The recent cases of Dr. Lawrence G. Nassar, the physician for the U.S. women’s gymnastics team, and Dr. George Tyndall, the gynecologist at the University of Southern California student health center, involve allegations that they inappropriately touched young female patients, often while doing a pelvic exam. Here’s what women should know about gynecological exams, including what to expect and what is out of bounds.
What happens during a routine gynecological visit?
Gynecological visits cover a wide range of topics, especially because many women do not regularly see any other physicians. “For most women, I am functioning as a primary care doctor,” said Dr. Iffath Hoskins, a clinical professor and director of safety and quality in obstetrics and gynecology at New York University. “A gynecology visit is much more than putting fingers in the vagina and doing a Pap smear. I want to make sure you’re O.K. overall before I make you take your clothes off.”
So, questions may go well beyond the gynecological. Dr. Hoskins asks about domestic violence, social habits, drinking and smoking. (“When a patient says ‘I only drink one or two a week,’ I double it,” she said.)
Doctors will ask about any genital pain or problems, and depending on circumstances, about menstruation, sexual activity or birth control. The topics discussed vary, depending on the patient’s age and experience. Teenagers who are not sexually active usually don’t need screening for sexually transmitted diseases. Women under 21 do not need invasive vaginal exams unless they have specific conditions or medical risks.
Doctors might perform a Pap smear, which is a test for cervical cancer. The patient lies on her back, places her feet in supports called stirrups and the doctor inserts a speculum to keep the vagina open enough so that a swab can be inserted to scrape a small sample of cells from the cervix. Pap smears used to be done annually, but guidelines now recommend them for women age 21 and older every three to five years. A breast exam might also be done.
Sometimes, but not always, gynecologists conduct a pelvic exam, which is usually the most uncomfortable part for patients. A doctor uses a speculum to examine the vagina and cervix and then places fingers of one hand inside the vagina and presses on the abdomen with the other hand. It’s intended to assess whether the uterus, fallopian tubes, ovaries and cervix are of a healthy size and position and an attempt to detect ovarian or other cancers.
When should gynecologists perform pelvic exams?
They are definitely not necessary for every patient. In fact, the American College of Physicians recommended in 2014 that pelvic exams not be done on nonpregnant women who show no symptoms of gynecological problems. That report found no evidence pelvic exams were better at detecting ovarian cancer than ultrasounds or blood tests, and slim evidence of success detecting other conditions like bacterial vaginosis. And it said some patients experience effects like embarrassment or anxiety and sometimes don’t return for another visit if the pelvic exam caused pain.
The American College of Obstetricians and Gynecologists recommends pelvic exams for women 21 and older, even if they have no symptoms. But it says the exam is unnecessary to screen for sexually-transmitted diseases, which can be done with vaginal swabs or urine tests. And it isn’t needed unless a woman has begun taking oral contraceptives. Hormones from birth control pills can affect the vaginal lining and the cervix, and a pelvic exam can identify those effects, said Dr. Hoskins, who is also chairwoman of A.C.O.G.’s New York State district.
She also does pelvic exams on women who engage in “risky behavior” like “if she’s telling me, ‘On weekends, I go to parties and I have multiple partners,’” Dr. Hoskins said.
What kind of touching is appropriate during a gynecological exam?
“Only the necessary amount of physical contact required to obtain data for diagnosis and treatment,” said A.C.O.G’s ethics committee in guidelines it issued in 2007 geared toward preventing sexual misconduct. Also, “appropriate explanation should accompany all examination procedures.”
Dr. Tyndall is accused of using his hands instead of a speculum to examine patients and moved his fingers in and out during pelvic exams.
Using hands might not always be a problem, said Dr. Isaac Schiff, a former chief of obstetrics-gynecology at Massachusetts General Hospital. “There are some cases where you might use your hands instead of a speculum,” like checking on, “a 70-year-old woman who tells you she has difficulty with bladder control,” he said. But “you’re not to move your fingers in and out.”
The key is to “do the business you went in for and that’s it,” said Dr. Hoskins. “When I go to get my hair cut, I don’t expect her to massage my shoulders or anything like that.”
She added: “Any time you’re touching a patient you’re going to tell her, ‘I’m going to be touching you. I’m now going to examine this part of your tummy, or I’m going to touch the inside of your thigh.’ Your first step is never to put your fingers inside her vagina.”
Dr. Hoskins said that if patients think a doctor is doing something out of the ordinary, they should not hesitate to ask the doctor about it.
Should the doctor be alone with the patient?
This should be up to patients and physicians, experts say. “The ideal is that nobody should be alone in the room with an undressed patient because anybody can feel they were taken advantage of verbally, physically,” Dr. Hoskins said. “A second person in the room will be a pacifier to the patient and the doctor.”
But in reality, other staff members aren’t always available. And sometimes, patients request to speak only with the doctor, feeling more comfortable discussing personal issues one-on-one.
Dr. Hoskins said she tries to ensure a nurse or other medical colleague is present when patients are undressed or in otherwise vulnerable situations.
What kinds of comments are appropriate for doctors to make to patients?
“Physicians should avoid sexual innuendo and sexually provocative remarks,” A.C.O.G says.
“It’s a very serious exam,” Dr. Schiff said. “It’s a very private exam. It ought to be purely at the medical level without the editorial or description.”
Some patients have said Dr. Tyndall told them they had “perky breasts,” “flawless skin” or an “intact hymen.”
Dr. Schiff said, “saying perky breasts, it’s offensive,” and “I don’t know why he would have said it.” Other comments might be more understandable. Describing the condition of a patient’s muscle tone might be appropriate if she came in “complaining about bladder control,” Dr. Schiff said. “You might say the woman has good tone.”
Dr. Hoskins said most gynecologists are trained to do most of their talking when patients are fully clothed and sitting up.
“If you’re in the middle of a pelvic exam when you’re naked, I may say, ‘Your hymen looks fine, your labia looks fine.’ There’s nothing wrong with that. I can say, ‘Your breasts look fine,’ but I don’t have to say they look perky.”