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Doctors should be able to examine a patient's vagina without consent forms or chaperones, says medical student Liz Frayn

Trust me - I'm a doctor

One of Britain's most high-profile doctors is due before the General Medical Council to answer charges of serious professional misconduct. Dr Kypros Nicolaides, a pioneer in the field of screening for foetal abnormalities, is accused by his patient Jenny Sabin of making 'innuendo-laden' remarks to her and her female companion while carrying out a delicate procedure to save the life of her twin foetuses, suffering from the rare twin-to-twin transfusion syndrome. Sadly, neither baby was saved. Dr Nicolaides claims he was 'trying to lighten the atmosphere'; obviously his attempts misfired.

In the coming months we can expect to hear of more cases like this. 'Appropriate' communication skills and behaviour towards patients is a hot topic in medicine at the moment, and nowhere more so than in the specialities of obstetrics and gynaecology where there is particular concern that medical students should be aware of the sensitivities of their patients.

In the past potential embarrassment was dealt with by simply ignoring it. The Carry On film portrayal of an arrogant consultant marshalling a dozen medical students to peer up a patient's vagina as casually as if they were inspecting her ear, was a fair representation of teaching on many gynae wards. Now things are different.

When we began our obstetrics and gynaecology rotation last term, two new skills had to be learned: firstly, carrying out internal examinations, and secondly getting consent from patients to do these examinations while they are under anaesthetic. This usually involves asking the patient to sign a form giving you their permission to examine them while they are unconscious - a procedure referred to as EUA (Examination Under Anaesthetic).

EUA is one of those issues that lends itself to outrage and it is no surprise that several women's magazines have run agitated features about women examined in this way without their consent. If you have never worked in a hospital it sounds like a horrible affront to a woman's dignity, an invasion of her privacy, which is why most medical schools now insist that no student should examine a patient without consent, worried that women who find out they have been examined might make a fuss.

The feminist pressure group Women in Medicine lobbied for this change after discovering in a 1992 survey of 17 hospitals that only six required written consent, eight relied on verbal consent and three had no formal request procedure. The Royal College of Obstetricians and Gynaecologists (RCOG) has come around to Women in Medicine's way of thinking, issuing guidelines which insist that 'Fully informed written consent must be obtained from the woman before she comes to the operating theatre...preferably...for a named rather than a generic medical student'.

Medical students do need to learn how to examine women's genitalia. Bi-manual vaginal examination, where the fingers of one hand are inserted to palpate the uterus and tubes via the vagina, and the other hand feels the uterus through the abdomen, is a first-call method of detecting abnormalities. Speculum examinations are essential for assessing the health of the vagina and cervix. And because - just like mouth, eyes and ears - one woman's vagina differs from another (and none feels like the plastic teaching models) until you have felt quite a few, it is impossible to tell what on Earth you are feeling, let alone identify abnormalities. As one of my colleagues has pointed out, 'If they all start saying no, what can you do? You've got to learn somehow'.

Fortunately, women rarely do say no. Male medical students have the most problems. One male friend said: 'The worst thing is when they are all in the pre-day surgery ward, in beds next to each other. As soon as one says no, you know the next one will, and then the next'. A more inventive male colleague finds that 'If you ask them in the right way, it's fine. Call it a "pelvic" or "internal" examination - certainly not "vaginal", that's a no-no'. Responses range from the relaxed: 'Don't worry about it, I lost all my dignity when I had my kids!' to the more tentative 'I suppose you need to learn', and occasionally the downright 'no'.

Assuming that women patients are rational, sensible beings - and most are - why should they object to such examinations? Why should a medical student examining your vagina when you are unconscious be worse than him massaging your open heart or putting his hands into your abdomen?

Women who object do so presumably because they are embarrassed about the sexual connotations. This seems a little bizarre given the circumstances in which these procedures take place. Believe me, just as there is nothing erotic about examining lumpy testicles, so there is nothing erotic about bi-manual exams.

To imagine that there may be some impropriety is to distrust doctors. And unfortunately this distrust is more likely to be fuelled than calmed by mandatory consent procedures. To raise the issue of specific written consent for an exam with a woman implies that there might be a reason why she would wish to refuse it. The act of getting consent shows that medical schools are also suspicious of women, and the accusations they might make. This kind of mutual distrust does not provide a constructive basis for learning, or for patient care.

The RCOG's report seems to go out of its way to reinforce a lack of trust. It starts from the premise that 'Vaginal examination and bi-manual palpation of the female internal genitalia are among the most intimate and potentially embarrassing examinations carried out in clinical medicine'.

Embarrassing yes. Intimate no. A man in a white coat, sticking a speculum or a gloved finger into your vagina as you lie legs akimbo on a hospital bed does not constitute intimacy in my book. I suspect asking any self-respecting female patient if you could 'intimately examine' her would result in a slap in the face.

As for embarrassment, it seems to me that the best way to tackle this problem is, in a rather un-90s way, to ignore it. It may not be a very enjoyable procedure, but most women realise that it is necessary, and that doctors do it all the time.

In my experience, most women would rather just get this procedure over with as quickly as possible. The more self-conscious doctors become, the more loaded and embarrassing the situation becomes. Women do not want doctors to even think about impropriety. The RCOG code, however, ensures that the possibility of it will prey on the doctor's mind during the examination.

The RCOG also recommends that: 'A chaperone should be offered to all patients undergoing intimate examinations...regardless of the gender of the gynaecologist.' This was widely reported in the press, so presumably the RCOG regards it as quite a vote-winner. But why should women need a chaperone? Your average gynaecologist may be insensitive and even unpleasant, but does he need a nurse behind the curtains to stop him trying it on when you are in a vulnerable position?

The other side of the coin is of course that the doctor too feels vulnerable: after all, nowadays, a patient may sue him for trying it on and he needs a witness to prove otherwise. With the presence of a third party, however, a purely medical relationship becomes potentially a complex legal or sexual situation. This hardly seems conducive to trust between doctor and patient.

When I had my first smear test the nurse winked and instructed me to lie back and think of England. Really, I think this kind of reassuring, let's-get-on-with-it attitude would make things easier for women and doctors. On much reflection, I would put my neck on the line and argue that, for adult women undergoing gynaecological procedures, being examined beforehand by a medical student without getting special consent is fair enough.

We examine other bits of them - hernias, broken arms, lumps and bumps - and even assist in their operations, so why not vaginas? After all, from a medical point of view, it is no different. You could protest that from a woman's point of view, it is different. But be reassured; as far as a doctor's concerned, he might as well be looking at your elbow.

The Royal College of Obstetricians and Gynaecologists Guidelines include:
  • 'A chaperone should be offered to all patients undergoing intimate examinations...regardless of the gender of the gynaecologist.'

  • 'Verbal consent should be obtained prior to all pelvic examinations.'

  • 'Induction courses for junior doctors should include training on the appropriate conduct of intimate examinations.'

  • 'No remarks of a personal nature should be made during pelvic examination.'

  • 'Every effort must be made to ensure that intimate examinations take place in a closed room that cannot be entered while the examination is in progress and that the examination is not interrupted by phone calls, bleeps or messages about other patients.'

The doctor's speculum - intrusive, but hardly intimate

Reproduced from LM issue 108, March 1998

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