Is it possible to identify physician abuse or misconduct in gynecological examinations?

Gynecological exams are essential to detect serious diseases, such as cervical cancer, the third most common type among women in Brazil. But what should be the medical conduct when performing the procedures? How to know if the specialist has crossed the ethical threshold?

According to Maria da Guia de Medeiros Garcia, gynecologist and Health Care Manager at the Januário Cicco Maternity, from the Federal University of Rio Grande do Norte (MEJC-UFRN), linked to the Ebserh Network, there is a recommendation from the Federal Council of Medicine. (CFM) and the Federal Nursing Council (Cofen) which, in theory, should be followed by all hospitals, laboratories and other places where these tests can be performed.

“This recommendation says that when the doctor or nurse is going to perform an exam, they need to have, next to the patient, a second professional, such as a nursing technician”, says the specialist.

For the doctor, this would be the correct way to perform any gynecological exam, because a second professional, in addition to bringing more safety to the patient, is a person prepared to detect any inappropriate behavior during the procedure.

“When a male person is going to conduct the exam, he needs to have a nursing technician or an assistant in the room, next to the person who is doing it, not in the anteroom or in the hallway. This is essential”, emphasizes Garcia.

Another important point, according to the specialist, is that many people do not know how the exam will be performed; they do not ask, and the professional, in turn, does not explain at the time, an essential communication that should not be neglected.

“It is not possible for us to take an exam without even knowing what will be done with us, with our body. Health is everyone’s right and a duty of the State. So, we have to seek the right to clarification, and the State, as a health provider, needs to do this through public policies”, emphasizes Januário Cicco, a gynecologist at the Maternity Hospital.

Gynecological examination

When the patient goes to a routine consultation, most of the time, the doctor examines the breasts, first with her sitting, and then lying down, palpating the region to detect the presence of possible nodules. This is normal.

“Some do not do the breast exam, but the fact is that every gynecologist examines the patient to see if there is any lump, nodule, retraction or lesion”, guides Zenilda Bruno, gynecologist, head of the medical division of Maternity-Escola Assis Chateaubriand (MEAC), from the Hospital Complex, linked to the Ebserh network, from the Federal University of Ceará (UFC).

Bruno also explains that the breast exam should be done at all ages. “Obviously, breast cancer is more frequent from the age of 40, but here at the hospital we have patients aged 27 and 29 who have breast cancer”, warns the specialist.

According to her, the next step would be to examine the belly to see if there is any abnormality in the region or if the person feels any pain. “And after that, we examine the genital region. That would be the right thing to do, although not every doctor does it that way”, points out Bruno, who is also a professor at the Faculty of Medicine at the Federal University of Ceará.

pap smear

The well-known pap smear is the main preventive gynecological exam, whose function is to analyze the cells of the uterine cervix in order to detect, mainly, cervical cancer. He can also often identify the presence of fungi, changes in the vaginal flora and infections.

To do this, the patient usually takes off all her clothes and puts on a disposable apron —or a nightgown—with an opening in the front. Afterwards, she lies on the “bed” in a gynecological position, that is, with her legs higher, spread and with her knees bent and wide apart.

The doctor, in turn, puts on gloves and begins by examining the vulva, which is the outside of the vagina. So it is really necessary for him to look closely to see if there is any lesion, ulcer, wound, etc.

“Then, the doctor asks the patient to push to see if those genitals are not externalized, because sometimes the patient has a fall of the uterus or bladder. And we also observe if there is also any discharge that is externalizing “, explains Bruno.

The next step is to place the speculum — an instrument used to dilate the entrance of certain organic cavities — and which in many hospitals or offices is already disposable.

“Then, the material is collected from the outside of the cervix, with an object that resembles a popsicle stick. And then, with a brush, the substance is collected from inside the colon canal and placed on the slide. Then he takes the speculum. This is the most correct way to collect the pap smear”, describes Bruno.

There is also another technique with a brush that “sweeps” the cervix, and the material is placed in a liquid solution, which is sent to the laboratory to complete the procedure. According to specialists, this is a more modern method and some studies say that the result is better, although it is still not commonly used in Brazil.

And after harvesting this material, the doctor still makes a touch penetrating two fingers to know the size of the uterus. All this is expected during the procedure.

“All specialists, even if they are women, must do this in the presence of someone so that they have the support that they have carried out all the necessary procedure. This is important even in case the patient feels less embarrassed, but this is not a law”, emphasizes Bruno, professor at the Federal University of Ceará.

According to her, it is very difficult to establish what it means to go beyond what is necessary in a gynecological exam, because it is really very intimate. “The patient must always be awake and be informed exactly about what will be done: ‘Look, now I’m going to touch your breast, place the speculum, do a touch’. The specialist must always wear gloves, not touch the clitoris and demonstrate respect, so that she feels that the correct procedure is being done”, guides Bruno.

On average, this exam takes about 30 minutes, however, there are cases that can take longer. It is worth noting that, according to the National Cancer Institute (INCA), in 2022, 16,710 new cases of cervical cancer are expected, with an estimated risk of 15.38 cases per 100,000 women. , the Pap smear is extremely important.

Mammography

It is a high-resolution X-ray exam that analyzes the presence of changes in the breasts, such as lumps (cancers) or cysts. This test is not usually done by a doctor.

For the procedure, the patient must remove the upper part of the clothing. Then, the professional “fits” the breast in the machine, which slightly tightens the region to make the images that are then evaluated by the radiologist.

In Brazil, excluding non-melanoma skin tumors, breast cancer is the most common cancer in women in all regions, with higher rates in the South and Southeast regions. For the year 2022, the National Cancer Institute estimated 66,280 new cases.

Ultrasound of the breasts or pelvis (transvaginal)

The breast ultrasound is a simple exam, which must be done by a doctor who evaluates – through a device called a transducer – if there are nodules, cysts or lesions in the breasts.

And just like in the Pap smear, the patient needs to take off her clothes (some allow her to keep her panties on) and put on her apron. Then, already lying down, the specialist opens the apron at the top and passes a gel in the region, which facilitates the sliding of the device.

“It is also difficult to tell when the doctor is abusing and when he is not, but, normally, he does not take the patient’s breast with his hand, only with the transducer”, says Bruno.

The transvaginal must also be performed by a doctor who needs to be wearing gloves. Its function is to evaluate organs such as bladder, uterus, ovaries, tubes, portion of the rectum, and identify the presence of possible fibroids, polyps, ovarian cysts or tumors, endometriosis, adenomyosis. It is also widely used to define causes of vaginal bleeding and increased or painful menstruation, in addition to pelvic pain.

In terms of preparation, there is not much difference from the others: the patient takes off all her clothes and puts on the apron so that the specialist can insert the transducer device, which is a little thicker, into the vagina with a condom.

“In this exam, the doctor does not hold the patient with his hand, he only uses the transducer to make movements inside the vagina, the appropriate evaluations and identify possible changes according to our criteria”, describes Bruno, remembering that it is not possible to determine a specific time to perform this procedure.

Hysterosalpingography

This is an x-ray of the uterus to see if the tubes are leaky or obstructed, which would be a reason why some women cannot get pregnant. The procedure is very similar to a Pap smear, but it is not a frequent exam.

The woman can choose which professional she wants to take the exam with, if there is availability.

Because they are intimate exams, it is common for many women to feel embarrassed in front of a man. So, if there is an option, she can, yes, talk about the preference for a woman.

However, it is known that in some regions of the country, especially in the more peripheral areas, it is not possible to choose, since the demand is very high and there are not enough professionals.

Abuse in exams causes psychic damage

Sought by the report, the Federal Council of Medicine (CFM), has not yet reported whether there are reports of complaints made by women who felt neglected during a gynecological examination. If there is an answer, it will be added to the text.

For Joel Rennó Júnior, director of the Women’s Mental Health Program at the Instituto de Psiquiatria (IPq) at Hospital das Clínicas de São Paulo, women are seen as multiple complainers, a medical jargon used to define the behavior of patients who complain about something. that does not show up on exams.

“But these complaints occur when there is a history of violence that often cannot be verbalized”, warns the specialist, who is also a professor in the Department of Psychiatry at the Faculty of Medicine of the University of São Paulo (FMUSP).

This behavior, according to Júnior, must be understood by the professional who is performing the gynecological examination, because, often, when touched, the woman may have a panic attack, report pain, begin to tremble, among other symptoms.

The result of violence during an exam, whether physical or verbal, can cause serious harm to your mental health.

“Of course, physical sexual violence is much more shocking, however, we see many doctors and even doctors doing psychological violence. Sometimes, they humiliate the patient, disqualify, call attention with aggression, or think she is complaining too much pain. So there is no sensitivity”, evaluates Júnior.

Among the main mental health problems that can be triggered in these cases are:

• Constant memories of what happened;
• Feelings of denial or guilt: when she pretends she forgot, that nothing happened, or blames herself;
• Post-traumatic stress disorder (PTSD);
• Feeling of helplessness: when you regret not having said anything at the time of the abuse;
• Increased anxiety;
• Social isolation;
• Mood swings, irritation;
• Social intimidation, making love relationships difficult, for example.

“Many times these women are pre-judged and people, unfortunately, disqualify the testimony of these victims of violence”, laments the professor of the Department of Psychiatry at the Faculty of Medicine of the University of São Paulo.

Children must be monitored

Although it is not a widespread subject, many children go to the gynecologist, for example, due to problems with discharge. Already in puberty, it is common and essential for them to attend medical appointments.

“I examine many children and always in the presence of the mother. This is very important, but it is a recommendation, because there is no law about it”, points out the gynecologist at the Hospital Complex of the Federal University of Ceará. “Especially because many of them are accompanied by their father, neighbor or nanny, and if it is too restrictive, there would be no way for them to be examined”, she adds.

This text was published on the BBC News Brazil website.