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First year Northwestern University medical students perform a pelvic exam on rubber dummies using a flash light and a vaginal speculum during a human anatomy class in Chicago, Illinois March 15, 2007. Despite new guidelines intended to crack down on the practice, Canadian women under anesthesia may still be subject to pelvic exams without their consent, charges a new report in the Canadian Medical Association Journal.

JOSHUA LOTT/REUTERS/JOSHUA LOTT/REUTERS

Despite new guidelines intended to crack down on the practice, Canadian women under anesthesia may still be subject to pelvic exams without their consent, charges a new report in the Canadian Medical Association Journal.

Patients must be informed if medical students are to play a role in their care and provide consent for a pelvic exam, according to updated guidelines published in September 2010 by the Society of Obstetricians and Gynaecologists of Canada and the Association of Academic Professionals in Obstetrics and Gynaecology.

But the guidelines, which were updated in response to a public outcry over the fact women were routinely given pelvic exams by students for educational purposes while under anesthesia and without their explicit consent, don't appear to apply to medical residents, according to the new paper in the CMAJ Monday.

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As a result, residents may still be able to do pelvic exams without patients' knowledge, a serious issue that needs to be revised, said Elaine Gibson, lead author of the analysis and associate director of the Health Law Institute at Dalhousie University.

"It shows a lack of respect for women. It's degrading even, potentially," Prof. Gibson said in an interview. "This one has its impacts directly and exclusively on women…in what would be considered the most private part of women's bodies."

The issue of pelvic exams and consent came to a head in 2010, after publication of a Calgary-based study that found few women who had undergone gynecologic surgery in the past were aware a medical student could have performed a pelvic exam while they were sedated. More than 70 per cent of women surveyed said they expected to be asked for consent before an exam can be conducted.

Guidelines at the time said patient consent for pelvic exams was "implicit" when patients agreed to a medical procedure where trainees may be involved.

But media attention to the issue prompted the SOGC and APOG to revamp the guidelines in 2010.

The updated version maintains that it's important for medical students to conduct pelvic examinations in order to better understand women's health. The guidelines also state that doing exams while patients are under anesthesia is beneficial in several ways, including the fact patients don't experience discomfort and there is less time pressure involved.

But it spells out that patients must provide explicit, verbal consent before any pelvic exams are conducted by students.

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Many gynecologic experts and patients said the move is an important step to ensure the rights and dignity of patients are respected.

Now, Prof. Gibson is raising concerns that the wording of the updated guidelines still allows too much leeway for medical residents. The previous guidelines governing pelvic exams, published in 2006, referred to "medical trainees," but the new version only speaks to medical students.

The concern is that residents can still routinely do pelvic exams for educational or training purposes without consent.

"With the replacement of the 2006 practice guideline by the 2010 policy statement, a substantial gap was created," according to the analysis published in the CMAJ. "Residents are subject to fewer requirements with respect to pelvic examinations for teaching purposes than are medical students, but there is no logical or legal justification for this."

In a statement, the SOGC disputes the accusations, pointing out that the guidelines state consent for pelvic examinations performed while the patient is under anesthesia must be obtained by the surgical team, which includes the resident.

"A careful review of our policy statement will identify the presence of appropriate and necessary statements regarding the practice of pelvic examinations involving medical students and/or residents," the statement says.

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The guidelines state in several places that before pelvic exams can be done while patients are sedated, verbal permission must be obtained "by the gynecologic surgical team, including the medical student."

But Prof. Gibson issued a written response that says because the guidelines fail to address the issue of medical residents and the need for them to obtain verbal consent, women may still not be fully protected against the practice.

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