August 31st, 2016

Why Men Shouldn’t Have to Do Pelvic Exams

Scott Cuyjet, RN, MSN, FNP-C, practices adolescent medicine in the San Francisco Bay area.

Scott Cuyjet, RN, MSN, FNP-C, practices adolescent medicine in the San Francisco Bay area.

I want to be totally honest up front and say that my real motivation for this blog post is that I don’t want to do any gyn/vaginal exams. I am uncomfortable doing something so intimate on a patient. After the exam, we would both know I had looked at, touched, or been inside the patient’s vagina. It is not that I cannot do the exam: I have been trained, practiced on the professional gyn models, and practiced on some patients, but that was a long time ago, and like the medical student in this GomerBlog article, I have avoided it ever since. I am bringing it up now because due to a personnel change in our practice, I have been asked to consider performing vaginal exams. It would also be helpful if I were trained to insert and remove intrauterine devices.

I work with adolescents age 12-25 and I have seen — or projected — discomfort in their eyes and in their body language when I have brought up even the notion of future Pap smears or vaginal exams. Even if they are not uncomfortable, if I am, they will pick up on that, which may make them uncomfortable.

pregnancy-MD001285The current Pap recommendations are to start at 21 years of age and, if negative, repeat every 3 years until age 30, and then repeat every 5 years. Women also need pelvic exams if they have a growth in their genital area, a change in vaginal discharge, a change in smell emanating from the vagina, genital itching, painful intercourse or abdominal pain. Until now I have been able to defer this practice to a female provider in our clinic, but with the recent decrease in our providers, this may change. I and other males may be perfectly capable, but historically, and in other countries, it is an exam done by women such as midwives or female OB/GYNs.

To avoid doing pelvic exams, I have had some patients do self-swabs, have switched patients with another provider, or have had patients come back to see a different provider. One of the reasons I feel I should not have to do these exams is that there are plenty of female providers (although some may be opposed to doing them as well). According to this article from the McGill Journal of Medicine, 58% of U.S. medical students are now women, up from 9% in the 1970s, and 72% of OB/GYN residents are women. That same article cites a study at one hospital showing that only 32% of high school students would accept an intimate examination by a medical student of either gender. In addition, 22% of clinic patients overall – and 55% of high school students — said they would accept only a female student.

Part of my apprehension is that, according to the National Sexual Violence Resource Center, 25% of girls will be sexually assaulted by their 18th birthday, and according to the Rape, Abuse, and Incest National Network, 54% of sexual assault victims are between the ages of 18 and 35. I don’t want to remind patients of such trauma, even though the exam could be a positive experience through demonstration of consent and empathy. During my clinical rotations, I was overly gentle when doing pelvic exams specifically because I am a male and will never know what it is like to have one done on me. This is also mentioned in the McGill article when the authors state, “In fact, men might even have a heightened sensitivity about the distress that a gynecological exam can cause as they themselves have never undergone one. Something as routine as a Pap smear can be a really difficult experience for some women, and some men might go more out of their way to be gentle and explain what they’re doing than female gynecologists, who may feel it’s not that big of a deal because they’ve been through the process themselves.” That being said, I still don’t want to perform these exams.

Lastly, most of the women I know as patients and personally do not like having pelvic exams done, as they are awkward and uncomfortable.

 

32 Responses to “Why Men Shouldn’t Have to Do Pelvic Exams”

  1. max voysey says:

    I think this could be the same as any procedure . . . . It is reasonable for any practitioner at any level to decline the procedure, as long as they provide timely and reasonable alternatives. If the patient demands it, you should point to your waiting room practice policy statement and apologize that due to your low waiting times and highly efficient practice model your patient may not have had time to read it!

    • Scott Cuyjet, RN, MSN, FNP-C says:

      Max,

      Thanks for reading and for taking the time to respond.

      I agree that it could apply to other procedures as well.

      Scott

  2. Lmw says:

    This is ludicrous. Not wanting to do an exam because of your inexperience is one thing and your gender is another. As a male OBGYN that performs pelvic exams routinely I would have to warn against applying statistics to justify why you feel insecure as a provider in caring for your patients. Pelvic exams are of great utility and aren’t only able to be comfortably done by a female.

    • Scott Cuyjet, RN, MSN, FNP-C says:

      Lmw,

      Thanks for reading and responding.

      I am curious…can you and do you do everything as a provider? Our provider who left also used to do toenail removals, but none of the remaining providers are taking that on. We refer those patients to podiatry. Many general practitioners refer their pelvic exams to a GYN.

      Scott

  3. Sara Sherman-Levine says:

    Very interesting perspective, Scott. As a female NP (who, incidentally, worked in adolescent medicine for nearly 5 years) I never considered that male NPs would experience trepidation at performing pelvics. Simply, it never occurred to me! Thank you for writing about his and providing opportunity to hear your interesting point of view.

    In the nearly 40 years I’ve been an adult, I’ve had both male and female OB/GYN providers. My first pelvic occurred at age15 by a male physician at Planned Parenthood in Southern California. That experience was profoundly disturbing. Not because the provider was male – but because the situation was rushed and the process was explained very poorly to me. (The MD and his RN stated they were required to do a pelvic to measure me for a correct-fitting diaphragm. But they didn’t explain what a pelvic entailed, so I was shocked to find myself legs akimbo on an examination table with instruments and hands inside me.) After the exam, I found myself trembling uncontrollably as I dressed; I felt completely violated. In fact, I remember thinking to myself: “I bet I can do that exam better than they can.” That thought diminished as soon as I left the clinic … but fast-forward 24 years and there I was doing 5-6 pelvics a week in my NP practice to teenage patients exclusively. The difference: the clinic where I worked was teen-oriented and because of that allowed all the time necessary to complete the entire process, including building trust via sufficient explanation. Planned Parenthood, circa 1975, was set up differently; it was not teen-oriented.

    An experienced adolescent provider that you are, you’re keen on teenagers having “BS” meters that pick up on people’s true feelings. If you exude a degree of ambivalence toward any procedure, your patients will feel it too. I support your decision to eschew performing pelvics. I just hope the management of your operation agrees and supports your decision as well. I believe a teen will be happier to have the exam performed by somebody who feels comfortable and will be willing – happy even – to return to the clinic for a future appointment as long as it’s with the right provider.

    • Scott Cuyjet, RN, MSN, FNP-C says:

      Sara,

      Thank you for reading the blog and taking the time to write a thoughtful and personal response. I appreciate that you have a good insight having worked with the same population vs. working with an older population or a strictly GYN population.

      Scott

  4. Margaret A Conte says:

    So women physicians should not do genital and rectal exams on men? Might I remind you that just a generation ago that men were the only GYN providers. With sensitivity and tact I believe that we can do such intimate exams on men and women no matter what our gender as providers

    • Scott Cuyjet, RN, MSN, FNP-C says:

      Margaret,

      Thank you for reading and taking the time to reply.

      I am saying that people need to look at their population, the comfort level of their patients and themselves when considering their practice. I wonder how many providers refer their female patients to a GYN vs. the general practitioner doing the exam themselves?

      Scott

  5. Abdulrahman says:

    What a narrow minded idea you are providing. We are in the 21st century and this is totally against modernisation and honesty of thinking ( this would have been the reaction to this noble and natural expressing of opinion by the author, had been this opinion presented by an Arab or a Muslim scholar – totally agree with your experience and support your approach even been from a different culture).

  6. Dr. J.M. Krick says:

    Perhaps you’re not suited for the practice of medicine. Of course women and men are uncomfortable with genital exams. Women PA’s in my urology practice do male genital and rectal exams every day because that is the nature of our practice. The acceptance of the patient stems from the provider’s level of professionalism and confidence in addition to his or her empathy towards the patient.

    • Scott Cuyjet, RN, MSN, FNP-C says:

      J.M.,

      Thank you for taking the time to read and respond.

      Your female providers do male genital exams cause they work in urology. I am not a GYN but a general practitioner. How many of your patients are referred to your practice because a general practitioner sent them not for follow up to a positive exam, but because they don’t do the exam?

      Scott

  7. Chris Walker, MD says:

    This is one of the most dissapointing opinions in medicine that I have ever read. Only a child thinks they shouldn’t have to do something because they don’t want to. The gyn exam should never be ignored. There are fatal diseases that stem from the female reproductive system that can be detected with such an exam. Could you face the family of a young woman who died from an ectopic or untreated PID and tell them… I didn’t do the exam because it makes me uncomfortable??? Shame on you for displaying discomfort with the female reproductive system while taking care of teenagers. Teens already have enough body issues without adding your unprofessional awkwardness. There are a lot of things doctors have to do that we don’t enjoy, if you want to practice medicine like a doctor you need to toughen up.

    • Scott Cuyjet, RN, MSN, FNP-C says:

      Chris,

      Thank you for taking the time to read and reply.

      This has nothing to do with your a doctor and I’m a nurse practitioner. As a general practitioner, I am not a GYN, I cannot do everything and so have to refer to other providers. Ask a GYN how many pelvic exams or PAPs are referred to them cause a GP does not do them or have time to do them. Our provider who left also used to do toenail removals, but none of the remaining providers are taking that on. We refer those patients to podiatry.

      Scott

  8. LE Vaughan,MD says:

    The problem here is that you are treating a newly sexually active group of patients. Vaginal and pelvic exams are an absolute necessity!
    Get over your squeamishness, young man… Your job is to provide the best and most thorough care for these kids. ‘Self swabs’ and rescheduling them to come back to see another provider is not the best care you can provide.
    You absolutely need to change your specialty if you are unwilling to provide this basic and necessary service to your female patients. They deserve better.

  9. Ms T. says:

    Hmm. Glad you feel free to say your opinion but this is just plane ridiculous. Saying pelvic exams make you feel squirmish makes me feel sorry for your patients in general. When you decided to be FNP, I’m not sure what you thought you would be doing. Do everyone a favor and perhaps go work in urology or somewhere where you will have mostly male patients. I’m honestly not sure why you decided to write this blog. Seems pointless to me. If as a ‘provider’ you are not able to separate yourself from the procedure, then maybe you should find your missing curriculum. Good luck

  10. Doug S. says:

    Have you considered choosing a different specialty? Seriously. Women’s health is a pretty large part of adolescent medicine. The way you describe the exam (being “inside” the vagina??) is off-putting at best. If you are unable to overcome your own awkwardness regarding female anatomy, perhaps it’s time to switch specialties and do your patients and colleagues a favor.

  11. Naeemah Ghafur, MD says:

    Before women were nearly 50% of the physician workforce who do you think did all pelvic exams? Female nurses and midwives? No Sir. Who were the OBs and Gyns?
    Perhaps you should do male STD clinics? Or work only with male patients? Because your reasoning is flawed and you do a major disservice to not only the physicians you are supposed to be assisting but to your female patients and yourself.
    I honestly can’t believe you posted this on the Web and that NEJM was okay with that.

  12. JG says:

    OB/GYNs are not the only group of healthcare providers qualified to do pelvic exams. Internal Medicine, family practice, emergency medicine, peds are just a few that are expected to be able to do these exams, as a fnp wasn’t it part of your training to be able to do these exams, as an internal medicine physician we were required to know how to do pelvics and paps. The fact you work in an adolescent clinic and don’t feel comfortable doing the exam should be a sign that perhaps you should work elsewhere.

  13. Appalled says:

    You made a reference to a GomerBlog article, I hope you realize that’s a satirical blog.
    I practice medicine and work with several outstanding male and female NPs who have never dumped a pelvic or male genital exam on me regardless of patient age. That’s because they are professional and they want to do a thorough job of ruling out life threatening conditions that pertain to the reproductive system in the appropriate cases.
    I would agree with you that most women do not like pelvic exam, I’d add that most males don’t like to have prostate exams, but that’s not an excuse to neglect an important exam that could reveal important pathology.

  14. Jennifer Nizen MD says:

    This is unprofessional and immature and truly disappointing to read. The pelvic exam is standard preventive care for women. Calling the exam intimate is equating it with a sexual act. If you are uncomfortable doing examinations that are within your specialty scope of practice and needed by your patients to maintain their good health you are not doing your job and should find a different specialty or career.

  15. Peds Doc says:

    (typos edited)

    As a medical student I had to perform rectal/prostate exams on male veterans at the VA. I didn’t use the excuse that I am small and have small hands, that I am a woman, or that any of my patients might have been raped/abused in combat or elsewhere, to get out of doing these exams. Also as a student it was my job to insert Foley catheters, regardless of gender. At that time, they were my patients and it was my job to care for them.

    While I can understand your being uncomfortable with possibly triggering unpleasant memories in a female patient, I don’t agree that you should not be able to provide care for any patient who walks through the door. What if there are no female physicians/NPs/PAs available at the time? Will you force your patient to wait unnecessarily, either later in the day or for an entirely different day?

    What will be your liability if you choose not to see the patient and there is something severely wrong that is worsened by this delay? Having a patient do a self-swab sounds dangerous and borders on malpractice. What if the girl/young woman perforates her vagina, uterus or rectum? Who is responsible for that? You, or your collaborating physician? If you have a collaborating physician who would then be responsible, how is that fair?

    If you didn’t want to provide basic primary medical care to basically half of the world’s population, you maybe should have considered a different field. Like, not adolescent medicine.

  16. Mary Cairns MD says:

    I appreciate the discussion this has raised, as well as the clear message and tone of the article. I feel compelled to express the following:

    1. A pelvic exam is an exam, not a procedure. Women’s health exams are a core-component of a family medicine provider’s scope of practice. Toenail removals and IUDs, while optional procedures for a FM provider, are not.

    2. Scope of practice is a very complex concept. I base my scope of practice on those things I can competently and safely perform, not those things that make me feel awkward. Limiting scope of practice based on “comfort” should be judiciously applied, ideally in the context of examining our own counter-transference and anxiety. Going to such great lengths to avoid something due to discomfort or anxiety could, depending on the context, be defined as a phobia.

    3. Discomfort and awkwardness are inherent qualities to any provider-patient encounter and indeed, one could argue, the human condition. As example, most providers find rectal exams to be somewhat uncomfortable and awkward. Thus evolved the old adage “the only excuse for not performing a rectal exam is if the pt doesn’t have a rectum or the provider doesn’t have a finger.” Couldn’t this easily be applied to a pelvic exam from a family-medicine certified provider? “The only excuse for a FM trained provider not being willing to perform a pelvic exam for acute vaginal concerns would be patient refusal or lack of a vagina?” I find myself wishing this article had been titled this “why I’m uncomfortable doing vaginal exams” instead of “why men shouldn’t have to do pelvic exams.” Many of the cited articles and/or justifications remind me of reasons a person might give, not for defining scope of practice within a specialty, but rather for choosing specialty to begin wtih i.e. “I chose internal medicine because I didn’t want to treat children” or “I became a pathologist because I didn’t enjoy direct-patient-care as much as I expected.”

    4. Patients will generally self-select for people who they don’t want to treat them. My male husband (FM physician) has fewer pts schedule with him for annual well-woman exams then I (a female) do. Part of medicine is treating the person that comes to you, especially in a primary care clinic. This may sound inflammatory, but one could use most of your same arguments to say white people shouldn’t have to treat black people, or heterosexual providers should not have to treat homosexual patients, if personal preference (with various justifications about “discomfort” and “plenty of other providers who are willing”) are enough.

    5. If a women is having vaginal discomfort and needs treatment, standard of care is to do a pelvic exam. It is not to refer and delay treatment while she waits to see another provider. It is not even (though variations of this may be commonly practiced in ED settings) to empirically treat without some degree of workup and narrowing the ddx.

    6. Family medicine is an excellent specialty for providers interested in working with adolescents. Our “Cradle to Grave” training positions us to assist w/ healthcare through life transitions. Fundamental aspects of adolescence include sexuality as well as learning to take increasing amounts of ownership into self-care and interacting independently with the health care system. It makes me sad to hear that not all FM trained providers (of all training backgrounds) feel the same since of humanistic obligation to our specialty’s identity and purpose as “Gatekeepers.” Women’s health, including pelvic exams, is a core component of such gatekeeping (see classic BMJ article below).
    http://www.bmj.com/content/298/6667/172

  17. Dr L says:

    Perhaps find a new line of work or retraining in how to perform these exams if you are uncomfortable performing certain aspects of care. Your patients deserve better. Instead of having a provider they theoretically know and trust perform a sensitive exam you send them to someone else? Really?

  18. John B. says:

    Very interesting article! The citation from the McGill Journal of Medicine by Dr. Balayla is one of the best articles on the subject, Great read!

  19. Brian Elkins, M.D. says:

    Performing pelvic exams and Pap smears is a basic part of the comprehensive primary care of young adult women. If you can’t comfortably provide that service, perhaps you should limit the adult portion of your practice to young men. But the real issue is that you have not worked through your own discomfort with the procedure, and you are correct that patients pick up on that rapidly. All of us who provide this service have had to work through the issues of being able to do what is needed in a professional, competent, compassionate manner. That is a basic part of being a health care professional: putting the patient’s well-being first, and growing in our professional ability to do so confidently. Young women who have been sexually abused or assaulted may be uncomfortable with the exam and may decline, and in such a case we should be compassionate regardless of whether the patient accepts or declines the exam; but it is our responsibility to at least offer the appropriate care, not fail to offer or perform it because some will be afraid of it or decline. Your job is to help them feel more comfortable, and to do so you must grow in your own comfort with this aspect of care, not give up because you are uncomfortable.

  20. Andrew McWilliams, MD says:

    I am loathe to pile on more criticism of the author here -who stated at the outset that they were attempting to be honest about their perspective (something many would attempt to hide behind rationalizations and excuses). That said I have to agree with the above comments that this position is unacceptable in a medical practitioner of any gender or with any degree. We treat people, period. And we go where their pathology may be without genuflecting to societal taboos or hangups. This has always been an essential part of medicine. Yes, talking about or showing your genitals to another person may be uncomfortable, but a doctor has to be different and has to have and display the emotional courage and confidence to overcome the social awkwardness of full exposure, physical or otherwise.
    And as an ER doctor I wish to point out another aspect of this:
    when some providers start violating the social norm that any doctor can and should examine and treat any patient regardless of gender, religion, race or sexual orientation it makes it that much more difficult for those of us who don’t have a choice.
    At 3am when I am alone in the ER and a woman comes in with vaginal bleeding, I don’t have a choice about who does her pelvic. It only makes things harder if she has become used to outpatient providers bowing to her reflexive discomfort and finding a female pinch hitter.
    This is a slippery slope that none of use should start down it. When you are wearing the white coat you have to act as if you are a doctor -not a man or a woman, white or black etc.

  21. John Cooper MD says:

    When I was in medical school my father who was a general practitioner supplied me with an important adage: “If you don’t put your finger in it, one day you will put your foot in it.”
    One of my patients died from metastatic malignant melanoma that began on the inner aspect of one of her thighs. She had selected a specialist for her GYN care who was oblivious to the enlarging, hyperpigmented skin lesion.

  22. archie b says:

    Scott,

    Disregard all these negative comments and thank you for being a rational thinker. What YOU realize than most here do not, is that despite your training, how YOU (the physician, nurse, etc.) view a PE, the patient has none of your training and will view it very differently.

    All these people posting negative comments here have no problem with PEs because they are the ones who are keeping their clothes on.

    Let me point out further proof that they are wrong. One referenced:

    Thus evolved the old adage “the only excuse for not performing a rectal exam is if the pt doesn’t have a rectum or the provider doesn’t have a finger.”

    Let me give another reason: NO EVIDENCE. American College of Surgeons (ACS) who developed the Advanced Trauma Life Support (ATLS), dropped the DRE from ATLS in 2009. (Reference: http://commons.pacificu.edu/cgi/viewcontent.cgi?article=1139&context=pa)

    The prostate exam (DRE) is has been dropped by the USPSTF due to lack of benefit and increased harms.

    Your last line points to the major problem with PEs (as well as many other intimate exams). You stated:

    “Lastly, most of the women I know as patients and personally do not like having pelvic exams done, as they are awkward and uncomfortable.”

    The issue is consent. You fail to touch on that and even allude to how these are “pushed” on patients (many times through coercion). Here is proof: A 2013 study found that nearly 33% of ob-gyns and family medicine physicians, AND 45% of advanced practice nurses in primary care reported always requiring a pelvic examination when prescribing oral contraception when one was NOT REQUIRED! (PubMed source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3745305/ )

    Consent in pediatrics is even worse. How often does the practitioner say that they “need to do it” or one is required.

    Let me give another example: Sports physicals. Both men and women can get an inguinal hernia, yet ONLY MALES are screened for sports participation physicals? Is not the aim of the PE to determine if the person can play sports? An inguinal hernia does not preclude someone from participation. (Reference: https://books.google.com/books?id=w6FSamw-7_AC&pg=PA159&lpg=PA159&dq=inguinal+hernia+does+not+preclude+someone+from+participation&source=bl&ots=DjARoDVD86&sig=CLLwJuTIf-YtgX1_nN_ILMKvBRU&hl=en&sa=X&ved=0ahUKEwj1qeXkqaHPAhVMMz4KHQwaCo0Q6AEIHDAA#v=onepage&q=inguinal%20hernia%20does%20not%20preclude%20someone%20from%20participation&f=false)

    NCAA dropped the hernia requirement in the NCAA 2008-09 Sports Medicine Handbook. (Reference: https://www.ncaapublications.com/searchadv.aspx?IsSubmit=true&SearchTerm=MEDICINE ) Yet, organizations like the AAP continue to push this for “males only.”

    What you have not addressed either is if a patient who trusted you wanted a PE. I am sure that you would be more comfortable doing one if you had that relationship that built trust of the patient.

    I would love to hear your comments about consent. I believe that that is the bigger issue that you are dealing with. And yes, consent is a problem for providers when it comes to PEs. I am talking about the practice of teaching PEs on anesthetized women, an issue first brought to light in 2003. (Sources: http://www.ncbi.nlm.nih.gov/pubmed/14640251 , http://www.ncbi.nlm.nih.gov/pubmed/16206868 , http://www.ncbi.nlm.nih.gov/pubmed/16471023 )

    We were still having this conversation in 2012! (Source: http://www.ncbi.nlm.nih.gov/pubmed/22996113 )

    You are a much better and more compassionate practitioner of the healing arts than most.

  23. Elizabeth Smith MN, FNP-BC says:

    Scott,

    While I appreciate your honesty, I have to agree with most of the other comments: you simply can’t choose not to do an examination because you’re uncomfortable! It’s unethical and very bad medicine. Especially if you work with adolescents you have to be competent and skilled at discussing/examining/treating most everything to do with the human reproductive system. Aren’t you forgetting that a pelvic exam may be necessary in evaluating lower abdominal pain? I’d hate to be the practitioner who missed PID because I didn’t want to check. My best advice: spend some time training at your local Planned Parenthood. You will learn more than you ever thought, and you’ll become comfortable in talking to girls and women about this aspect of their health.

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