Tag Archives: informed consent

Trans Vaginal Ultrasound Equipment Doesn’t Care If You’ve Had Sex–But Some Doctors Do

Laurie and Debbie say:

A transvaginal ultrasound (TVUS) is a procedure where a technician inserts an ultrasound probe into your vagina (about 2-3 inches in) to take a picture of what’s going on in your uterus. It’s an invasive procedure that can be disturbing or even traumatizing, and at the same time it’s a very useful diagnostic tool.

We were shocked to learn that a significant number of doctors refuse this procedure to women who haven’t experienced penetrative sex. In the United Kingdom, the policy is clear:

According to the guidance from the British Medical Ultrasound Society, “if a patient has not had penetrative sex, they are still entitled to be offered, and to accept, a TVUS [transvaginal ultrasound] in the same way that cervical screening is offered to all eligible patients.” 

“The concept of virginity plays no part in the clinical decision making for a TVUS, and the examination should be offered by the ultrasound practitioner, when clinically indicated. It is, however, acknowledged that health tests such as cervical screening and TVUS may be more uncomfortable for patients who have not had penetrative sex, and therefore the ultrasound practitioner must be extra vigilant if they are to proceed.”

Nonetheless, Women’s Media Center reports that women are being told that they can’t have the procedure, and some are being told that they will “lose their virginity” if they do have it. So let’s set the record straight:

Medically, there is no such thing as virginity. Many, but not all, women have hymens, generally thin pieces of tissue that spread across the vaginal opening. The first time something is inserted into the vagina, this piece of tissue can break and bleed (usually not seriously) … unless it’s not there, incomplete, or is more than typically stretchable. There is so much variation in hymens that there is absolutely no validity in using their presence, absence, or condition to judge the sexual history of anyone with a vagina. But, of course, that doesn’t stop the patriarchy, including the medical profession.

To the extent that virginity means anything, it’s cultural, and very self-defined. In that sense, it’s rather like “race,” a genetically meaningless concept that nonetheless is used to control too much of our lives.  We each know what “having sex” means to us, and we can each determine (if we care) when we “had sex” for the first time. We can decide that that only means consensual sex. We can decide it only means one kind of sex. We can decide that we had several “virginities,” and we lost them at different times, alone or with different partners, or never. No doctor can tell what our sexual histories are by looking between our legs.

Nonetheless, we did a little research, and the problem is also prevalent in the US. Caroline Reilly has an excellent article in Teen Vogue (from 2019):

One patient told me she was told they “simply could not do it because [she] was a virgin.” Another told me that because her doctor knew she hadn’t had vaginal sex, they said “well they can’t do a transvaginal, so it will just have to be external.” Patients reported having comments made to them about the transvaginal ultrasound ‘damaging’ patients who hadn’t had vaginal sex and one said the doctors were “very focused on whether I… was a virgin, which was really disorienting as I was in extreme distress and pain.” I spoke with patients who felt their diagnoses were compromised as a result of this practice, and who had to travel to a hospital further away to seek proper care.

The Women’s Media Center article is short and informative; Reilly’s is long and packed with thoughtful responses and nuances about both how this does work and how it should work.

Stephanie Tillman is a certified nurse-midwife who writes and speaks on issues of informed consent, patient empowerment, and trauma-informed care. She says that for a patient to be asked about their sexual activity, and to have that answer justify withholding a proceeding is not “appropriate medical care,” – that what should occur is a conversation between a provider and their patient to most comprehensively inform a patient of their options, recommendations, and their rights. This, she says, is called shared decision making; it involves making sure a patient has all the information they need to “engage in informed consent.”

Just as TVUS shouldn’t be refused to patients, it also shouldn’t be required. It can be traumatic, and it can be uncomfortable. If they can refuse a procedure to “virgins,” they can forego it for someone who doesn’t want it. Here’s Reilly again:

… aligning this procedure with something sexual in nature is … problematic and harmful for patients. It takes the same stigmas and taboos that shouldn’t even be part of a conversation about sex in the first place and infuses them into a vital and routine medical procedure. It’s important for patients to know that not only can you not have a transvaginal ultrasound withheld or forced on you because of your sexual history – you shouldn’t even be asked.

There are cases where your sexual history is your doctor’s business–if you think you might be pregnant, or have an STD, or some other cases. This isn’t one of them; if you are in this situation, advocate strongly for yourself and, if you don’t think that will work, take a feisty friend with you to the appointment for support.


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When Nonbinary People Face the Obstacle of “Transnormativity.”

The nonbinary pride flag has yellow, white, purple, and black horizontal stripes
Nonbinary Pride Flag

Debbie says:

Andrea Becker’s article, These nonbinary patients were seeking trans health care. But in a binary system, they felt ‘invalidated.’, published at The Lily, feels all too familiar. In 1994, The New Yorker published one of the first popular articles about trans men (behind a registration wall). One thing I remember clearly from that article is a trans man righteously complaining that he couldn’t convince his (male) bottom surgery doctor that he didn’t want a large penis. The doctor’s preconceptions were stronger than the patient’s preferences.

I suspect that this is a problem trans men run into much less frequently now, because there are many trans men, and there are many fine trans care clinics. But the preconceptions and exclusions have, according to Becker, shifted to treatment of nonbinary people. Here Becker (a medical sociologist) quotes Chase Weaverling, a 35-year-old enby:

“I get back there, and it’s not a conversation at all,” they said. “The nurse is telling me what’s going to happen and how I have to do things. The assumption was, you’re here for [testosterone], therefore you’re a trans man, therefore you want maximum testosterone and effects, and that’s what we’re going to do.” …

The nurse not only assumed Weaverling was a trans man, but also bypassed all of their questions about starting slowly with a low dose of testosterone to see if they liked the changes, and instead prescribed a rigid plan that they could not customize,

The protocols are known, the assumptions are fully in place, and despite the fact that one million Americans identify as nonbinary (a number that surprised me), customization is apparently not the order of the day:

while trans men and women might want full doses of hormone replacement therapy and aspire to complete all of the available steps of transgender care, nonbinary patients might want surgery without hormones. Others, such as Weaverling, may want to experiment with microdoses of hormones for more subtle changes.

One of the problems seems to be that trans people still have to defend their own need for care:

In the current trans medical model, the onus is on patients to prove they are “transgender enough” to qualify for gender-affirming care. As proof, providers often expect descriptions of gender and bodily and social discomfort that fit the accepted diagnostic criteria. If the narrative matches these characteristics, patients are diagnosed with gender dysphoria. This psychological diagnosis then serves as a green light for subsequent trans medicine, provided the person follows the requisite steps in the correct order.

A nonbinary person, on the extra hand, might not match all (or any) of the “accepted diagnostic criteria.” Any medical model that relies on intense discomfort for a diagnosis is already setting itself up to be rigid, and to exclude even a subset of the people it’s intended for. So if we then add a different group of people in related situations that don’t fit the exclusionary framework, we are substantially increasing the percentage of people who don’t get what they need, because they don’t fit in the predesigned box.

I never expected to see or hear the word “transnormativity,” but it is apparently in common use in these circumstances. I find this intensely distressing, and not at all surprising.

Becker does provide some hope for the future:

Experts say standards of care must recognize that sex and gender are both spectrums and there is no “right way” to engage with trans medicine. As part of this, providers can move toward a patient-centered approach to gender-affirming health care.

For [Evan] Vipond, [a PhD candidate in gender, feminist and women’s studies at York University], this approach hinges on the idea that “each patient’s needs and desires in regard to transitioning are different and equally valid.”

And there’s a well-understood solution, used in many medical situations every day:

In an informed consent model, providers grant patients all of the available information regarding risks and benefits — empowering the patient to make their own decisions about a medical procedure, whether that’s hormone therapy or surgery. This takes concerns about a patient regretting a procedure out of the hands of a provider and allows patients to be an active participant in their care.

Experts agree that informed consent for trans health would help reduce the stigma attached to medical transition and trans identities and make gender-affirming care more accessible to those who need it.

Informed consent is an excellent approach. At the same time, I will never stop wishing that we could just believe people when they tell us what they need, whether it’s gender-related or not. I can imagine a world where we don’t need an “informed consent model” because as a society and culture we are committed to taking people seriously and working with each other so that everyone’s preferences are respected and we all get what we need.

Utopian? Moi?

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