being appropriately cared for lies entirely in your expectations and what you consented to.

Over 40 million pelvic exams are performed under anesthesia every year in the United States. According to research, 84% of medical students report performing at least one pelvic exam during their training. While pelvic exams under anesthesia are one way for students to practice, this educational need must be balanced with patients' bodily autonomy through explicit disclosure and consent.

But the critical question remains: Did patients always know what was happening to their bodies?

The History of Informed Consent

The concept of informed consent was formalized in the landmark 1914 court case of Schloendorff v. Society of New York Hospital. Judge Benjamin Cardozo famously wrote that a patient has the fundamental "right to determine what shall be done with his own body."

Before this pivotal moment, the medical establishment argued that pelvic examinations under anesthesia (EUAs) were essential components of gynecologic surgery. They claimed that medical student involvement was implicitly included in patient agreements at teaching hospitals, comparable to other medical procedures that caused no harm to anesthetized patients. Some even argued that requiring explicit consent would limit educational opportunities for trainees.

This is clearly outdated thinking. In modern medicine, we must practice with respect for patient autonomy. Current standards require that patients be allowed to choose not to be cared for or treated by trainees when it does not compromise patient safety.

Informed consent is essential to protect patient autonomy, ensure transparency, and foster ethical learning environments. The American College of Obstetricians and Gynecologists now recommends that trainees participate in pelvic EUAs only when:

• Patients have provided explicit consent for their participation
• The examination is relevant to the surgical procedure
• The patient recognizes the trainee as part of their care team
• The examination is performed under direct supervision

Current data show that approximately 80% of medical school-affiliated hospitals now have policies requiring explicit consent for medical students to perform pelvic EUAs.

The Troubling Reality: Gaps in Informed Consent

While policies have improved, we still don't know exactly how many pelvic exams are performed under anesthesia without informed consent. However, the available data is concerning:

Among medical students who performed pelvic examinations under anesthesia, only 42% consistently observed informed consent processes. Of those who did observe consent, 67% never or rarely witnessed explicit explanation that a medical student might perform the examination.

In a Canadian study, the numbers were even more alarming. Among students who had performed pelvic examinations under anesthesia:

• 28% were unsure if consent had taken place
• 26% reported no specific consent
• 25% had mixed experiences of consent
• Only 20% reported specific consent

While these statistics don't capture conversations that may have occurred outside observed periods, they underscore a critical point: You must advocate for yourself as a patient, especially before undergoing sensitive procedures.

The Risk of Anesthesia Awareness and PTSD

Here's what many women don't know: when you're under anesthesia, your memory formation is heavily impaired, but that doesn't mean fragments can't slip through. Your hearing is most likely to remain intact, which is why some patients remember hearing things during surgery if the anesthesia is too light.

The genital area is particularly sensitive. Even under anesthesia, a patient might react to stimulation in that part of the body. This reaction doesn't necessarily indicate something inappropriate occurred—it's simply a physiological response to sensitive stimulation.

However, when the body is stimulated more than the anesthesia can suppress, patients can form unusual memories. They may not remember exactly what happened, but they may experience vague feelings of unease or arousal. While rare with modern anesthesia, it can still happen.

The devastating consequence is that patients often struggle to piece together what occurred because anesthesia has scrambled most of their memories. They may not recognize what actually happened to their body, and doctors and therapists rarely think to ask about surgical experiences when evaluating psychological distress.

Research on awareness during anesthesia demonstrates that approximately 15% of patients who experienced unexpected explicit recall during sedation or regional anesthesia were diagnosed with PTSD, with about 40% experiencing persistent psychological consequences.

The risk is substantially elevated in women with prior trauma exposure. Women with histories of sexual violence who also have PTSD experience significantly more distress, fear, and embarrassment during pelvic examinations compared to women without these histories. For survivors of sexual violence, the examination itself can feel eerily similar to previous traumatic experiences.

Your Rights: 4 Essential Questions to Ask Before Surgery

We can all agree that medical students need quality education. The medical system should facilitate their learning without compromising patient autonomy—especially when patients are unconscious.

Federal rules and several state laws now require that consent be obtained specifically for pelvic examinations under anesthesia, with penalties including licensing board disciplinary action or misdemeanor charges.

Here are 4 questions you should always ask to preserve your autonomy while still supporting medical education:

1. Is the pelvic exam relevant or necessary for my procedure?

Not every surgical procedure requires a pelvic exam. Understanding whether it's medically indicated for your specific case helps you make informed decisions.

2. Can I view the consent form that specifically describes student participation?

General consent forms often don't provide explicit detail about trainee involvement. Request to see the specific language about who will be examining you and when.

3. Can I meet the whole surgery team before falling asleep and understand each person's role?

Knowing exactly who will be in the operating room and what they will or won't do eliminates ambiguity and helps you feel more in control.

4. Will the pelvic examination be performed under direct supervision?

Direct supervision ensures that a qualified attending physician is present during any trainee examination, protecting both your safety and educational quality.

Important tip: Ask these questions before the IV line goes in. This gives you one less thing to worry about before that needle poke, and it provides the surgery team time to introduce themselves before things get rushed as you prepare for anesthesia.

Taking Control of Your Healthcare

Fortunately, the risks of unauthorized examinations appear very low in modern medicine. However, we want you in the driver's seat, feeling confident and in control.

The more confident and in-control you feel, the more smoothly surgery and anesthesia tend to go. And smoother surgery is safer surgery.

Our Commitment to Women's Health Advocacy

As healthcare providers, we have a responsibility to advocate strongly for women's health. Women's health seriously lacks research funding and attention, particularly around critical areas like bioidentical hormone replacement therapy (BHRT).

At Clarus Health, we're committed to:

• Transparency in all medical procedures
• Informed consent that goes beyond checking boxes
• Patient education that empowers women to make their own healthcare decisions
• Evidence-based approaches to women's health, including BHRT

Your body is your responsibility to care for, and you deserve the best guidance. And you deserve providers who respect that fundamental truth at every stage of your medical care.

Ready to learn more about our approach to comprehensive women's health? Speak with a doctor at Clarus Health today to discover how we're helping women take control of their health through informed, personalized care.

Remember: You have more power over your health than you've probably ever been told.

References

1. Consent Policies for Pelvic Exams Under Anesthesia Performed by Medical Students: A National Assessment
2. Ethical issues arising from the performance of pelvic examinations by medical students on anesthetized patients
3. Professional Responsibilities in Obstetrics & Gynecology - Patient Autonomy
4. Medical Student Perspectives on the Ethics of Pelvic Exams Under Anesthesia: A Multi-Institutional Study
5. Consent and Educational Sensitive Exams on Anesthetized Patients: Experiences of Medical Students Across Canada
6. Psychological impact of unexpected explicit recall of events occurring during surgery
7. Legal implications of informed consent