From the ##metoo movement to reports of sexual assault being front and center on national television with the confirmation hearings of Supreme Court Justice Brett Kavanaugh, consent has been making the news headlines. Health care providers have an opportunity to provide a safe space to discuss enthusiastic consent in relationships and to model it in the exam room by obtaining explicit consent from our patients prior to performing intimate exams in the office. Consent is an important component of establishing a respectful and trusting relationship with your patient—one that improves satisfaction, adherence, and ultimately, outcomes.
Obtaining consent for an exam does not need to mean having a patient sign a lengthy consent form before a pelvic exam is performed. It does involve asking and waiting for verbal permission to touch. Here are a few practical examples of how you can incorporate the language of explicit consent in the exam room:
1. Greet your patients when they’re fully clothed
Sending the message that you care about consent and welcome patients as equal participants in their health care starts before you walk through the door. When your staff asks a patient to undress before you even meet them, such that they’re in a gown, sitting on the exam table at your first meeting, you’re taking away their opportunity to consent to each step of that interaction with you. Equally problematic is the fact that you’re establishing an uneven power dynamic at your first meeting. You, the clothed person (who already holds more power in the relationship as the provider), have your dignity and personhood intact, while your patient is left feeling exposed and stripped of any markers of identity their clothes may hold for them. They’re reduced to being just a body.
2. Ask before you touch instead of tell before you touch
Small changes to the way you communicate can let patients know they have choices and are in control of what happens to their body. Asking for consent to proceed with an exam, offering the option to defer an exam to another visit, and clearly communicating that you can stop the exam at any time can go a long way towards building trust. Instead of telling the patient, “Now you are going to feel my touch,” you could ask, “Is it okay if I touch now?” This shift in language does not require any additional time but is much more patient-centered.
3. Check in during the exam
When performing a pelvic exam, ensuring that the head of the table is elevated about 30 degrees allows you to make eye contact with the patient and to get visual feedback about how the exam is going for them. Checking in during the exam by asking, “How are you doing?” or “Tell me whenever you are ready to proceed or if you want to stop,” will help them feel more comfortable asking you to stop.
For patients with a history of sexual abuse or trauma, studies have shown that the ability to maintain control over the exam is essential to making them feel respected and valued by their health care provider. Preface your exam with a statement such as, “I will stop anytime you ask me to,” and then uphold that promise. If a patient asks you to stop what you are doing, stop immediately, no matter how close you are to the end of the exam or procedure, and wait for permission to continue.
4. Offer a chaperone
Regardless of your gender, offering a chaperone during breast and pelvic exams can help patients feel more comfortable. However, be aware that while some people may feel more comfortable with a chaperone in the room, others may feel less comfortable having anyone in the room other than the provider—it’s the offering that’s key! Additionally, if you work with learners, like students or residents, it is essential that you ask for permission to have them present for or participate in the exam. Asking for permission BEFORE the learner or chaperone comes into the room gives the patient permission to decline without having to say it in front of that person.
5. Stop if your patient says “no”
If your patient says “no” to an exam, it is essential to respect their decision. That means you don’t proceed with an exam until you have consent, and you don’t pressure your patients into giving consent. Carefully consider how much information you will be getting from your exam, and, if it is reasonable, create a plan of care without it. Pressuring patients into giving consent or proceeding without it isn’t just counterproductive to establishing trust, it’s a violation. A good next step is exploring the patient’s concerns by actively listening and using open-ended questions. Perhaps they are worried about a prior negative experience or maybe they are simply worried about how much something will cost.
6. Consent applies to birth control too
Respect your patient’s decisions about their contraceptive choices. What matters most is not what you think is the “best” choice for them but what they think is best for them. (If that strikes a nerve for you, you may want to spend some time thinking about why you’re having trouble respecting this particular patient’s decisions. You may want to look into implicit bias.) Realize and respect that the factor patients feel is most important in their method may not be its effectiveness, and that pregnancy desires vary widely (and include ambivalence).
Respecting patient autonomy is particularly important with methods that have to be removed by a provider, like IUDs and the implant. Providers should remind patients that they can choose to have these methods removed at any point for any reason (or no reason at all!). And if a patient wants a method removed, it is your obligation to remove it without any unnecessary delay.
7. Always get consent for an exam under anesthesia
Obtaining explicit consent for any pelvic exam while under anesthesia is crucial to ethical care. It is essential to discuss the reason for performing a pelvic exam while under anesthesia, who will be present, and who will be participating in the exams and procedures. If you have a learner who will be performing an exam it is essential that they meet the patient before induction of anesthesia and that you have explicit consent for your student to perform an exam.
Respecting our patients by prioritizing communication and explicit consent in the exam room strengthens the patient-provider relationship and ultimately improves health. (It’s also the right thing to do!) When we respect our patients and their choices by advocating for consent and encouraging participation in exams and care plans, we are reinforcing that they have the right to speak up and to be heard. And when patients feel heard and respected, they are more likely to come to us when they need our help instead of avoiding getting care.