Consent is the cornerstone of ethical medical practice. However, there are instances where this fundamental principle is not merely disregarded but entirely overridden.
Recently, when scrolling online, I came across an article on the American actress Brooke Shields. She has been promoting her newly released memoir, Brooke Shields Is Not Allowed to Get Old. In an excerpt, she recounts how sometime after her children were born, she decided to consult a plastic surgeon for a labiaplasty, recommended by her gynaecologist. In the memoir, Shields recounts how the surgeon performed an unwanted ‘rejunification’ while unconscious under anaesthesia.
Shields, in an interview with Us Magazine, said that her experience was violating. “It felt like such an invasion — such a bizarre, like, rape of some kind.”
Such experiences, perpetrated against women, but also men, raises the important but often overlooked issue of non-consensual medical interventions related to intimate health.
Patient autonomy and permission is not always respected, which has ethical, and sometimes legal, implications. This can be a difficult and sensitive topic to broach, as ingrained shame around the issue of intimate health has allowed malpractice to thrive. But difficult conversations must be had to protect the rights and health of women.
The common law as relates to the UK, is staunch. Case law stretching back to the 1990s allows for a woman with mental capacity to have the absolute right and ability to consent or decline medical intervention in maternity care. Such rights continue even if the woman (or foetus) may die as a result of her decision (Re MB [1997] 2 FLR 426).
According to the General Medical Council, Montgomery v Lanarkshire Health Board [2015] UKSC 11 stipulates that medical professionals have the duty to “make sure” that patients are aware of any material risks involved in treatment. In this case, the Supreme Court set the benchmark that an adult with capacity to consent is entitled to decide what treatment they undergo. The British Medical Journal reported that some hailed the Montgomery decision as “The most important UK judgment on informed consent for 30 years.”
However, research cited by Durham University highlighted that in 2020 - five years after the Montgomery decision - fewer than 50% of women “felt that this was reflected in their experience of care.” The lived experiences of women do not reflect the quality of care that they are entitled to under common law. In many hospitals and Trusts across the UK do not uphold the principle of informed consent.
This can be seen most evidently in practice of pelvic examinations.
Non-consensual pelvic examinations might seem like a thing of the past. For decades in the latter part of the 20th century, pelvic examinations were routinely perpetrated by doctors on anaesthetised women without their consent. Most widely and egregiously, this practice has been used in teaching hospitals and medical schools as an opportunity to teach inexperienced students. The logic behind this was much “easier” to examine a woman and learn about pelvic pathology and anatomy when a patient was anaesthetised and unable to feel the effects. However, this gives rise to the impression that if the woman was unable to feel the examination she would not have been aware that the practice had taken place.
So why did doctors and medical professionals continue to practice pelvic examinations on anaesthetised patients?
Well, as in the horrific experience of Brooke Shields, a woman who is unconscious does not have the capacity to say no to a medical practice or ‘surgery’ she would most likely decline if she had the ability to.
In the last few decades, more protections have been introduced to safeguard women from invasive and violating practices. Case law from the European Court of Human Rights recognises that gynaecological examinations performed without consent will breach Article 8 of the European Convention on Human rights, which stipulates that everyone has the right to respect for his private life.
In the UK, pelvic examinations as a teaching technique does not have the same history or notoriety as it does in the US. It was only in 2024 that guidance from the United States’ Department of Health and Human Services (HHS) stipulated that hospitals must obtain written informed consent before performing intimate physical examinations on patients, or risk losing federal funding. However, the law in the US and the UK is still murky as to the exact legality of such practices.
It is entirely possible, and perhaps still probable, that even with these protections, patients are still suffering from violating examinations. The data is just not there, because of course, many patients may not even know what has happened to them while under anaesthesia.
VICE News reported in 2019 that a law student at the University of East Anglia, only referred to as Jane, only discovered she had been given a pelvic exam while under anaesthesia six months after the case. In Jane’s case, she was only supposed to undergo routine surgery on her abdomen. It was only after Jane launched an official complaint that she uncovered what exactly had happened while she was under anaesthesia. Jane told VICE that she felt “violated” by her experience.
VICE reported on the experiences of another woman, named as Rebecca, who was suffering from abdominal pain so underwent a laparoscopy (keyhole surgery to examine the abdomen or pelvis). Much like Jane, she had been given a pelvic exam. Also like Jane, Rebecca did not know this examination had been performed on her until months later when she complained.
The General Medical Council in the UK states that doctors are banned from performing these procedures without consent. On the face of it, this is true. However in practice, this ‘consent’ is blurry.
Unlike the new HHS guidance for doctors in the US, in the UK, this ‘consent’ to pelvic examinations, normally while under anaesthesia, can be expressed or implied consent. In the case of Jane and Rebecca reported on by VICE, this consent can be seen as ‘implied’ because both women willingly consented to their laparoscopies.
This issue around express or implied consent with regard to pelvic exams and other intimate gynaecological care is a serious grey area within the law in the UK, and perhaps in need of serious reform.
Codified legislation defining what consent is and how it may be given alongside other patient rights is perhaps needed to protect women and others from this malpractice. In recent years, the UK government has understood the need for reform in dealing with intimate health abuses, such as in 2022 when it passed the Health and Care Act across the UK. The HCA 2022 notably made it illegal to perform or offer to perform ‘virginity testing’ and hymenoplasty in the UK. It is certainly feasible that there is the political goodwill to pass further legislation governing other intimate health violations by doctors and surgeons. Specific legislation is needed.
The experience Brooke Shields suffered at the hands of her surgeon, and the experiences of Jane and Rebecca and all those who undergo non-consensual pelvic exams are very different. But they both appear in the wider framework of abuse of women and their autonomy in the medical context. The gender bias in medicine has a long and documented history, and women are still being let down.
The shame surrounding such topics allows mistreatment and violations to become endemic. In fact, nearly one third of young women in a study from Indiana University have admitted they avoided going to the gynecologist altogether due to shame or embarrassment.
Of course, the vast majority of doctors and medical professionals uphold the highest of standards relating to patient care. However, it is still difficult to obtain answers and recourse for patients who feel like they were violated or mistreated. This is why it is essential to raise the issue of intimate health violations so that necessary reform can take place, and the experiences of Brooke Shields and other women can be consigned to the past.