WARNING: The following report may be triggering for survivors of sexual assault.
CLEVELAND — She woke up screaming. She felt disoriented. Her clothes had been removed. Her feet were in stirrups.
Ashley Weitz remembers hearing the doctor say, "I'm almost finished."
It was hours after she was admitted to an emergency room for nausea, vomiting, and a rapid heartbeat.
It was years before she determined the pelvic exam the doctor performed while she was unconscious should never have happened at all.
After all, she said no one asked her about an intimate exam before she took a sedative to manage her illness.
"It felt like a violation because it had been a violation," she said.
'Unethical and unacceptable'
Pelvic exams require physical inspection of the most private areas of a woman's body.
They usually occur during gynecologist visits, when a patient is awake and consenting, and are critical to conduct screenings for cervical cancer, sexually transmitted infections, and other issues affecting women's reproductive health.
No one tracks how many pelvic exams are performed without patient consent. It is also difficult to determine how often they happen because patients are unaware the exams occurred.
However, a recently published study by The Hastings Center, a bioethics research institute, estimated as many 3.6 million U.S. women and men may have received an intimate exam without their consent within the past five years.
"It is unethical and unacceptable to do something to any patient’s body without their consent," said Lori Bruce, Associate Director, Interdisciplinary Center for Bioethics, Yale University. The Chagrin Falls native is also the lead co-author of the study, New Findings on Unconsented Intimate Exams Suggest Racial Bias and Gender Parity.
"This is an issue that is kind of a no-brainer from a bioethics perspective," she said.
The study also revealed significant racial disparities. Black respondents to a survey were nearly four times as likely as white respondents to report they experienced an unconsented intimate exam.
"That finding is sadly consistent with evidence of longstanding racial disparities within medicine," Bruce said. "We need to have more attention on racial disparities in this area and elsewhere.
'Common practice'
Surveys show unconsented intimate exams are often conducted while women are under anesthesia for surgeries or other medical procedures. The exams can be medically necessary, but surveys also indicate they are commonly performed by medical students for the sole purpose of their education.
"Medical students often feel awful," Bruce said. "We all intrinsically know that people have the right to decide what happens to their bodies.
A 2005 University of Oklahoma survey found most medical students had performed pelvic exams on unconscious patients and believed the patients did not authorize the exams.
Alexandra Fountaine, a fourth-year Ohio University medical student, said it is still the way medical students learn to perform pelvic exams.
"This is very common practice," she said. "It happens a lot, unfortunately."
On her first day of rotations as a third-year medical student, when Fountaine was in the operating room of a Columbus hospital, “the senior resident looked at me and said, ‘Hey, now’s a good time to practice your pelvic exam,’” she said.
"I thought, ‘Oh my gosh. Is this happening'?" she said. "I knew it was wrong. I almost panicked."
When asked if the patient required a pelvic exam, Fountaine said, "Not to my knowledge. She did not."
When she talked to other medical students, she realized her experience was not unique. She said they were also instructed to practice pelvic exams on unconscious patients without their permission.
"They feel like they're traitors to women," she said.
Ohio law
Advocacy by medical students, bioethicists, and legal scholars has led to a wave of bills banning medical students from performing pelvic exams without explicit consent.
So far, 25 U.S. states have passed legislation to end the practice, according to Prof. Robin Fretwell Wilson, who has tracked legislation for years.
But News 5 Investigators found Ohio does not require physicians to obtain explicit consent for intimate exams, including pelvic exams.
A legislative proposal to require patient consent for intimate exams sponsored by OH Rep. Brent Hudson Hillyer (R-District 51) and OH Rep. Munira Abdullahi (D-Columbus) was introduced in the Ohio House of Representatives in March.
After a second hearing in May, the bill has languished in the Public Health Policy Committee.
Fountaine was one of 18 supporters who testified during the hearing.
"There is no other profession where asking professional learners to complete educational tasks tantamount to sexual violation is acceptable," she told lawmakers.
Eight states proposed legislation that later failed.
Eleven states have not introduced any legislation addressing intimate exams.
"This just doesn't need to happen," Fountaine said. "There's a right answer to this."
She and Bruce said research shows patients will participate in medical students' training if asked.
"These decisions are being made based on bad data," Bruce said. "When you look at a number of surveys and policies that have been implemented already that require explicit consent, patients are enormously in favor of agreeing to these exams."
OH hospital policies
News 5 Investigators surveyed the ten largest healthcare systems about their practices and policies.
We asked if they allow "medical students to perform exams for their benefit that repeat exams performed by attending physicians, including, but not limited to, pelvic exams?"
Only The MetroHealth System and The Ohio State University provided copies of their consent forms.
The forms do not specifically address prior consent for intimate exams under anesthesia or training exams, but acknowledge students can be part of your care team.
In an e-mail, a The MetroHealth Medical System wrote, “The safety of our patients is always our number one priority and a responsibility that we take seriously. Medical students are not permitted to perform exams or tests on patients without consent. All students are trained to respect patients in their care by following HIPAA guidelines and maintaining ethical practices. Unnecessary test exams are not performed on any patient."
The Ohio State University wrote, "The Ohio State University College of Medicine has a long-standing policy that explicitly prohibits pelvic and other exams without consent."
Here is the excerpt from the student handbook:
“EXAMINATIONS AND CONSENT The American College of Obstetricians and Gynecology Committee on Ethics states in Opinion Number 500, August 2011 that: “Physicians must learn new skills and techniques in a manner consistent with the ethical obligations to benefit the patient, to do no harm, and to respect a patient's right to make informed decisions about health matters. These obligations must never be subordinated to the need and desire to learn new skills.” Procedures under anesthesia, such as pelvic, rectal, breast and other examinations for teaching purposes, require specific consent and medical students should not perform such an examination unless that consent has been obtained. Such examinations should be related to the planned procedure, performed by a student who is recognized by the patient as part of their care team and should be done under direct supervision by the educator.”
Five healthcare systems, including the Cleveland Clinic and University Hospitals, sent statements that said they do not permit the practice. However, they declined to share their copies of of their policies or consent forms.
Despite repeated calls and e-mails, three health care systems, including UC Health, TriHealth, and ProMedica did not respond at all.
Read hospitals' statements here:
News 5 also reached out to the American College of Obstetricians and Gynecologists.
Rachel Kingery, Senior Media Relations Manager, emailed us the following statement and information:
"ACOG’s Committee Opinion on Professional Responsibilities in Medical Education and Training here, which addresses pelvic exams under anesthesia. The relevant section is below. I’m also linking a statement from the Association of Professors of Gynecology and Obstetrics (APGO) which ACOG endorsed. I hope this helps!
"Some procedures, such as pelvic examinations under anesthesia, require specific consent 6. In women undergoing surgery, the administration of anesthesia results in increased relaxation of the pelvic muscles, which may be beneficial in some educational contexts. However, if any pelvic examination planned for an anesthetized woman offers her no personal benefit and is performed solely for teaching purposes, it should be performed only with her specific informed consent, obtained before her surgery 7 8. When patients are not making decisions for themselves, as may be the case with minors or those with brain injury or intellectual disability, consent for these pelvic examinations under anesthesia must be obtained from the patient’s surrogate decision maker (eg, a parent, spouse, designated health care proxy, or guardian); however, when possible and clinically appropriate, the health care provider should also obtain the assent of the patient herself for such examinations."
Fountaine said it's unlikely patients would be able to find out if this happened to them because an exam for training purposes would not be noted in your chart.
A patient, like Weitz, who has a medical record and memory of an unconsented intimate exam is rare.
For years, Weitz said she buried her feelings about her experience.
"I just kind of filed it away in the back of my mind," she said.
She blamed her history for the pain, discomfort, and confusion she felt during the exam.
"I thought, 'Okay, because I have this history of sexual abuse and assault, I was triggered," she said.
Then, in 2019, she learned Utah had proposed legislation to require explicit consent for intimate exams. She eventually spoke in support of the proposal. It passed and became law.
Since then, she has continued to advocate for patients to be required to be asked to consent for pelvic and other intimate exams.
"If I am fully awake, lucid and clothed in a clinic visit, and a student walks in, I can say, 'Oh, no thanks," she said. "Why am I not afforded that opportunity when I'm even more vulnerable?"
Experts we interviewed encouraged patients to speak up if they have concerns before they undergo surgery. Ask if students will be part of your care team and let them know if you don't want them to to practice using your body.