She wanted treatment. She understood why she needed it. But when it came to the intimate part of her care, she struggled to continue.
The patient had survived sexual assault. Now, years later, medically necessary treatment required her to expose her body, tolerate intimate examination, and surrender some degree of physical control to people she rarely knew.
By the conventional markers of informed consent, nothing appeared to have gone wrong. The treatment had been explained. The patient understood the risks and benefits. She had agreed to proceed. Still, watching her struggle through the procedure made consent look far more complicated than I had been taught to understand it.
As an undergraduate interested in reproductive medicine, I occupy a unique space in the hospital, close enough to patient care to watch these encounters unfold, but far enough from clinical responsibility that I am still learning the practices physicians are expected to carry out. In classrooms and premedical training, informed consent sounds highly procedural. Explain the treatment. Discuss the risks, benefits, and alternatives. Make sure the patient understands. Ask permission. Respect the answer.
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But in reproductive, gynecological, and urologic medicine, where intimate exams are common, a patient’s initial agreement to treatment is only one part of the consent process. A patient can want treatment and still be frightened by it. They may understand exactly what their physicians are doing and still feel overwhelmed once the procedure begins. They can consent to an examination while still experiencing distress, fear, or traumatic memories as it unfolds.
In intimate care, consent should not be understood as a single decision made before an examination begins, but as permission that must remain present throughout.
Her experience reflects a broader challenge in reproductive medicine. Pelvic examinations and gynecologic procedures frequently ask patients to undress, assume vulnerable positions, and allow physicians to touch parts of their bodies that would be intensely private in almost any other setting. For survivors of sexual violence, these routine elements of medical care evoke fear, loss of control, or memories of prior trauma.
Genital examinations can trigger flashbacks or increase anxiety in about half of people who have experienced sexual assault. The American College of Obstetricians and Gynecologists (ACOG) warns that pelvic examinations can evoke feelings of powerlessness, violation, and fear in survivors, and recommends explaining procedures in advance, helping patients identify ways to reduce distress, and making clear that they can stop the examination at any time. These recommendations may seem simple, but watching a patient struggle showed me how consequential small acts of communication can be.
As a student, I learn medicine not only through lectures and textbooks, but also by watching other people practice it. Long before I will independently perform a pelvic examination or obtain consent for a procedure, I am learning what those interactions are supposed to look like.
Students notice whether a physician warns a patient before touching them and whether an examination is narrated or simply performed. We notice whether a patient who stiffens is offered a pause, and whether consent is treated as a two-way conversation or a one-sided explanation.
Those repeated observations can eventually become habits. Trauma-informed care should not be something that future physicians are expected to absorb incidentally. ACOG recommends incorporating a trauma-informed approach throughout obstetric and gynecologic practice and specifically calls for building a trauma-informed workforce by training clinicians and staff. Yet, the educational gap remains. Trauma-informed training remains sparse in medical education, and few curricula focus specifically on obstetrics and gynecology, particularly during clinical training. This gap matters as clinical habits begin forming long before independent practice.
Just as medical students learn how to hold a speculum, identify anatomy, and perform an examination, they should deliberately learn how to preserve a patient’s sense of control while doing so. Students should learn to explain what will happen before touching a patient, ask whether the patient is ready to proceed to the next step, and minimize unnecessary exposure. They should learn to offer pauses without making a patient feel like they are delaying care, and recognize that a patient’s silence should not be assumed to indicate their comfort or willingness to continue.
Trauma-informed training also means recognizing that clinicians may not always know who has experienced trauma. Although some survivors disclose sexual assault, many do not. A patient’s chart may contain no indication that an otherwise routine examination is profoundly difficult for them. Rather than reserving trauma-informed practices for patients known to have experienced trauma, clinicians should make them standard in intimate care.
None of these approaches imply that reproductive medicine can fully eliminate discomfort. Some treatments and examinations are inherently invasive. Patients may still need invasive or uncomfortable procedures they would strongly prefer to avoid. Trauma-informed care cannot change these medical realities, but it can change how much control patients lose while experiencing them.
A stark difference exists between the vulnerability medicine sometimes requires and the loss of agency it can unnecessarily create.
This patient’s struggle demonstrates that consent cannot simply occur before an intimate examination; it must remain an ongoing process throughout. While I am not yet responsible for performing these procedures, I am watching which habits medicine chooses to pass on to the students who eventually will be. That makes trauma-informed consent not only a clinical responsibility, but an educational one.
Reproductive medicine asks patients for an extraordinary amount of trust. Future physicians should learn not only how to earn that trust before touching a patient, but how to preserve and respect it once they do.
Michael Duell is a premedical student.
