#MeToo. #TimesUp. Social media sparked the now widespread social movement that has encouraged women to speak out. Sexual harassment, assault, misconduct, and abuse, all of which are perpetrated predominately by powerful men against women in less powerful positions, have opened the floodgates of complaints and accountability, taking down one man right after another—Harvey Weinstein, Kevin Spacey, Matt Lauer, Larry Nassar, and many others.
It is important to not only think about women, as well as men, but also other vulnerable individuals such as those who are disabled and those with severe mental illness.
My colleague Stephanie Tillman, a certified nurse midwife, brings our attention in this editorial to the vulnerability of another population of individuals—women undergoing pelvic/gynecologic care—and the care that should be taken to protect our patients.
Mona Shattell, PhD, RN, FAAN
I am a gynecologic health provider. The abhorrent, repetitive, and years-long sexual assaults of Larry Nassar (Schuman, 2017), seemingly in the name of health care, threaten the work of my profession. Not only did countless individuals in authority ignore the reports of students and athletes, not only did those same individuals trust in a health care provider so deeply as not to consider his work in the realm of assault, but the profession of gynecologic providers stayed silent. I will not. Above all else, the incredible voices and strength of those who came forward to report his crimes, and those in community with them but who were unable to speak, bring me a bonfire of passion to speak out, and intentionally practice and teach empowering, consensual, and evidence-based pelvic care.
One in five women will be assaulted in their lifetime (National Sexual Violence Resource Center, 2015), and the numbers are higher for queer and trans individuals (Human Rights Campaign, n.d.), and again higher for individuals of color (Meyerson, 2017). Sexual assault coverage currently dominates mainstream media with the #MeToo and #TimesUp campaigns, and Time magazine naming the collective group of individuals coming forward as the 2017 Person of the Year (Zacharek, Dockterman, & Sweetland Edwards, 2017). These movements have encouraged survivors to name assailants from years or decades prior, speaking to the fact that women and trans individuals have not been safe in their lives and bodies for a long time. Some of the most well-known and previously respected film figures are now publicly shamed for their crimes against individuals' bodies from decades ago (Digh, 2017). However, those speaking out continue to risk persecution, and we watch known attackers experience no recourse. The anonymous creator of the “Sh*tty Men in Media” list, made to protect colleagues in the workplace, was forced to name herself and now fears for her safety and livelihood (Donegan, 2018). The anonymous report of Aziz Ansari's sexual aggression somehow has now led to people calling the question of whether women coming forward have somehow gone too far (Gray, 2018), as if going too far is a possibility when the highest ranking elected official in our country is a bragging sexual assailant (Bush, 2017).
Further, assaults on women and trans individuals' bodies in the name of health care is, horrifyingly, not new. When abortion was illegal, women reported sexual abuse by the provider (Grimes, 2015): this was an understood risk of seeking critical but clandestine services. The history of unconsented sterilization (Ko, 2016) against women of color is so well-established there are now legal stop-gaps to prevent its recurrence. Medical students continue to write about performing pelvic and bimanual examinations on women under anesthesia for non-pelvic procedures (Barnes, 2012), without their explicit consent. Pregnant women have been forced into continuing pregnancies they do not want (Valenti, 2017), or undergoing cesarean sections against their will (Redden, 2017). A woman who declined an episiotomy during labor was subsequently cut 12 times by her male physician (Grant, 2017). Larry Nassar is yet another example.
In considering Nassar's circumstances, the opportunity for unchecked and unquestioned assault was multifactorial: patients, by labeling, are at a decreased power level to their providers; women, by existence, are at a decreased power level to men; and students and athletes, by role, are at a decreased power level to their institutions. It is an atrocity, but somehow not a surprise, that the nexus of power and knowledge of the white male physician, with the availability of women's bodies and the power of medicine behind him, led to women's reports of sexual assault being overwhelmingly ignored, and permitted Nassar's rapes and violations to continue.
One of the hardest parts for me as a clinician is understanding the innumerate adults who believed the care he was providing was without question, despite the stories coming forward. Consistently, individuals in authority responded by labeling the reported assaults as a misunderstanding. At times, parents, who presumably consented on behalf of their children, were in the room during the violations. Was it that these adults and authority figures could not understand that pelvic care could be abused? Was the intimate nature of the examination itself, the overlapping possibility of it being an assault, and the complicated disentangling of health care and sex too uncomfortable to truly be addressed?
Nassar's sexual assaults cannot be said in the same breath as health care. But health care providers must acknowledge that his actions exist in the context of historic and current abuses of gynecology. I believe the general silence from gynecologic providers speaks volumes to the profession's intentionality to disentangle the nature of sexual experience and pelvic health care, and its desire not to conflate the two by engaging in discourse about Nassar's assaults. But we must. All individuals should be able to question their health care provider. All individuals should be heard and believed if they say someone assaulted them. All health care providers should deeply evaluate their consent process and disentangle, to every extent possible, sexualized language or touch from clinical care.
In midwifery school, I was trained to discuss transferring power prior to starting any external or invasive gynecologic care (e.g., “This exam is in your control, you can stop me at any time for any reason, please let me know if there's any pain and I'll change what I'm doing”), what will happen before an examination even starts (e.g., “I'll use a swab to collect a sample and then insert the speculum”), use language throughout the examination to continue to ensure understanding and give opportunities for questions or reclamation of consent (e.g., “You'll feel my hand on your leg and then on the outside”), check in throughout the procedure (e.g., “Tell me if you're feeling any pain”), and then afterward (e.g., “Tell me if there's anything I can do next time to make that exam more comfortable”). I have written before about the importance of providers making space for transferring power during care (Feminist Midwife, 2014), and strategies to do so in pelvic care specifically (Feminist Midwife, 2016). Luckily, many in my profession continue to question the need to enter individuals' bodies for pelvic care (Crawford, 2017), carefully considering recommendations for when to do so.
I experience myriad emotional, physical, and intellectual reactions when discussing pelvic examinations. As a patient who has had good and bad pelvic examinations. As a survivor of sexual assault. As someone who exists in a world where my body is always, seemingly, available for assault. As a queer person for whom a digital examination mirrors sexual intimacy. And now as a clinician. All these factors lead me to question my profession's overlap with conversations around sexual assault: How many students in health care professions have witnessed an attending clinician inappropriately examine a patient? How are providers being taught consent, power transfer, and ensuring patients know their rights? How do clinicians practice trauma-informed care knowing that their work parallels individuals' intimate lives or history of assault? How can patients have space to question what happened during an examination, and feel safe doing so? How can all individuals be given language to challenge the medical model when something goes terribly wrong? And how do all clinicians really talk about Nassar's impact on pelvic health care?
Now in my sixth year of gynecologic practice, I believe more than ever that the most important knowledge base is the individual whose pelvis needs care. And in my 34th year of being alive, I believe that women should be trusted and believed when they say something happened to them. Clinical care is currently organized and reinforced as a model where the provider holds power: this hierarchy must continue to be challenged and changed. Evidence-based, consensual, and empowering pelvic care must be a space where individuals feel safe to own their bodies, ask questions, and receive true care.
Stephanie Tillman, CNM
University of Illinois at Chicago
- Barnes, S.S. (2012). Practicing pelvic examinations by medical students on women under anesthesia: Why not ask first?Obstetrics & Gynecology, 120, 941–943. doi:10.1097/AOG.0b013e3182677a28 [CrossRef]
- Bush, B. (2017, December3). Billy Bush: Yes, Donald Trump, you said that. Retrieved from https://www.nytimes.com/2017/12/03/opinion/billy-bush-trump-access-hollywood-tape.html
- Crawford, C. (2017, April25). AAFP recommends against pelvic exams in asymptomatic women. Retrieved from https://www.aafp.org/news/health-of-the-public/20170425aafppelvicexam.html
- Digh, P. (2017, December6). The cognitive dissonance we feel because of Matt Lauer, Charlie Rose, and Kevin Spacey. Retrieved from https://www.huffingtonpost.com/entry/the-cognitive-dissonance-we-feel-because-of-matt-lauer_us_5a2299f5e4b04dacbc9bd781
- Donegan, M. (2018, January10). I started the media men list. Retrieved from https://www.thecut.com/2018/01/moira-donegan-i-started-the-media-men-list.html
- Feminist Midwife. (2014, October22). 12 ways to be a feminist healthcare provider. Retrieved from http://www.feministmidwife.com/2014/10/22/12-ways-to-be-a-feminist-healthcare-provider/#.Wnof_LT82iJ
- Feminist Midwife. (2016, April4). Feminist midwife scripts: Painful cervical exams during labor. Retrieved from http://www.feministmidwife.com/2016/04/04/feminist-midwife-scripts-painful-cervical-exams-during-labor/#.WnogALT82iJ
- Grant, R. (2017, December18). Ethics of the delivery room: Who's in control when you're giving birth. Retrieved from http://www.independent.co.uk/news/long_reads/childbirth-delivery-room-ethics-doctor-patient-healthcare-a8085346.html
- Gray, E. (2018, January16). On Aziz Ansari and sex that feels violating even when it's not criminal. Retrieved from https://www.huffingtonpost.com/entry/aziz-ansari-sex-violating-but-not-criminal_us_5a5e445de4b0106b7f65b346
- Grimes, D.A. (2015, January15). The bad old days: Abortion in America before Roe v. Wade. Retrieved from https://www.huffingtonpost.com/david-a-grimes/the-bad-old-days-abortion_b_6324610.html
- Human Rights Campaign. (n.d.). Sexual assault and the LGBTQ community. Retrieved from https://www.hrc.org/resources/sexual-assault-and-the-lgbt-community
- Ko, L. (2016, January29). Unwanted sterilization and eugenics programs in the United States. Retrieved from http://www.pbs.org/independentlens/blog/unwanted-sterilization-and-eugenics-programs-in-the-united-states
- Meyerson, C. (2017, October19). Sexual assault when you're on the margins: Can we all say #MeToo. Retrieved from https://www.thenation.com/article/sexual-assault-when-youre-on-the-margins-can-we-all-say-metoo
- National Sexual Violence Resource Center. (2015). Statistics about sexual violence. Retrieved from https://www.nsvrc.org/sites/default/files/publications_nsvrc_factsheet_media-packet_statistics-about-sexual-violence_0.pdf
- Redden, M. (2017, October5). New York hospital's secret policy led to woman being given Csection against her will. Retrieved from https://www.theguardian.com/us-news/2017/oct/05/new-york-staten-island-university-hospital-c-section-ethics-medicine
- Schuman, R. (2017, November29). How Larry Nassar got away with it. Retrieved from https://slate.com/culture/2017/11/larry-nassar-preyed-on-young-gymnasts-whod-been-taught-their-bodies-were-not-their-own.html
- Valenti, J. (2017, August9). Pregnancy can kill. No one should be forced to give birth against their will. Retrieved from https://www.theguardian.com/commentisfree/2017/aug/09/pregnancy-can-kill-right-to-chose-jessica-valenti
- Zacharek, S., Dockterman, E. & Sweetland Edwards, H. (2017). The silence breakers. Retrieved from http://time.com/time-person-of-the-year-2017-silence-breakers