When Ari Silver-Isenstadt was attending the University of Pennsylvania Medical School in the 90s, another student warned him about something that might happen during his OB/GYN rotation: A supervising surgeon might ask him and other students to perform a pelvic exam on a woman under anesthesia without her knowledge or explicit consent. The move would be just for practice and not for her medical benefit. To perform the exam, students insert two gloved fingers into the patient’s vagina and place one hand on her pelvis in order to feel the uterus and ovaries. Multiple medical students might do this, and patients would have no idea any of it happened.

The practice of using non-consenting, unconscious patients as pelvic-exam training tools for medical students has continued to an unknown degree across the country since Silver-Isenstadt, now a pediatrician in Baltimore, first learned about it. It happens not only during gynecological surgeries, but also in the midst of unrelated procedures like stomach surgery. As a student, Silver-Isenstadt was ready to avoid doing such an exam at all costs, and his refusal became part of a movement to end the practice—an effort that would ultimately lead to statewide bans, first in California in 2003, then in Illinois, Virginia, Oregon, Hawaii, Iowa, Utah, and Maryland.

While some individual medical schools like Harvard ban it, the practice remains legal in 42 states. For some current medical students—like Savanah Harshbarger, who enrolled at the Duke University School of Medicine in 2016—these pelvic exams are still routine. “I estimate that I did about 10 of these exams last year,” she said.

There is no federal legislation regarding unauthorized exams. Despite people being concerned about the ethics of the practice for decades, this issue hasn’t garnered sustained national attention. But in the #MeToo era, that may be beginning to change.

“I estimate that I did about 10 of these exams last year.”

In 2007, Ashley Weitz was admitted to the hospital in Utah for extreme nausea, and her doctor anesthetized her when other treatments weren’t working. Weitz, who is a rape survivor, woke up to find the doctor examining her genitals, and began screaming. But it wasn’t until years later, when she learned about the movement against unauthorized pelvic exams, that she realized it was ethically wrong. “Not only did this feel like a violation, it absolutely was a violation,” Weitz said.

Weitz said testifying about her experience in support of Utah's law in February was nerve-racking, especially because she expected there to be other women at the hearing at the state house with similar experiences, but she was the only one. Given the nature of these exams, people don’t know if it's happened to them. She said it was “a very healing practice to say 'this shouldn't happen to me, it shouldn't be happening in the way that it is happening in an institution.'” But there are still parts of the incident that she hasn’t recovered from. “It changed the way that I sought and received medical care,” she said. “I was, you know, thereafter very certain that I was never going to be sedated or unconscious in a manner that would have allowed that situation to happen again. So it was in itself very traumatizing.”

Utah's ban, which requires both medical students and doctors to get specific consent to perform pelvic exams on anesthetized women, was signed into law at the end of March. Its success seemed to hinge entirely on Weitz's testimony, said Robin Fretwell Wilson, a law professor at the University of Illinois who specializes in medical ethics and advocated for the bill’s passage. Wilson herself has been pushing to stop unauthorized pelvic exams for nearly two decades, and has been an influential player in the passage of the early handful of laws banning it.

Wilson first heard about it when she was on a statewide ethics committee for medical schools in South Carolina and a medical student came to her about the practice. "I thought, 'Surely, no, there's no way that anybody is going to teach abnormal or normal anatomy by using patients without asking them.' And so we start digging behind it. And it turned out in fact, they were, and they weren't even very embarrassed by it."

In the early 2000s, Wilson investigated the practice for the Federal Trade Commission (FTC). Opponents of the bills say the general consent forms patients sign when they enter teaching hospitals should be enough, but advocates want specific consent for pelvic exams done for educational purposes. Professional groups agree that it's ethically wrong to use unconsenting patients to practice procedures that don’t benefit them.

"I thought, 'Surely, no, there's no way that anybody is going to teach abnormal or normal anatomy by using patients without asking them.' And so we start digging behind it. And it turned out in fact, they were, and they weren't even very embarrassed by it."

Just this year, Wilson said, bills banning unauthorized exams have been introduced in 11 states: Connecticut, Maryland, Minnesota, Missouri, Nebraska, New Hampshire, New York, Oklahoma, Washington, Texas, and Utah. (New York's bill would also ban rectal or prostate exams done without explicit consent. Like unauthorized pelvic exams, there haven't been studies estimating the frequency of similar rectal or prostate exams, but there is anecdotal evidence that they occur.) Wilson said although she’s been denouncing this practice for decades, she’s “elated” that things finally seem to be changing.

The #MeToo movement has helped people like Weitz better understand that the violations they endure are part of a wider cultural problem. Arthur L. Caplan, the founding head of the division of medical ethics at NYU School of Medicine, believes that #MeToo, along with other cultural shifts, has helped draw attention to the fact that these unauthorized exams are still happening.

Last May, Caplan wrote an op-ed condemning the practice after a medical student reached out saying he’d been asked to do such an exam—Caplan was surprised the practice was still occurring. Since his op-ed, Caplan said he's received emails from a few other students in different parts of the country who said they’d also been asked and were dismayed. (He notes that NYU's policy is to obtain consent or use paid subjects.)

The fact that students speak about these exams at all marks a change, Caplan said. “They felt more empowered to say 'this isn't good.'” He said medical school is “a little less hierarchical, a little less tyrannical than it was.” Caplan thinks this change coincides with an increased focus on medical ethics across the country. While in the early 90s, when Silver-Isenstadt was a medical student, one third to half of the schools had a required medical ethics program. Almost every medical and nursing school has one now, Caplan said—but students are still likely to feel pressure to keep quiet.

Silver-Isenstadt works with medical students at teaching hospitals, and said he’s also noticed a change in their attitudes as more bans are introduced, including in Maryland, where he works. (He is a professor of clinical pediatrics but isn't cleared to speak on behalf of his affiliated universities.) While he had always been careful to work with his students to “vaccinate them against getting trained in a way where they think they have a right to another person’s body,” he said that, just in the last six months or so, students have started to tell him that his lessons are “idiosyncratic.” They insist unauthorized pelvic exams aren’t something that’s done anymore, while before, many of the students he pulled aside told him they'd already had to do it.

On the other hand, some medical students, like Harshbarger, don’t see this as a big ethical issue. She said students at Duke feel comfortable debating practices like this, but it still doesn’t come up much. “To the contrary, joining the field of medicine feels somewhat like joining a secret society—there are things we see, hear, touch, and smell that are foreign or unimaginable to most people in the outside world, things that stay with you, things that each of us carry around daily. Medicine has its own rules, hierarchies, and principles, and the practice of pelvic exams performed under anesthesia appears to be very far down on the list of things that meet the threshold for conversation, both in terms of morality and notability,” Harshbarger said. She added that she does think informed consent forms should be clearer about the specific things that might happen to patients.

It's clear that it's still happening, but there’s little recent research to show how common this practice is across the country. The data we do have comes largely from the era when Silver-Isenstadt first began grappling with this issue 20 years ago.

"Joining the field of medicine feels somewhat like joining a secret society—there are things we see, hear, touch, and smell that are foreign or unimaginable to most people in the outside world."

After the day a classmate told Silver-Isenstadt he might be pressured to do an unauthorized pelvic exam, he began behaving in a way that could have cost him his degree: He started showing up late to OB/GYN surgeries and procedures on purpose. If he wasn't in the room when the directive was issued, he wouldn't have to comply. Life in medical school was regulated by a strict hierarchy and philosophy—doctors determine students’ grades, which can affect where they get placed for residencies—and Silver-Isenstadt had no desire to actively challenge that structure. He just hoped he could keep his head down and make it through without having to do something he considered morally compromising. His perspective was heavily influenced by his wife, Jean, a doctoral student in history and sociology of medicine at the time, who "help[ed] me have sort of a meta view of my own training."

But of course, people noticed that he wasn’t showing up to surgeries on time. He had to meet with the dean, and they eventually came to a deal. In exchange for Silver-Isenstadt not exposing the school to the Philadelphia Inquirer, he would be allowed to graduate without performing the exam. As part of the arrangement, he also took a year off to study the ethical implications of practice at Penn’s School of Education—and that work would later become part of a nationwide push to stop unauthorized pelvic exams in teaching hospitals.

The study he subsequently conducted at five Pennsylvania medical schools made waves after it was published in the American Journal of Obstetrics and Gynecology in 2003. News outlets jumped all over the statistic that more than 90 percent of students surveyed had done such an exam. Silver-Isenstadt also asked students how they felt about this practice at different points throughout medical school and demonstrated that, while at first they were uncomfortable with it, they eventually became used to the idea.

Lawmakers noticed. Some of the first states to enact bans cited research including his 2003 paper. Illinois passed a law in 2004 but since then, legislative action has happened in spurts several years apart.

Today, it's a similar cycle of med students, research, and media coverage that appears to be driving change. Phoebe Friesen, a postdoctoral fellow at Oxford University with an interest in bioethics, first learned about the practice while leading a bioethics seminar for students at Mount Sinai Hospital in New York City, where she worked from 2014 to 2017. Several brought up unauthorized pelvic exams as a concern—giving her a chance to help them question the ethics of the exams.

“Space to reflect is so important,” she said, adding that medical students are “getting bombarded with really wild experiences over and over throughout the day, like things they've never encountered. I think it's hard to sort of pick out which of these are problematic for what reasons and which ones are weird but maybe okay.”

Like Silver-Isenstadt, Friesen decided to grapple with the practice through research. Her paper, published in Bioethics last year, took up ethical questions relating to unauthorized pelvic exams—like why a pelvic exam has specific moral implications. Friesen wrote that these exams occur “during an extremely vulnerable moment, when [the patient] is both undressed and unconscious, and most in need of a physician who is deserving of trust.”

Her work has driven some of the renewed attention to the issue, and is part of a shift toward recognizing the importance of true informed consent. After Friesen wrote about exams done without consent for Slate, she said some people were able to see them in the context of the Me Too movement, while others were still skeptical. “Some people were very angry, some denied this would ever happen, others were horrified and outraged," she said. "A couple women online said they had experienced this and began using #metoopelvic.”

Wilson said things were different in the early 2000s, when she was investigating unauthorized pelvic exams to make a presentation for an FTC hearing. At the time, medical school faculty “were more than willing to stand their ground and say, ‘not only do we do it, but the patients in our hospitals have a duty to participate.’” Caplan agrees that, 15 years ago, many schools “did not see it as an issue.” The argument went like this: If you asked patients for permission, they’d say no, and that would deny valuable training to medical students. In today’s culture, Wilson said, it’s harder for medical faculty to stand up and say that consent for this exam doesn’t matter. And surveys show that most patients would consent to an exam under anesthesia if they were asked.

Silver-Isenstadt fears that even if these exams are legally banned in more states, the law will be hard to enforce. In order for authorities to find out, students would need to both be aware of the law and willing to report wrongdoing by their supervisors, so he’s hoping the culture is what will ultimately change. Friesen agrees that it’s necessary to “really teach students that asking is important, before you use somebody's body to learn something, even if it's, you know, a good thing you're learning in order to help them.”

Follow Hannah Harris Green on Twitter.