Patient modesty concerns pertaining to surgery

[creinkent]

Want to get feedback about how we all handle pt concerns about modesty and/or being naked as part of surgery. Concerns about who sees them and for how long? Why do they need to be naked? When is the gown removed, etc? How much do you tell them? How do you handle pt that is concerned about students practicing pelvic exams on them without concent? How to handle the situation when after the surgery they realize they had been "exposed"?

[ImaWonderer]

Let me be clear.........I am not for pushing an advocate on anyone who doesnt want one.I would WELCOME just as many men to go into the field as women. Actually I think it sounds like a great opportunity since men/boys often feel their modesty concerns are never taken seriously.(true)

Also when it comes to an advocate not doing much for modesty because it would just be one more person in the room. I believe that the role of what your advocate does can vary. They may or may not even be in the room. They could possibly be the person insuring no unneccasary people enter the room if those are your wishes..... The way it is now anyone seems to just be able to walk in. (i'm not actually talking about surgery) but its common during certain intimate appointments to have a gang on students, interns ,people who you have no idea who or what position they are in to simply walk in because they want to.

So for me if I'm having a appointment or in the hospital for MANY things I WOULD NOT desire an advocate. But in other cases if I have to be knocked out and in a state of undress or some type of intimate procedure then I would certainly want someone there on MY behalf.

Is the advocate simply there to put a damper on unprofessional behaviour. To a LARGE extent as far as i am concerned YES YES YES......If I am under I do not trust that unneccassry people will not be in the room,that pictures are not being taken,that unprofessional comments on everything from breast size to genitals are being talked about,I dont trust that a medical student isnt allowed to come in and practice a pelvic exam,I dont trust that I'm not being exposed IF it isnt nessacary. If I had an advocate someone on my behalf looking out for me I would feel FAR MORE CONFIDENT........

Even if a patient is fully conscience they may still want an advocate. Many times during a medical situation its not uncommon that a patient will be scared, intimidated,overwhelmed and feeling extremely vulnerable. In cases like these some patients may very much want an advocate some may not. Again I believe the role of WHAT an advocate does and to what extent can vary.

I will agree with an earlier person who stated an advocate should have training and it would be very difficult for a (spouse, friend, relative) to see their loved one being cut on, see blood, etc and it could lead to more problems than being helpful ...Great point!!!!. I'm ALL for having these types of discussions!!!!!!!!

Im not dismissing GENDER at all.....someone mentioned having retired medical professionals enter this field (paid/volunteer) Yes most nurses are females but what about male retired Doctors/EMT/paramedics/surgical techs. There is a VAST amount men with a medical experience that would be phenominal candidates to advocate for men/boys. Again this doesnt mean they would be staring at you get your prostate examined....but men have these legitimate concerns so they should yell, scream ,protest,organize, demand changes and make the system better.

I am concerned for modesty male/female but we as patients are going to have to demand it.

[ImaWonderer]

I just read the great post by tbrd450....

I'm repeating myself but thats my point of why you cant let the fox guard the hen house.

A doctor should not be able to just "pop in" to talk about a tv show Its to the point where the doctor doesnt care or is completely oblivious about what this does to the patient. So now the patient is exposed needlessly and to anyone standing in the hallway while the doctor has opened a door that should have not been opened.

The woman giving birth is busy.... who is there to protect her against the "live studio audience" ...the skateborder with his gentals on display for ANYONE walking down the hallway.....this is simply humiliating and inexcusable behaviour. This MOB mentality and psychology of the GROUP is not going to change unless we put the brakes on a say YOU CAN NOT DO THIS!!!!! Tell a nurse to take her pants off an walk around the hallway and see how she feels.......weve all seen a lady parts before....no big deal right!!!!!!!

Let has these people get written up for violations like this, let them know it will have on effect on them keeping their jobs to affecting their raises,etc . They are NOT looking out for patients when leaving someone unable to care for themselves "uncovered" ecause its faster......Ifthat was their mother,father,friend would they feel the same way......UHM NO...........

There was a poster who mentioned patients being brought up from the ER naked when thier was NO reason for it. I asked well why is this happening??????? uhm.....CRICKETS ...no answer.....Thats because their is NO EXCUSE!!!! The post goes on to say really "SOMEONE" should have gotton this patient a gown......I find this simply CRUEL and Dehumanizing.....What in the world are these people thinking?.....Their thinking so what its not them its just patient ABC........

To any medical professional who would resist an advocate for the patient (outside of them)for fear of not being "trusted" or being "watched" this is EXACTLY why many patients need it....left to their own devices and the ability to police themselves patients end up naked in the hallway being told "Dont be embarrassed...you dont have anything we havent seen before......We're all professionals here:nurse:

[Cul2]

Good summary, tbrd450 -- but also consider this. Doctors and nurses have their values, attitudes, sexualities and hangups, too. They're human. They carry that baggage with them into the exam room and into the OR. They use strategies to protect them from the pain and heartache, smells, suffering, embarrassment, humiliation they see every day. Distancing and desensitization aren't just cultural responses to repetition. They can also be defense mechanisms used to protect. Expressions like "We've seen it all before, etc." are other strategies designed to reflect the patient emotion away from the patient and back toward the caregiver. It becomes about them, not the patient. Problem is, those phrases are often taught or passed on as good strategies, and for some patients they may work. But not for all. But they're passed on a catch all phrase, "We're all professionals here, etc." Doctors and nurses see differently than the average person. They are taught to focus on specific body parts, specific details as they work. How we see is a cultural/professional issue. Different professions see differently, and are taught to ignore certain things, considering them not relevant. Nakedness and nudity are among the events that many doctors and nurses learn to ignore and regard as not really relevant. These are the elephants in the room. Obviously, the patient and his or her family, not being medical professionals, see this elephant in the room that is often ignored by caregivers. But they're not talked about or acknowledged. It's as if nakedness, nudity and modesty doesn't exist in some cases. Some of the strategies doctors and nurses use to protect themselves from this particular issue of nakedness and modesty include

-- Using a chaperones (I know, they're supposed to be for patient comfort and

protection.)

-- Objectifying the pataient.

-- Empathizing with the patient and protecting his/her privacy.

-- Joking about sex

-- Threatening the patient (This can be blatant or subtle bullying)

-- Looking or sounding professional.

I'm not suggesting these strategies are necessarily bad,

except for threatening the patient.. In and of themselves

they can be good or bad depending upon the context of

the event and the personal makeups of the caregiver and

the patient, and the entire tone of the encounter. Some of

these strategies can be used merely to protect the doctor

and nurse with little consideration of patient feelings or

values. Or, they can be used to empower the patient with

dignity and respect.

Lest you think I'm making this all up, it comes from a

brilliant yet neglected study called "Not Just Bodies: Strategies

for Desexualizing the Physical Examination of Patients" by

Patti A. Giuffre and Christine L. Williams, found in Gender and

Society, 2000; 14; 457. The article ends thus:

"This study of desexualization strategies reveals how gender

is embedded in the informal organization and daily interactions

with patients in the hospital. It is difficult to imagine how an

embodied procedure such as a physical exam could ever escape

gendered meanings. But recognizing how cultural assumptions

about gender and sexuality shape this experience is a critical

first step toward eventually reconfiguring those expectations in

more just and liberating ways."

I like the last sentence -- "...in more just and liberating ways."

If you accept that last paragraph as correct, one must wonder

what it's like for one gender, men, to enter a culture that is

dominated by one particular gender, women -- who are intimately

involved in these kinds of embodied procedures, and, as the

disadvantaged gender, often having no choice in who does what

to you. Yes, cultural assumptions about gender and sexuality

do shape patient and caregiver experiences. These exams and

procedures do indeed have gendered meanings, and the

health care system must continue to find more "liberating and just" ways

to come to grips with this issue.

[tbrd450]

A lot of great stuff coming out here.

Let's all agree to one absolute -- this sort of has to serve as a foundation from which subsequent analysis is possible:

I don't care how professional a person looks, acts or behaves. I don't care how many layers of white gloves a person rolls on. I don't care how many "desexualization strategies" one is tuned in to, and attempting to employ. A female caregiver treating a nude male patient has unique cross-gender dynamics, from the patient's perspective. A male caregiver treating a nude female patient has unique cross-gender dynamics, from the patient's perspective. It will always be so.

They placed female prison guards pecisely in the position of guarding nude male detainees in Abu Ghraib for a reason. The Intelligence folks, employing pschologoical consultants, identified those unique dynamics as effective means of "breaking" boys and men (presumption being they had information to disclose). It was a deliberate attempt at humiliation as a means to an end. Granted, they were also told to ramp up the humiliation tactics, but it was their mere presence alone that was the main focus of this pschological strategy. Some female soldiers behaved extremely "professional" around the hundreds of nude boys and men, pyramids of bodies and daily degration efforts. It didn't matter, they were female and they were there. That was humiliating enough. The Muslim culture, for example, establishes that viewing of the naked body by someone of the opposite sex is generally Taboo in all situations. The fact that these females had uniforms on and where "soldiers," meant very little. They were clearly seen as female by the detainees....they knew that, the soldiers knew that, the government knew that, the psychologists knew that...and then the entire world knew that.

Make no mistake about it, no matter what uniform, coat, gloves, nametag, or other professional identifier a nurse or doctor enters the room with, he is still a he and she is still a she first and foremost for the vulnerable, exposed patient waiting.

We all get that right?

Generally, boys and men, as patients, worry about things equally as girls and women as patients despite the perception otherwise. However, what precisely they worry about is sometimes different. No female, for example, ever in her life worried about an involuntary erection at the wrong time, and all the things that may be interpreted from that. No male, for example, ever really worried about being examined in that stirrup device....eek! (they don't ever have to go there do they?).

My point though is that gender matters for many patients -- for patients with modesty issues.

Statements like "I've seen it all before," and "we are all professionals here,"... I find it truly difficult to believe they ever really work for the patient. They may produce some positive results for the caregiver but not the patient. One thing they do is shut down the dialogue prematurely. I, personally, would much rather hear something to the effect of: "I know this is awkward, uncomfortable and embarrassing, but here is why we need to do this procedure. ...blah...blah...blah.. and we will only be leaving you exposed long enough to accomplish our task." That is a statement of fact, an acknowledgement of normal feelings, and clearly educational in that it explains why the person is expected to be exposed. If the professional can't say all that...then say nothing. But for heavens sake... please don't say the other stuff.

[tbrd450]

Let me be clear.........I am not for pushing an advocate on anyone who doesnt want one.I would WELCOME just as many men to go into the field as women. Actually I think it sounds like a great opportunity since men/boys often feel their modesty concerns are never taken seriously.(true)

Also when it comes to an advocate not doing much for modesty because it would just be one more person in the room. I believe that the role of what your advocate does can vary. They may or may not even be in the room. They could possibly be the person insuring no unneccasary people enter the room if those are your wishes..... The way it is now anyone seems to just be able to walk in. (i'm not actually talking about surgery) but its common during certain intimate appointments to have a gang on students, interns ,people who you have no idea who or what position they are in to simply walk in because they want to.

So for me if I'm having a appointment or in the hospital for MANY things I WOULD NOT desire an advocate. But in other cases if I have to be knocked out and in a state of undress or some type of intimate procedure then I would certainly want someone there on MY behalf.

Is the advocate simply there to put a damper on unprofessional behaviour. To a LARGE extent as far as i am concerned YES YES YES......If I am under I do not trust that unneccassry people will not be in the room,that pictures are not being taken,that unprofessional comments on everything from breast size to genitals are being talked about,I dont trust that a medical student isnt allowed to come in and practice a pelvic exam,I dont trust that I'm not being exposed IF it isnt nessacary. If I had an advocate someone on my behalf looking out for me I would feel FAR MORE CONFIDENT........

Even if a patient is fully conscience they may still want an advocate. Many times during a medical situation its not uncommon that a patient will be scared, intimidated,overwhelmed and feeling extremely vulnerable. In cases like these some patients may very much want an advocate some may not. Again I believe the role of WHAT an advocate does and to what extent can vary.

I will agree with an earlier person who stated an advocate should have training and it would be very difficult for a (spouse, friend, relative) to see their loved one being cut on, see blood, etc and it could lead to more problems than being helpful ...Great point!!!!. I'm ALL for having these types of discussions!!!!!!!!

Im not dismissing GENDER at all.....someone mentioned having retired medical professionals enter this field (paid/volunteer) Yes most nurses are females but what about male retired Doctors/EMT/paramedics/surgical techs. There is a VAST amount men with a medical experience that would be phenominal candidates to advocate for men/boys. Again this doesnt mean they would be staring at you get your prostate examined....but men have these legitimate concerns so they should yell, scream ,protest,organize, demand changes and make the system better.

I am concerned for modesty male/female but we as patients are going to have to demand it.

For what it is worth, I actually think patient advocates as an option/solution here would probably be very effective for female patients. The concept is a good one. I just know that it would never truly address the issue for male patients. Not only would the advocate pool likely be lopsided (females to males)...regardless of how well recruiting is handled.... but males simply won't utilize them when they do exist. Why? Because the embarrassment of asking for one is probably on par with the embarrassment of inappropriate behavior on the part of the caregiving team while he is under. It's just not a practical, realistic solution for half the patient population. Although it certainly is for the other half.

I want to fix the root cause of why "professionals" ever find it appropriate to conclude that leaving the exposed skate-boarder in a humiliating position is okay... if we can get at that, then the need for nudity police and surveillance cameras becomes a moot point.

The fact that a doctor thought it was okay to jiggle that patient's fat and sing a song is mind-boggling to me. Why? Because he did that knowing that there was a room full of his colleagues listening and watching. That's the real story here... what could they have possibly been thinking? If that sort of thing is going to happen, and only not happen because an advoate is close at hand, well... we have deeper issues to address.

If students are popping in on nude patients... well... we have a more fundamental problem to address. We have to address the underlying medical culture/climate that permits that. Somebody isn't doing his/her job.

Consequences -- we need real consequences when morons act like morons. Fine the doctor a couple grand every time he acts like an idiot in the OR. Take away a vacation day every time the nurse fails to properly cover up a nude skate boarder.

[Cul2]

Some good thoughts tbrd450 . But it's not all black and white. It's more complicated and very contextual. Some of those phrases may make a patient feel better. I've head that from patients. It depends upon how it's said and the nature of the patient. But I do agree with you that a phrase like "I know this is awkward, uncomfortable and embarrassing..." will work for other patients. That's what makes this so difficult. Sometimes those catch phrases are used to shut down dialogue. But not always. They may be spoken with good intent -- I know -- the road to hell, as they say, is paved with good intentions. And you're right on with Abu Ghraib and GitMo. These were specific policies our government promoted, psychological torture. But that's war -- and don't think these kinds of treatments haven't been done to women in war too. Look at parts of Africa where even today rape against women is policy and strategy of war. It goes both ways in warfare. But you're right -- in our culture we would never do the kinds of things as part of policy to women prisoners that we did to those Muslim males. That goes to the double standard. Look at the way we used to induct male recruits -- long lines of naked males being examined, with, in some cases, female clerks gazing and ogling at the sight. Look at how young boys used to (still?) were given sports physicals -- lines of half or fully naked boys examined sometimes by a female doctor and a female nurse, then the infamous hernia check. Medical culture needs to understand the symbolic power the naked body has for the human psyche, and the highly charged sexual symbolism and power of certain body parts.

One other point, tbrd450 -- "No male, for example, ever really worried about being examined in that stirrup device....eek!" Where have you been? Research some urological procedures for men, and research some kinds of prostate cancer treatment. Men do have to face the stirrups.

[CBsMommy]

Story #2: Went into have my gallbladder removed, laying on the table in OR, they tell me to count to ten backwards. 10 9 8 7 6...(OH GOD...I can't breathe!! God? do they know I can't breathe? Please God, I'm scared, please tell them I can't breathe!! :eek:What are they doing? I can feel that! Don't they know I can feel that??) As they are cutting my abdomen open I hear someone saying "did you see that? her stomach just jumped...is she under?"...

After that I don't know what happened, so apparently they put me UNDER! no one told me about intubation, what that meant, or that it would be done to me, and I didn't know enough to Ask prior to the surgery.

Holy crap! When I asked the surgeon about it when he came to check on me he looked over at the intern who was working on me, and they both just looked at each other, and didn't say a word. Needless to say, the anesthesiologist was in my room in no time at all apologizing, and we never did get billed for his 'services'.

FYI, they now have monitors that are placed on your temples and scalp to monitor for some type of brain activity that indicates paralysis versus being "under".

Now I never want to have surgery again!! Hope I never have to.

Yikes! I am having surgery this Friday and this is my WORST fear! I don't care if people make fun of me, if they poke my belly, if they re-dress me, whatever.....but PLEASE make sure I'm out for the surgery! I do NOT want to feel a thing. And the surgery is in my neck....which is already scary in itself!

[CBsMommy]

Might I add that when I am an RN, I will NEVER make fun of/embarass any patient and do not condone that behaviour!

[advo-kate2]

"Doctors and nurses have their values, attitudes, sexualities and hangups, too. They're human." If we agree that this is true, then we would have to agree that it is impossible for them not to be aware of our values, attitudes, sexualities and hangups. To say they are not in truth relevant, would devalue them as human beings as well. It is not logical to apply standards in one setting and not the other/ values in one circumstance and not all others.

To say that they project the theory that it is not relevant may be more honest. Afterall, to be able to perform the task hinges on convincing a person that it can't be relevant, or else they can not do it and they would be jobless. Perhaps some people are looking for justification and those types of projections work, but I would really have to wonder if it is not just a matter of 'denial for convienence'. They didn't really buy it. They didn't really believe it. But they did manage to get through it for now.

These are dangerous games, and not everyone is well suited to play them. I would prefer to give them up and fix the playing field. So much damage is being done. Maybe it is not 'relevant' to see the damaged person a caregiver sends home.

[SandraCVRN]

I'm sorry for what ever happened to the naked skateboarder (I can't keep up with whos who) but I have never seen a naked pt in a hallway, maybe in a trauma room for a couple minutes while actually being accessed for injuries, then at the minimun a sheet covering the pt.

I have never left a pt in the OR uncovered for any longer then absolutly necessary. I have never seen a pt being exposed for a procedure in a regular room where people were allowed to just come and go. As far as nursing or medical students they kinda have to watch some things sometines, how are they going to learn anything?

[tbrd450]

I'm sorry for what ever happened to the naked skateboarder (I can't keep up with whos who) but I have never seen a naked pt in a hallway, maybe in a trauma room for a couple minutes while actually being accessed for injuries, then at the minimun a sheet covering the pt.

I have never left a pt in the OR uncovered for any longer then absolutly necessary. I have never seen a pt being exposed for a procedure in a regular room where people were allowed to just come and go. As far as nursing or medical students they kinda have to watch some things sometines, how are they going to learn anything?

The skate boarder story is, I think, somewhere in this thread many pages ago. Or, maybe another similar modesty thread. Not sure. If I remember correctly, he wasn't left in the hallway (I was trying to drive home a point and purposely embellished tying that story in to my point). My point had less to do with the details of the story and more to do with the double standard climate. The teenage skate boarder, if I remember correctly, was having something like his arm or ear worked on, and he was stripped below the waist and left uncovered as a group of female student nurses observed his treatment. And, he apparently was obviously embarrassed and made some attempt to cover himself but got no support or assistance from his main nurse...something like that. I think she may have even said something, subsequently, about his concern being silly since they were there to help him.

Basically, a group of females were standing there looking at his bits and pieces, and it wasn't necessary. This pretty much sums many male patients' medical experiences, in a nutshell!

With regard to horror stories on the modesty front... I am basically just picking this up from the nurses and doctors themselves. They are the ones that speak of such horrible things they witness. They have the stories that span the years and the multitudes of patient experiences. Frankly, before beginning to read and post in here, I thought things were actually better than they appear to now truly be. Many of the nurses and doctors themselves seem to indicate they avoid treatment because "they know what really goes on!" YIKES!.. That's scary for me, a non-medical professional, to read.

Personally, the vast majority of my own medical experiences have been fine. I had a significantly bad experience a long time ago...so I know on a personal level that this stuff goes on. But, that appears to have been an isolated incident. I am still able to believe it is rare.

Then there is just my own intuitive understanding of human behavior. People are people. White gloves and a stethescope doesn't change that.

DonMD had a terrific post in one of these threads. As a doctor, he clearly spoke of and supported through numerous examples, situations he encountered and experiences he had that validate the concerns, and prove the gender double standard.

[tbrd450]

Some good thoughts tbrd450 . But it's not all black and white. It's more complicated and very contextual. Some of those phrases may make a patient feel better. I've head that from patients. It depends upon how it's said and the nature of the patient. But I do agree with you that a phrase like "I know this is awkward, uncomfortable and embarrassing..." will work for other patients. That's what makes this so difficult. Sometimes those catch phrases are used to shut down dialogue. But not always. They may be spoken with good intent -- I know -- the road to hell, as they say, is paved with good intentions. And you're right on with Abu Ghraib and GitMo. These were specific policies our government promoted, psychological torture. But that's war -- and don't think these kinds of treatments haven't been done to women in war too. Look at parts of Africa where even today rape against women is policy and strategy of war. It goes both ways in warfare. But you're right -- in our culture we would never do the kinds of things as part of policy to women prisoners that we did to those Muslim males. That goes to the double standard. Look at the way we used to induct male recruits -- long lines of naked males being examined, with, in some cases, female clerks gazing and ogling at the sight. Look at how young boys used to (still?) were given sports physicals -- lines of half or fully naked boys examined sometimes by a female doctor and a female nurse, then the infamous hernia check. Medical culture needs to understand the symbolic power the naked body has for the human psyche, and the highly charged sexual symbolism and power of certain body parts.

One other point, tbrd450 -- "No male, for example, ever really worried about being examined in that stirrup device....eek!" Where have you been? Research some urological procedures for men, and research some kinds of prostate cancer treatment. Men do have to face the stirrups.

Your point about females being abused during war....absolutely!.. I hope I never slighted their consideration in my description of the abuse inflicted on the men in Abu Ghraib. Of course...their abuse often looks a little different. I have spent many years, as a feminist, supporting women's rights and advocating on their behalf across many fronts.

The fact is, however, there was a systematic policy in place to deliberately and intentionally inflict humiliation on only males -- as DonMD recently pointed out, apparently the Pentagon released a memo stating that it would be okay (or so it was thought) because society would only tolerate it if it was later discovered to be happening to males. If photos got out. If it was discovered to be happening to females, however, the powers realized that then the backlash from society would be too great.

Double standard.

Have you ever watched the show on cable called Tosh.0? Just the other day he (the host) was showing a reality video clip of a young man throwing a football and beaning his buddy directly in the back of the head!... BAM!... The guy that threw the ball was seen off in the distance laughing his butt off. The canned laughter soon swelled to deafening heights as we all munched on our popcorn and enjoyed the victim's dizziness. The whole thing was caught on camera.

However, the host began to introduce the clip with an interesting observation. He sort of, tongue-in-cheek, commented: "you know what really makes me mad? ... if this happened to a girl, I would not be allowed to show it on TV." He's right. It would have been censored.

We see women beating the crap out of guys all the time on reality TV...cops arrive.... break it up and move on. Those silly love quarrels... have a good night.

When the guy hits the woman, sometimes in just self defense, well, then the pepper spray comes out, the tasers charge up and the cuffs go on. [PLEASE, ...I am not advocating domestic abuse is okay. Of course it is not...ever]

But, the fact that women are extended extreme latitude in our society has swung the proverbial pendulum a bit too far out of balance for healthy relationship. Hitting should be wrong. But, it shoud be wrong when the person getting hit is male or female.

It's funny when, on America's Home Videos for example, the plastic baseball bat flies around and clocks daddy in the groin. Hee... hee... good ole American fun. We all laught our butts off and pass the corn chips. Do you realize how much that really hurts. I had it happen to me once...I played along and yukked it up as best I could through watery eyes. The truth is, however, it made me sick for about a day. And, I amost defecated right there on the spot!... seriously though, why is that funny?

Double standard. It transcends the line between general society and the medical community. It leads to disparate treatment when it comes to covering our private parts, ensuring the door is closed, or insisting on only relevant people in the room.