Yeah, it's as bad as it sounds, if not worse. About thirty years ago when I was a newer obstetrical nurse, I remember a medical student, a woman, creating quite the ruckus because she had just realized in her training that women scheduled for any seemingly random surgical procedure, unrelated to gynecology, were being used as models of pelvic exams by medical exams. The case she shared in effort to end this treatment, was of a woman who had come in to have a procedure performed on her ear, under sedation, and following the procedure and still under anesthesia, the woman was moved into stirrups and a classroom of medical students were brought in, each taking turns using a speculum to enter her vagina to evaluate her cervix, followed up by each of them inserting two of their own fingers to identify her anatomy.
There is no question that the pelvic examination is a critical tool for medical students to learn, and to do well, but without adequate consent, this is a violation. The female medical student advocating for change, also shared that she shared her horror with the situation, but the chief resident explained this was standard practice and that the patient had ultimately consented when she signed her admission paperwork, allowing the medical team to do whatever else they felt necessary in her medical care, including allowing the participation of medical students.
This particular student also shared that this woman had called in a day or two after her procedure with concern about vaginal bleeding and the nurse didn't know what to tell her. The staff physician essentially gaslit her and told her that if it continues next week, to see her gynecologist for evaluation, but it should resolve by then.
Thirty years ago, as more women entered medical school and began speaking out about these training experiences, it became more widely known that this was a common event in medical school or common for women to endure these violations no matter their reason for sedation, and so women began fighting for protections, speaking to legislative leaders, female medical students would share testimonies in horror, yet this practice still continues today.
ELLE magazine wrote an article on this issue in 2019, after conducting a survey on 101 medical students, from seven major American medical schools, in which 92% reported performing a pelvic exam on a female patient who was under anesthesia (Tsai, 2019). Of those who performed the exam, 61% reported having done so without consent of the patient. Worse, only 47% reported being uncomfortable with how their schools handled these exams. In an older survey, 100% of women surveyed said they felt consent should always be attained prior to performing a vaginal exam while a woman is under anesthesia (Bibby et al., 1988).
Legislation for Consensual Pelvic Exams
This past week I was consulted by a malpractice attorney to review a maternity case. Within the chart, was a consent for vaginal exams, which I was impressed to find knowing this history. It specifically stated that in the state of Florida, consent is required prior to performing vaginal exams which is likely the result of advocacy efforts by constituents. The American College of Obstetricians and Gynecologists' opinion is that "pelvic examinations on an anesthetized woman that offer her no personal benefit and are performed solely for teaching purposes should be performed only with her specific informed consent obtained before her surgery" (2011).
Twelve states - California, Maine, Hawaii, Illinois, Iowa, Maryland, Oregon, Utah, Virginia, Florida, Delaware, and New York have outlawed nonconsensual pelvic exams. Since 2019, 22 bills seeking to ban unauthorized pelvic examinations have been put forth in 17 states since January of 2019 (Friesen et al., 2020). It can be shocking to realize, when you aren't working in the medical field, that this even happens - that women are having pelvic exams by multiple people, back-to-back, without consent. When you work in the medical field though, this almost seems routine. Nurses and physicians disassociate. A fourth-year medical student shared with ELLE that "patients have no way of finding out," so while "it felt a little weird," it was her best opportunity to practice.
Concept of Consent & Bodily Autonomy
The concept of consent and bodily autonomy isn't taught in medical programs. Most students have not read the informed consents offered patients (Tsai, 2019). They depersonalize much of what they have to do because the ends justifies the means. They watch chests being sawed open, screams of agony as bones are adjusted, and patients refusing life-saving medications in fear. They push through, dispassionately; the vaginal exam no different than the neurological exam.
In my own training, I was expected to do a specific number of prostate and pelvic exams, neither of which are as common anymore in primary care, because we can now offer serum testing to evaluate prostate health and the pap smear isn't performed as often as it was in years prior, for most clients. As I was nearing the end of my training, one of my mentors began asking clients if they would allow such exams, for no other benefit than my own learning, and not one consented to such. It seemed the most awkward request for me to be apart of , as well. Ultimately I paid a trained model who teaches graduate students to perform these exams, but even he said he can only permit about 8 to 10 a day or his stomach cramps up. Men under anesthesia have also had classrooms of more than 8 or 10 performing rectal exams, without consent or knowledge (Tsai, 2019).
The Slippery Slope for Obtaining Consent
Legislation from state to state differs regarding how consent should be obtained for women's pelvic exams. Some require written consent, while others only require verbal consent. Many states though work under the premise of implied consent, meaning that when patients receive care at a teaching hospital, they are aware that medical trainees will be involved in their care (Cundall et al., 2019). This argument, though, is built on the assumption that the patient is awake and conscious. It's also assuming that all these patients chose a teaching hospital and didn't arrive there from emergency transport or due to insurance coverage, or even geographical necessity. This also creates healthcare disparities, as systemic racism and differences in how insured and uninsured patients are treated, by limiting choices in what hospital they will go to, and teaching hospitals often provide higher rates of care in vulnerable communities.
As mentioned in the initial case, there are also clinicians who argue that cosent is obtained by the more general treatment consent or even the preoperative forms. However, these consents are authorization for therapeutic benefit, such as needing a blood transfusion or hysterectomy to control hemorrhage, not for educational purposes (Cundall et al, 2019). It's a huge stretch to assume that a general medical consent for safe care is the same as allowing a class room of medical students to perform vaginal exams without the patients knowledge.
Would you allow a classroom of students to perform this exam under anesthesia? It seems very dehumanizing. It's no wonder then that as physicians move through their training that they continue to carry that paternalistic authorial approach into their counsel with clients.
Trauma-Informed Care
The reality of women's health is that more likely than not, they are likely to have experienced some level of trauma (Buffalo Center for Social Research, 2025). Women also have a wide variety of life experiences that cause them to have very unique relationships with inequality of power, authority, consent, their reproductive system, and even their genitalia. A woman's sexual orientation, her gender identity, her religious beliefs, cultural background, marital status, her history of sexual trauma, even birth trauma will impact her comfort in this regard.
Sexual violence is prevalent in the United States with one in five women having been raped and 43.6% of women experiencing some form of sexual violence including contact within their lifetime (Centers for Disease Control and Prevention, 2025). When we ask for consent, specific and informed consent, then we are practicing trauma-informed care to avoid re-traumatizing women. There is simply no room for making paternalistic decisions on behalf of women, or individuals, for any reason, but especially because they believe this may "protect" her.
One certainly could make the argument as well that performing a nonemergency medical procedure without getting the patient's consent first, specifically the pelvic exam, is an assault.
Training of Future Physicians
I know of not one midwifery educational program that would permit their students to perform exams on unconscious or anesthetized women. Mutual decision-making is the foundation of our training, yet we are still capable of obtaining this necessary training in collaboration with women.
What intrigues me is that because there is such great concern that women may decline this training if they are granted autonomy or "protection under the law," surveys have been performed to evaluate if women would consent to allow physicians training opportunity (Wainberg et al., 2010). One survey of 102 women found that 62% would consent if asked beforehand. Only 14% reported they would refuse, but the great irony here that goes unmentioned, is that a significant aspect of this exam is performing an exam in collaboration with the client - appreciating and responding to her discomfort, navigating that boundary of consent through the procedure, and adapting to ongoing assessment based on her feedback. Even with consent, assuming that this is an effective training scenario in an unconscious woman is still exceedingly paternalistic and dehumanizing. Further, because this is a blind procedure, women can be physically harmed by these exams when not guided by the woman's verbalized sensations. Between 11% and 60% of women report experiencing pain or discomfort during pelvic exams, while 80% report fear, embarrassment, or anxiety (Bloomfield et al., 2014). Again, this exam is about much more than simply inserting two fingers and finding anatomical landmarks; it's also about learning to create safe space and responding with empathy.
The National Institute of Health however, seems to miss this point. They speak to the importance of respecting the rights of women and their right to consent, while also arguing that these assessments are vital so that all women for physicians, suggesting the compromise be that women should be offered written consent to have exams while anesthetized. What if physicians simply asked conscious women if they would be agreeable to pelvic exams, so they can be participants in this procedure as most all exams are performed in clinical practice, maybe even paying women to be consenting models (Cundall et al., 2019)? It's equally important for medical professionals to learn consent, and how to navigate mutually respectful care, as it is for them to identify anatomy.
References
American College of Obstetricians and Gynecologists. (2011). Professional responsibilities in obstetric - gynecologic medical education and training. Committee Opinion No. 500. Obstetrics & Gynecology, 118, 400-404.
Bibby, J., Boyd, N., Redman, C. W. E., & Luesley, D. M. (1988). Consent for vaginal examination by students on anaesthetised patients. The Lancet.
Bloomfield, H. E., Olson, A., Greer, N., Cantor, A., MacDonald, R., Rutks, I., & Wilt, T. J. (2014). Screening pelvic examinations in asymptomatic, average-risk adult women: an evidence report for a clinical practice guideline from the American College of Physicians. Ann Intern Med, 46-53.
Buffalo Center for Social Research. (2025). What is trauma-informed care? Buffalo Center for Social Research.
Centers for Disease Control and Prevention. (2025). About sexual violence.
Cundall, H. L., MacPhedran, S., E., & Arora, K. S. (2019). Consent for pelvic examinations under anesthesia by medical students: historical arguments and steps forward. Obstetrical Gynecology, 134(6), 1298-1302.
Friesen, P., PErsaud, R. D., & Wilson, R. F. (2020). Legislative alert: the ban on unathorized pelvic exam. Health Law Journal, 25(1), 29-31.
Hammoud, M., Spector-Bagdady, K., O'Reilly, M., Major, C., & Baecher-Lind, L. (2019). Consent for the pelvic examination under anesthesia by medical students. Obstetrics & Gynecology, 134(6), 1303-1307.
Tsai, J. (2019). Medical students regularly practice pelvic exams on unconscious patients. Should they? Elle.
Wainberg, S., Wrigley, H., Fair, J., & Ross, S. (2010). Teaching pelvic examinations under anaesthesia: what do women think? Journal of Obstetrics & Gynaecology Can, 32, 49-53.
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