By Before patients undergo intimate physical exams, including ones performed under anesthesia, hospitals must obtain written informed consent — or risk federal funding.
That’s according to new guidance from the U.S. Department of Health and Human Services, which calls out breast, pelvic, prostate and rectal exams done outside medically necessary procedures.
For decades, medical students have reported giving unauthorized intimate exams to patients while unconscious — sometimes even during unrelated procedures, such as a pelvic exam performed during stomach surgery.
These exams can be used for educational purposes, to give medical trainees a chance to hone their technique on living people. During a colon operation, for example, students might learn how to do a rectal exam by repeating one performed by a surgeon.
But in recent years, outrage over the practice has boiled up in the public, and patients, medical associations, lawmakers and doctors have strongly voiced ethical concerns. Such exams are “a lingering stain on the history of medical education,” physician Eli Adashi from Brown University in Providence, R.I., wrote in a 2019 article in JAMA.
Those concerns helped drive HHS’ decision to develop the new guidance, says a spokesperson for the department’s Centers for Medicare & Medicaid Services, who spoke on the condition that their name was not used, citing departmental practices. The guidance, released April 1, clarifies the process of obtaining informed consent from patients prior to sensitive exams. Informed consent has always been required before sensitive exams, the spokesperson said, but the new guidance now stipulates that hospitals must also obtain written consent.
This updated guidance is a “landmark achievement in patients’ rights,” says Lori Bruce, a bioethicist at Yale University. Taking the time to ask people — and obtain consent — before doing something to their bodies, she says, upholds one of hospitals’ sacred responsibilities: to respect their patients.
Until now, guidance for hospitals had been somewhat murky. For years, medical associations including the Association of American Medical Colleges and the American College of Obstetricians and Gynecologists have stated that these exams should happen only with informed consent. But these were only recommendations; actual legal statutes vary greatly by state. Current laws represent a hodgepodge of regulations on what exams are covered, who is protected and what is required of examiners.
With the new federal guidance, hospitals must comply or risk their participation in Medicare and Medicaid programs. That means hospitals would no longer receive money from those programs, which pay out hundreds of billions of dollars each year. Tethering funding to compliance is key, says University of Chicago Medicine obstetrician gynecologist Julie Chor. “It will be even more motivation for people to actually do what is right.”
Unauthorized intimate exams may be more common than you think
It’s still unclear exactly how often unauthorized exams occur. There’s no official count from hospitals, and medical student training isn’t always documented in patients’ charts. But Bruce and others in the field have scrutinized the scope of the problem, and it may be more widespread than originally thought.
A 2023 survey of hospitals affiliated with medical schools found that nearly 20 percent did not explicitly obtain patient consent for pelvic exams done under anesthesia, researchers reported in the Journal of Women’s Health. And in a 2022 survey in the Journal of Surgical Education, medical students reported feeling like they couldn’t object to performing unauthorized pelvic exams on anesthetized patients. They favored having more explicit consent procedures in place.
Those results peek behind the curtain of a largely hidden practice and hint at a pervasive problem — something that’s been backed up by Bruce’s research. In a national survey of more than 1,000 people published in 2022 in the Hastings Center Report, Bruce’s team found that 1.4 percent of respondents reported receiving unauthorized pelvic or prostate exams within the five prior years. That might seem small, she says, but when extrapolated to the U.S. adult population, it adds up to more than 3.5 million people. Even that is “frankly, very likely to be a conservative estimate,” she says.
In Bruce’s survey, men were slightly more likely than women to report an unauthorized exam, and Black respondents nearly four times as often as white people. That’s consistent with long-standing evidence of racial inequality in medicine, Bruce says (SN: 12/20/22).
Patients are generally willing to participate in educational exams
There’s a simple solution that both respects patients’ bodily autonomy and lets medical students keep up with training: just ask patients for their consent.
There have been concerns in the medical community that patients might say no, limiting teaching opportunities. But in colon and rectal surgeon Lauren Wilson’s experience, most patients understand that trainees are still learning how to practice medicine, and don’t object to being involved in the process. Having that conversation about consent is crucial, says Wilson, who works at Dartmouth Hitchcock Medical Center in Lebanon, N.H.
Her experience is borne out by data. When asked, almost 86 percent of nearly 4,000 gynecology patients consented to receiving a pelvic exam under anesthesia by a medical student, researchers reported in a 2023 preprint posted at medRxiv.org. Another study found similar results. Of 274 patients seeking abortions, 88 percent accepted such exams, Chor and her colleagues reported in the January 2024 Contraception.
Though Chor says she finds the argument that requiring written permission will impair student learning abhorrent in the first place, her work helps to debunk it. It “really refutes the premise that people are not interested in participating in educational exams.”
