Hello and welcome to FAB Gab. This is the podcast for the International Journal of feminist approaches to bioethics brought to you by fab Network. My name is Kathryn MacKay and today I'm joined by Stephanie Tillman, from St. Louis University to discuss her paper entitled 'presumed consent for pelvic exams under anesthesia is medical sexual assault.' Hello, Stephanie.
Hi, thanks so much for having me.
Thank you very much for joining me. So I wonder if you could give our listeners the paper in a nutshell.
Sure. So this paper is about educational pelvic exams under anesthesia, which are pretty common place in many hospitals or in educational settings from the perspective of student learners, namely medical students, but are not considered common at all for patients. And the paper in the way that I framed it is to discuss how presuming a patient's consent for educational pelvic exams under anesthesia, actually would meet criteria for sexual assault. And I approach that from a couple of different places. The first is to talk about rape culture generally, and the ways that some people's bodies are assumed, penetrated will penetrable and also at the discretion of someone in power, and how outside of a health care setting, there are better understood and respected definitions of when someone's body has been assaulted. But within healthcare settings, clinicians and educators somehow redefine what that looks like. And for patients, not only for sexual assault survivors in the healthcare setting, but for all patients, to have someone's body be penetrated, while they're unconscious is a very big deal. And from not only patients speaking for themselves, but then medical students who have conducted these exams, there is a lot of moral distress. And there is a lot of concern for whether or not this is sexual assault. There's also a growing legal movement that identifies these exams as sexual assault. But that's only in some states. And even in those states, educators and clinical learners still struggle with understanding why or under what conditions what they're doing, qualifies as sexual assault. So some of what I do in this paper is talk about why we should be talking about pelvic examinations as penetration, and how from both a feminist and a queer theory lens. That's an act of reclaiming the language from the patient experience to say what is happening to them. And also to talk about why the patient's point of view is the most important, particularly when we're talking about intimate exams, when we're talking about people who are already vulnerable within the asymmetric hierarchy of patients and providers, and then also have additional sex and gender based vulnerabilities within the system, by nature of the people who can receive a pelvic exam, as the ones that I'm referencing in the paper are in terms of educational tools. But then also, Recent data shows that these exams are happening more often on patients of color. And so it's a sex and gender based harm. It's also a racially based harm that's happening within healthcare. That's part of the history of pelvic health care that continues today. And part of my goal and being very blunt and being very forthright about calling this a form of sexual assault, naming it medical sexual assault is to really use the shock value on purpose to get people to pay attention to what is happening.
Yeah, thank you. I feel like I have a couple of sort of clarification questions, if you will. I mean, it's, it's really stunning to think about this happening. So I guess my first sort of question for me and for the listeners is just like, what's the prevalence? How much does this actually happen? And I guess that's also connected to a question about like, jurisdiction. Where does it happen? Does it happen sort of all over the world? Or is this something hasn't been outlawed anywhere? You're saying something about the different states um, In the US, but like what's Is there something happening outside of the US.
So as far as I know, there's no international data to talk about where else this is happening. We do know that it is happening across the United States. Medical students every few years, will come forward to disclose that they were put in the position of being told to practice an exam, it does take a unique medical student to feel empowered to do so to feel safe doing so to find the right outlet to do so. And also it takes a unique student to know how wrong it is, particularly because within Ray cultures, so many people are normalized to how we learn and other people's bodies or how normal penetration is in some people's worlds, to think that that exam may not rise to the level of explicit consent for a patient. It's happening across all types of surgeries. So a lot of people will assume it's only happening when someone's coming in for a surgery related to their pelvis or related to their obstetric or gynecologic health care, when in actuality, it's happening across all surgeries. And again, the data is very hard to know exactly. There was a study that came out that showed just some general idea of how often it's happening. But the most recent data shows that it's happening far more often than we would think all across the US across different sex and gender identities. So there is concern it's happening for anyone who can receive a rectal exam, there's also reasonable concern to worry that anyone under anesthesia might become an educational tool for any part of their body. So it could be that patients are experiencing penile exams, breast or chest exams, again, rectal exams on top of any pelvic examination. And really, this sort of comes from wanting to ensure that students are getting appropriate experience that they're having an opportunity to learn pelvic examinations out of a worry, either that that surgical patient would not consent to that exam, or that once the student is in the clinical setting, that patients would be declining. So perhaps for some people, it is coming from a place of beneficence, wanting to make sure that students are having these opportunities, and also wanting patients to not experience pain or discomfort while a student is learning the early portions of an exam. However, we haven't pull it enough data, we have so much data to show that patients want to be asked, and that most patients will say yes, if they are asked particularly if they're asked respectfully, if there's a very clear understanding of what is happening. Instead, the cognitive dissonance in clinical education is that educators are not asking because they assume the patient would say no. And some of what I talk about in this paper are the multiple layers of harms that that causes that if you think someone's going to say no, and you do something anyway, what does that harm if you believe that someone would decline being penetrated, but you're going to force penetration on them anyway? What is that harm? So trying to find the names for those harms is part of what I was trying to do.
Yeah, and I think you've just answered something that I was going to ask you, which is basically like, so people are not asking. So the patients have widely clearly said that they'd like explicit consent for this. And it turns out, most people would say yes, if they were asked, but it seems like the presumption has been that they would say no. And so the idea is, well, we just won't ask. I mean, that just seems totally appalling.
You're right to be appalled. I'm appalled. I remember when I was a clinical learner and I came to learn that this happened, I was so taken aback. I almost didn't have words to describe how offensive it was to understand that part of my own colleagues learning was essentially completely disregarding consent and penetrating someone without their knowledge, some of what I talked about in the paper. In fact, the way I open the paper is with a song lyric that essentially refers to someone being assaulted while unconscious at a party. And in the introduction, I compare that to And you know, when someone is sexually assaulted very often there are these questions about what were you wearing? Did you say no? How forcefully Did you say no. And in a clinical setting, someone who's dressed in a hospital gown, they feel like they have to say yes to certain things. They don't even know what they're not saying yes to. And in both circumstances for a drug to assault, whether we're talking about in a healthcare setting or in someone being sexually assaulted outside of the healthcare setting, people will wake up and realize something is not right, they will realize that there is gel on the outside of their genitalia, they will recognize that they have pain, especially if penetration is not typically a part of their life, or especially if there are other reasons that they would know that they had been penetrated. People are waking up and knowing that something happened to them. And it's absolutely unacceptable. That would ever happen in a healthcare setting. It's also heartbreaking. It's also infuriating, but it's it's unethical. And it is violence and really drawing the strongest comparisons I can to the ways that people are sexually assaulted elsewhere, to say, why are we allowing so many similarities to exist in the healthcare setting?
Yeah, definitely. And I want to pick up on something that you sort of said at the beginning, because you were talking about your clinical experience, and you also go by the moniker, the Feminist Midwife. So you are a practicing midwife. And I guess this might be a good time to ask you sort of, who were you writing this for? Were you writing this for your clinical peers?
Yeah, that's a good question. So I had been writing about feminist healthcare since 2012, under that name, and had been a clinician since then, and had been very fortunate to be an out queer clinician and have a lot of queer patients, in my practice, have a lot of people who have disclosed sexual assault histories. And a large part of what I do clinically is trained providers on what's called trauma informed care. And over the last 11 years now of talking about feminist healthcare, and talking about trauma informed care and teaching different clinicians, I have found that part of what comes up, even after I've sort of presented an entire trauma informed care framework is clinicians really still struggling with understanding how the care that we provide every day can be traumatizing to people. And it can be very hard to recognize that even the standard care that we do can cause people harm. And part of what I hope to continue to write about as an ethicist and also as a clinician is to really say, you know, there are ways to provide care that does not cause harm. And talking about the ways that actually we willfully ignore the harm that we're doing contributes to this broader narrative of how people are experiencing harm in the system. So whenever I do write under a feminist midwife or elsewhere, I'm always trying to write both for patients and for clinicians, and for clinical learners, because I think a the power dynamic within healthcare is a problem. That's the most simple way to put it. We really need to be reframing what empowerment looks like in the healthcare setting, and really rethinking if patients come in with all the power, and we as clinicians just receive pieces of that power to be able to provide the care that they're asking us to provide for them. How differently would all of this go? And consent is one of the easiest sort of interlocutors to think about how are we distributing power between ourselves is consent being respected as this communicator of whose power exists where and in terms of writing for both clinicians and for patients language like this language like medical sexual assault, and the broader work that I'm working on around clinical rape culture is meant to be language that is accessible to patients so that they can use that language so that they have that her hermeneutic to draw from when they're describing their own experience to say like something about this didn't feel right. I could call this the same thing that I would call it if it were outside of the set. I can use the exact same language. So my hope is, you know, as scholarly and convoluted as some papers can be, and I feel like in spots in this paper it is that it's also meant to be an everyday language that people can draw from.
I want to ask you a question about that. And I feel like this is going to be, yeah, kind of an awkward question to get out. But anyhow, I'll give it a shot. Because I was wondering through the paper. So you, in the paper, you provide, in one place a distinction between kinda like, I'm paraphrasing, this isn't how you put it, but something like sex sexual assault that happens within a medical procedure, or a medical setting, from more like straightforward sexual abuse by somebody. And I think you're contrasting like the very recent Larry Nasser case where he had this role with the American Olympic gymnast team. And he was just doing sexual predation. And I think that you were drawing a contrast against that kind of like predation case, from the educational case. And I think I can I think there might be a reason to do that. Because I guess this is getting to a broader question. I told you, this is gonna be awkward. Sorry about this. Okay. It's getting to another question about like, what makes a sexual assault sexual compared to just a violent assault, it doesn't have to involve any kind of sexual intent or sexual reward on the part of the attacker? Or does it simply have to involve the parts of a person's body that are connected to or thought of as being sexualized, because I was guest I was wondering like, so we've got Larry Nasser, who's doing like definite sexual predation on these young girls. But that's very different from medical students, or having to being told to etcetera, conduct these pelvic exams on unconscious patients. And then it seems also like, you could almost think that is an assault is an assault, whether it involves penetration or not, like you mentioned earlier in our conversation, like having your breasts examined, or maybe a penile examination, and I was even thinking that even having something done to your mouth can be very sexual. So like, does it have to involve genitalia necessarily? Or how do we sort of find where that border is for something to be a sexual assault compared to simply just a a medical assault? I guess?
Sure, yeah. So I think there's a couple questions in there. One is whether or not someone has to be penetrated for this to qualify as sexual assault. And there's a section in the paper where I say, I'm using these educational pelvic exams under anesthesia as this worst example of what happens that should check all these boxes to say this is medical sexual assault, there is no question there wasn't consent, there is penetration, this is sexual assault. But I also say later on, how penetration does not have to be involved, any intimate touch would qualify anything that the patient would identify as sexual assault should qualify. So it's not always the clinicians intention, like with these exams, since the intention is an educational opportunity, really, it's not a sexual fulfillment. And clinically, I have written previously about how important it is that clinicians are very clear how we define those boundaries to say nothing sexual is happening here, from the clinician side, even if for the patient, a lot of things might be happening for the patients, a lot of the touch that we do, maybe reminiscent of other things in their lives, or may call forward past experiences that they've had. We as clinicians, it is our responsibility to maintain a very firm clinical boundary around what we're doing. And I have written about that elsewhere. And I cite that here. So I would say in sort of the checklist, whatever the patient what identifies sexual assault is sexual assault, and that includes in the clinical setting, so breast or chest, rectal genital at penetrating exams or external exams. I agree with you in terms of things that happened with people's mouths there are. There was a case I believe out of Brazil, where an anesthesiologist during a surgery was on one side of the curtain while the surgeons were on the other and placed his penis inside of the patient's mouth while that person was unconscious or partially conscious. And the ways in which people who are anesthetized are othered and are sexualized and are used for people's personal means. Whether those means are sexual, or whether those means are for medical education, I find it to be a very blurry line. So you brought up how I described about the case of Larry Nasser, who was very clearly a sexual assailant, using healthcare as a crime of opportunity.
So the way that rape culture happens generally, and I mentioned it in this paper, but another paper is coming to talk about this more broadly, rape culture often is defined by systems of normalization, whether we're talking about language or behavior that then allow for systems of degradation, where people are openly bullied or openly harassed or openly shamed for their bodies or for their activity. Once you have these building blocks of systems where someone where something is normalized, and then people are openly degraded, it's much easier to have an environment where people are openly assaulted. So within sort of that environment of people being assaulted, whether we're talking about someone being assaulted in the name of healthcare exam, or someone being assaulted in the name of on purpose, sexually assaulting someone, I would argue, and I do in this paper that those lines are very fuzzy. However, as a clinician, who very much wants the best for clinicians and for clinical learners, I really firmly want to state that there are differences between what Larry Nasser did, and what people who are causing trauma to patients, perhaps without knowing or really without meaning to, and are coming from a good place. Those are two different groups of people. But the actual act of what they're doing, unfortunately, is very similar. And calling them the same thing is the purposeful work that I do in this paper to say, Stop doing this, no one wants any of us to be compared to Larry Nasser, so stop doing this thing that we know qualifies in the same way.
Yeah. Yeah. Thank you. That's really helpful. Did you face any challenges when you were writing this paper or conducting this research?
Yeah, that's such a great question. I would say academically speaking, I was incredibly well supported. So I am a PhD student at St. Louis University, as you mentioned, and definitely came into that program, very feministic. Ly focused, very focused on illuminating queer theory and my work, and very focused on talking about sex and gender and sexuality, in all its complexity in healthcare provision, and in healthcare reception, and whether with faculty or with classmates, I have just been so well supported. And I'm really grateful. I think I had a lot of internal strife. Trying to decide whether or not calling students rapists, or calling clinical educators rapists was the right move, and really sought to sort of reconcile that in my own soul to figure out is this going to have sort of the, the force that I'm hoping for it to? And I think it does, I think that I provide enough of an awareness for clinical learners and the position that they're being put in, and sort of this diffusion of responsibility that happens when we're educators or when we're working in a system or when we're working within our own specialties. Culture of this is how we teach people or this is what we do. As a clinical educator for 11 years. I know all of those nuances, and I hope that I was able to speak to them well enough to say, as educators as learners, no one wants to be putting anyone in this position. Least of all the patients who are experiencing assaults, so to really keep coming full circle in that way. I think to this is one of the first papers I wrote in my doctoral program, and I really felt like I had to get it all out and get a lot of things done. And so the opportunity to quote, one of my own feminist origin stories, Catherine MacKinnon, I mean, I just wound thinking about the fact that I was able to, quote, quote her. Same with Terri Kapsalis, her book, public, 'public privates' talking about people who are learning pelvic exams, she was one of the first people to label those as sexual assault, and I quote her here, like, it's just like heroes coming to mind. Similarly, thinking about calling forward Pat Parker's work, a queer black lesbian poet, to be able to say, Now, how can I bring these these folks forward, I also read a lot about sexual assault, listen to music about sexual assault, and the ability to use song lyrics from one of my favorite artists. At the beginning, I felt like I was just trying to squeeze it all in. And I really feel like I was able to and so it also, I feel like the energy that I had, as a first year doctoral student is also very much a part of this. It's nice to kind of have that all memorialized in one spot.
Yeah, that makes sense. I also wonder from what you said, is it ever a challenge for you to wear both hats as it were to be that kind of critical friend within your own field? Like, do you ever find a tension there? Or have you found a way to just reconcile those two roles that you have, basically?
Yeah, you know, I think as a nurse midwife as an advanced practice, clinician, part of our professional identity, part of our clinical identity, and part of the art of the work of Midwifery, is always being able to be interprofessional, to be able to be collaborative, to support, midwifery, and a nursing framework alongside the medical framework that we work within. So I feel like that dance is very much just a part of the clinical midwife life that I lead. And so now, you know, learning to be an ethicist and having some really lovely role models and ethics, who are able to balance both the clinical and the ethical mentality of things have really shown me how to be able to do that. Well, I think, for the clinicians, it's obvious that I'm talking as a clinician, even if I'm leaning much harder into the ethics scholarship. And I think for emphasis, it's very obvious that I'm talking as a clinician, so it'd be hard to divorce those, and I don't want to I'm trying to marry them beautifully. But I hope that I'm able to continue doing that dance. Because I think, especially in a field, where ethics does not come up nearly as often as perhaps it does in other fields, or doesn't have the same deep bench of tradition to pull from like end of life care, or things like that, that within sexual and reproductive healthcare and within clinical learning, intimate exams, and people's intimate bodies are not often talked about in ethics from that lens. And so, and I hope that I keep doing that well.
So I wonder if you have any final takeaway messages that you hope people will glean from a paper?
Yeah, I think really, pelvic exams in particular, for people who experienced them are such a vulnerable touch point, that if the first one is not done gently and compassionately and with full respect for people's bodily and decisional autonomy, it sets someone up for the rest of their life in their intimate health care, they will avoid care. They will be scared of their providers, it will be very difficult for us to rebuild a therapeutic relationship with someone. And so the utmost respect for consent and people's bodies should be happening, particularly around intimate exams. But really, these should be the canary in the coal mine for how we're treating people broadly across healthcare. And I think one word worry that I had with this paper as people will think that this only applies to educational pelvic exams under anesthesia. And really one of the things that I talk about is how I don't speak to the emergency doctrine in this paper. And that's the idea that if someone comes in in an emergency, we presumed consent to be able to stabilize that person, until they're able to then give consent related to the rest of their care. And something that I know very well as a clinician, and particularly from the perspective of a midwife is that things in healthcare are called emergencies that are not emergencies. And we will use emergencies as a way to just do what we want to do to people's bodies. And that can be in the case of somebody having a baby and an emergency coming up that in community or homebirths settings, we would never call an emergency but in the hospitals we do. And so we act against people's bodies without doing consent in the process or without taking a beat and realizing this person may or may not consent to what we're doing. And I think part of what is said in this article kind of in the background, is you should be seeking explicit consent for these exams. What I don't talk about in the paper is, what if someone says no, if there is a no, we need to be equalizing our support for someone consenting to or deciding against something. And consent is a very unfortunate word for what we do, because it linguistically sets up this idea of someone consents, they say, yes, there isn't a neutral word that we're using to say I'm either receiving a yes or receiving a no. Instead, it's a presumed receiving a yes. And if we can't get rid of the word consent, which I don't think that we can, because it's pervasive across the intimate experience at this point, then we need to recreate the narrative around receiving a no. And if someone declines if they decide against or decline instead of refuse, for example, then we need to say, Okay, this is then what this looks like, Thank you for letting me know what's going to work for you. And in the case of all educational student involvement, people should always be able to say no, and really, in all of people's health care, they should be able to say no. So hopefully, the extensions of this will reach that way. The second thing that I hope is that queer art really can be wonderfully integrated into publications. Pat Parker is one of my favorite poets. shipping goods, though, is one of my favorite artists. So to be able to say, you know, here are things that you know, our inner world or in our lives, that can absolutely be translated into the work that we do. And I'm so grateful for Ajay fab for this for to be to be able to include other art in this way, because the same way that the stories of what happens in healthcare reaches patients, whether through the news or through things like this. The art of what people's lived experiences are, should be reaching us to
thank you. It's been so good to speak to you, Stephanie.
Thanks so much again for having me.
And thank you for listening to this episode of FAB Gab. You can find Stephanie's paper linked in this episode's notes along with a transcript of our discussion. FAB Gab is hosted and produced by me Kathryn MacKay. You can find our other episodes on Spotify, Apple podcasts, radiopublic, or wherever you get your podcasts of quality. You can subscribe to FAB Gab so that you'll never miss an episode. Thanks again for listening. Bye
