Bioethics Discussion Blog: Patient Modesty: Volume 10





Tuesday, February 24, 2009

Patient Modesty: Volume 10

Here we go..on to Volume 10 on the subject of patient physical modesty. To aid in the transition from Volume 9, I will copy below my selection of some of the most recent comments. ..Maurice.

At Tuesday, February 24, 2009 3:09:00 AM, Anonymous Anonymous said...

Alan, I accept your admonishment for my making an extreme argument on cost-sharing. I was of course just raising the issue of the cost of responding to gender-based modesty.

Here's where I was partially coming from. Since joining this blog, I've done a kind of informal survey. It wasn't scientific, but I was careful always to formulate two questions in the same way. The first was, "Do you have a preference whether doctors or nurses are male or female?" The second was, "Do you feel uncomfortable in terms of modesty depending on whether doctors or nurses are male or female?"

I asked my mother what she thought her close group of women friends (65-85 yrs old) would feel. She said they probably preferred doctors to be men and nurses women because that's what they have always been used to, but male nurses "are like mini-doctors" and more women in general is good. I asked my Dad and his tennis foursome (same age range) and they all agreed they preferred male doctors and had modesty issues with both female nurses and doctors. I mentioned to my university class (ethnic and gender mix 20-26 yrs old) that I'd be participating here and asked the same question. Overall, they said it didn't matter at all. A couple of the young men, however, indicated they were more comfortable with both women doctors and nurses. Randomly asking maybe a dozen friends (ethnic mix of 30-48 yr olds and among them only one other naturist), the consensus was no preference or modesty problem. One Danish friend said he sought out female doctors because "they usually had to be twice as good to get into med school." A friend from Chile commented that she suspected it probably varies among hispanics depending on whether they come from the city or countryside. An Egyptian-American friend admitted that he thought he might have issues when he and his wife some time ago switched to a female doctor, but he was very happy, and it helped with his mom who "can't cope with any male medical care."

All this made me think that maybe "modesty issues" with regard to the gender of medical staff is both age-driven and actually more problematic for men. The older women, even those with a preference for male doctors, don't seem to have a problem with increasing numbers of women in medicine. Young people of both genders seem largely gender-blind at the doctor's office. In-between, women seem used to the male medical contingent (worries about sex-crazed anesthesiologists aside) but welcome more women. Does it make sense, then, to think the hump of the modesty problem is with older men who are still dealing with conflicting images of women's social and professional roles? If so, this might help medical staff be more alert, and it might help with short- and long-term staff resource planning.

(PT, I think we are trying to understand here is patient feelings and perceptions so that health care personnel are clear what constitutes "unprofessional behavior" with regard to "modesty." As Dr M has pointed out over on the clothesfreeforum, medical staff in principle get an enormous amount of training about proper conduct.) (CSM)

At Tuesday, February 24, 2009 8:48:00 AM, Anonymous Anonymous said...

CSM, I didn't mean to admonish you personally. I do agree with you on many of your observations. While I think the younger generation as a whole are less modest, I know from conversations in my office and among friends the modesty issue is still there. It also has some regional influence. Being from the midwest I would suggest we are more conservative and would have a different view than Calif. I don't have conflicting images of female physicians or nurses, for any procedure other than those requiring exposure I have no preference. It isn't that they are Doctors that I have concern with at all. I have two daughters and want them to be what ever they want...we have an office that has been together for over 10 years and have become very open over those years....the topic came up one day that a new Dr. (female) gyn had come to town, the vast majority of women from late 20's-50's all talked about trying her out and were glad to have the choice of a woman not only for themselves,,,,but for their daughters. I also know at a family get together they were teasing a nephew about his physical...he went to his family Dr. (male) only to find out he was on an emergency and the female NP did the physical...all of the nephews (16-25) winched and said they would have rescheduled when he talked about the hernia and that is a pretty small group...but I think it is preobably indicative of the area I live in...the interesting thing,,,very few studies seem to exist in this area...not so sure there is a norm...but I have to agree with your observation that it varies by age, gender, ethnic make up, region, religion...all sorts of things play into my question is why not err on the side of modesty, and allow those to opt out if they so choose...the cost has to be wieghed against the old "dying of embaressment" issue...the fact that the government ran a campeign "real men wear gowns" would make you think there is some recognition of the issue at the upper levels.....and CSM sorry if I came off to critical...didn't mean it that way.....alan (responding to Tues Feb 24)

At Tuesday, February 24, 2009 2:13:00 PM, Blogger MER said...


Perhaps your informal survey does indicate some trends. It's hard to say. But let me toss this out.

First of all, I don't think we can assume the word "modesty" means the same thing for everyone.

So asking people whether the feel unfortable in terms of "modesty" depending upon the gender of the provider -- may or may not produce a valid answer. If the questions were to be more specific relative to observation during a shower, shaving or an exam of the genitles, prostate exam -- then maybe you'd get specific responses to specific situations.

Secondly, perhaps one reason for the difference in attitude between older men and younger men -- if there is, indeed, a difference:

Most younger men have had little experience with intimate exams and procedures (excepting perhaps physicals)or long-term hospitalization. Thus, many of them are dealing mostly on theory, i.e. how do you "think" you would feel. There's a big difference between "thinking" about how you would feel and actually facing the reality of it. It's only when men get older, in their 50's and 60's, when then start having prostate and other problems that might need intimate exams and procedures. There are exceptions to this, but they are the exceptions.

Thirdly, that fact that this gender issue is so far under the radar in both medicine and the general public, shows how uncomfortable we all are with it.

Go to various radiology websites and look under various intimate kinds of procedures and exams. See what they say about embarrassment and/or the gender of the technician.

You'll find nothing. The silence is deafening. It's as if the problem doesn't exist.

This is true for other medical websites that deal with all kinds of intimate procedures. They'll explain the procedure in detail. In some cases they'll say there's no or little discomfort (meaning physical), that't it's "fast and easy" (from their point if view), etc.

Then, talk with patients about these procedures and see what they have to day and listen to their experiences.

When subjects like this are hidden away, it doesn't mean they don't exist or they're not a problem It more likely indicates they are problems that people don't want to face.

So -- I appreciate your survey. But what I'd like to see are exit surveys -- surveys done with patients as they leave the hospital asking them specific quesitons, some like the one's your asking, and other more realistic ones. Questions not about how they "think" they feel about things, but questions about how they actual "felt" about how things were done and whether they would have asked for same gender care if it had been offered and/or was available.

At Tuesday, February 24, 2009 4:39:00 PM, Anonymous Anonymous said...

My reply is if gender is not an issue for most why are female gyns busier than male gyns and why are male medical students refused more often than female students the opportunity to practise on real patients more so than ever before?
See these two articles: and
Clearly these show that there is a growing preference for same sex care for intimate issues.

At Tuesday, February 24, 2009 5:28:00 PM, Anonymous Anonymous said...

An interesting thing is that many of the facilities make no effort to address it on the front end, however will address it or accomodate when asked, I recently had some back and forth with a facility that was very supportive of acknowledging and offering to accomodate AFTER I asked, they indicated it was a valid concern and not the 1st time the issue had been brought up. I think it indicates more of an awareness than we might think, but they are not going to intiate the effort becasue of the "burden" it would put on them. We have discussed numerous reasons the fact that they take act as if it is about them (I have done this...) etc. CSM I intend to visit the site and appreciate hearing all sorts of perspectives......the one we seem to be missing is the professionals...I would assume some have visited...but whether they don't want to be confronted about it or the tone of confrontation....we don't get much from them...that would truely add to this....alan

At Tuesday, February 24, 2009 7:12:00 PM, Anonymous Anonymous said...

Dear CSM

In reference to Dr M's comments
that medical staff get in principle
an enormous amout of training about
proper conduct holds very little
Consider the analogy, most know
the dangers of running red lights
yet even the most seasoned drivers
do it.


At Tuesday, February 24, 2009 8:11:00 PM, Blogger Maurice Bernstein, M.D. said...

LH, two excellent links. Thank you.

New York Times article

Student British Medical Journal article

I hope all my visitors take a look at both. They certainly add to the discussion on this thread. ..Maurice.

At Tuesday, February 24, 2009 8:31:00 PM, Anonymous Anonymous said...

Back in 2007, there was a link posted on this blog which indicated the "gold standard" in gender sensitive care. The page is still online:

Let me quote some of it here.

"A Gender Sensitive Exam is an
examination that involves touching and/or inserting an instrument into a body cavity by a technologist or radiologist of the opposite sex...

No matter what exam you are scheduled for, everyone has the choice to request a same sex
technologist to perform the exam. If the same sex technologist is not available in a timely manner,
you have the following options:"

The hospital is in Toronto
but the text adds that "technologists... are registered under provincial Canadian and American governing

Hope this helps show what can be done.


At Tuesday, February 24, 2009 8:52:00 PM, Anonymous Anonymous said...

Dr. Bernstein:

The New York Times article on
the rights of the male OB-GYN
physician misses the point as
to why such discrimination is
allowed. It's not that women
feel more comfortable with women
doctors. That would be like
claiming a legal position
exists in that white people
feel more comfortable associating
with white people.

The legal position is that the
BFOQ provisions of the 1964
Anti-Discrimination Act allow for
discrimination in hiring when the
patient makes a request for
privacy LINKED TO MODESTY. These
female patients are actually voicing that position when they talk about their comfort level.
That's totally within their rights. The issue immediately

I once asked a constitutional
law professor how this position
can be maintained. He said it
is only maintained for the
same reason the "whites only"
position was the rule throughout
institutions in the south at one

At Tuesday, February 24, 2009 9:27:00 PM, Anonymous Anonymous said...

"The Hand That Rocks The Cradle don’t help to dispel the idea that some male doctors have something other than a mere clinical interest in the female genitalia."
So they are saying that it never is the case? So what do we make of all the sexual misconduct cases?

Graphic: From, an illustration from a book "The People's Common Sense Medical Advisor or, in Plain English, Medicine Simplified" by R.V. Pierce, M.D.
"Carefully Revised by the Author, assisted by his full Staff of Associate Specialists in Medicine and Surgery, the Faculty of the Invalids' Hotel and Surgical Institute." January 1895.

To me, it is interesting that the illustration seemingly showed no concern for depiction of a enlarged, pathologically filled man's scrotum and yet demonstrated modisty by not allowing the reader to see what would have been a normal penis under the leaf.

The text within the illustration was present as the description of the illustration in the original book. I added color to the original illustration for emphasis using ArtRage.

NOTICE: This Volume 10 is now closed for further comments. Continue the discussion on "Patient Modesty: Volume 11". ..Maurice.


At Tuesday, February 24, 2009 10:15:00 PM, Blogger MER said...


RE your comments:

"The legal position is that the
BFOQ provisions of the 1964
Anti-Discrimination Act allow for
discrimination in hiring when the
patient makes a request for
privacy LINKED TO MODESTY. These
female patients are actually voicing that position when they talk about their comfort level.
That's totally within their rights. The issue immediately

I don't think that' show it works. I'm not a lawyer, but the case law I've read says that the court looks at two basic issues:
1. The Essence of Business -- for example, if a nursing home can demonstrate that their female clients will not allow male nurses to do intimate care on them, and if that fact would cause the nursing home to go out of business because female patients won't use the home -- then the court will allow that home to hire all female nurses. The same would be true if the men complained in the same proportions -- but apparently they don't.
2. Scheduling. As in the case above, the nursing home would have to demonstrate to the court that they are unable to use simple strategies like scheduling with both genders to solve the problem.

As I understand it, it's not a matter of one patient complaining. It's has to be a pattern and the nursing home would have to have data to back up their case.

Also, I may have been the one who posted that link you mention. I've been looking for hospital likes like that and have found a few in Canada, specifially, Toronto.

At Wednesday, February 25, 2009 8:31:00 AM, Anonymous Anonymous said...

I don't know who the anonymous post at 9:27 pm on 2-24 was from, but it wasn't me...


At Wednesday, February 25, 2009 8:36:00 AM, Anonymous Anonymous said...

Just an interesting aside.....

Recently I have seen advertisements in one of the local newspapers for a clinic for men that advertises an all male staff. Has anyone else seen anything like this in your area?


At Wednesday, February 25, 2009 9:41:00 AM, Anonymous Anonymous said...

TT no I haven't I have seen/heard ads for gender sensitive care. Is there any way you could provide us with some specific info so we could research it and or send it to our providers as evidence of the issue ....alan

At Wednesday, February 25, 2009 12:33:00 PM, Blogger MER said...

TT -- Would you post info about where you found that ad for an all male staff at men's clinic? That's such a rare situation that I'd like the specifics.

Also, regarding CSM's survey. I had another thought, especially regarding young men and those who have had little hospital experience. People with little experience in hospitals really have little idea of what will happen to them, intimately, and who will do it. Their personal doctors, and even the specialists they go to, rarely if ever talk about gender care or modesty issues. I had a friend recently who had some serious surgery. He had had little experience in hospitals. I had told him about this topic. We discussed it and he chuckled. His opnion before his hospital experience was that this was a bogus issue, a non issue really.

Well -- after his experience he called me and we had a long discussion. His experience had opened his eyes. He hadn't thought gender would be an issue with him. But it turned out to be. And I don't think it was gender so much as the assumptions about how he would feel just being taken for granted. Did he say anything to the caregivers? No -- things happened so quickly, and without warning, that he found himself just going along with it. Then it was over before he could say a thing.

So I think interviewing people with little hospital experience, especially in intimate areas, only gives you their perception of how they feel. When they actually get to the hospital and it happens to them, they may feel differently.

Also, notice those two great links given us about males in gyn today. The focus on totally on women's comfort. Note that neither article even mentions anything about men's comfort with opposite gender intimate care.

Is this a conspiracy? Of course not. But it shows that, to the writers and the medical professionals they interviewed, men's modesty wasn't even a issue.
When you see articles like that and ask yourself what they're about -- consider this. They're not just about what's in the article. They're also about what's left out, what's considered not even relevant, or what isn't even considered at all.

At Wednesday, February 25, 2009 2:49:00 PM, Anonymous Anonymous said...

Alan & MER,

It was several weeks ago - specialty clinic for ED & other male GU problems. I did a quick google search using the qualifiers +clinic and +"all male staff" - apparently there are a number of these type of clinics around the US - at least 40 or 50 at casual glance.

They all stress privacy, confidentiality and an all male staff, so at least somebody gets it when it comes to at least these aspects of intimate care for men. At least it's a start - one can only hope that it will grow to cover other aspects of intimate male care for those patients that care.


At Wednesday, February 25, 2009 4:52:00 PM, Anonymous Anonymous said...

The situation with MER's friend going for surgery and then finding out what all happens with care is "right on." When people have no or little hospital experience it is only a "hypothetical" and people really don't know how they will react when things as such really happen to them.

He hit on what really happens. It is not discussed with a patient ahead of time and they are thrown into the situation with no time to react or process what is happening. It is then afterwards that people become furious, angry, upset, etc. and they have to live with it. The problem the way I see it is the same thing we have said here before: it is assumed men don't care because they aren't yelling about it at the time. Therefore, female nurses think MEN are fine with it all.

At Wednesday, February 25, 2009 5:09:00 PM, Anonymous Anonymous said...

Not even dead patients are immune to abuse.

At Wednesday, February 25, 2009 7:42:00 PM, Anonymous Anonymous said...

Speaking of abuse in nursing homes
just visit Albert Lea Minn. nursing
home abuse on the web and you will
see the three young women who were
abusing nursing home patients physically and sexually.
Now for the best story of them
all!!! It happened about 12 years
ago. I won't say where here,however,only if Dr M gives me
permission. An older gentlemen died
at a rather well known hospital.
His body was taken to the funeral
home. Sometime thereafter an employee of the funeral home called
the hospital stating that" we never
got papers for the organ donation.
The hospital employee stated that
"he was not an organ donor".Funeral
home employee" well he had to have
been cause his penis was cut off
clean and there was a pool of blood". Hospital employee," you
don't donate your penis" it's not
a donatable organ."
Me" where do they find these people at funeral homes. 2nd or 3rd
class idiots" Please chime in.
Then there was an investigation,
the police got involved. Was it a
homicide?. Did the patient die
from blood loss. This happened on
halloween night.
This is a true story. The case was
never solved. The family posted a
substantial reward for information.
My point is this, there are dangers of having a penis. Seems
women are either wanting to cut it
off or look at it! When will the
madness end?


At Wednesday, February 25, 2009 8:23:00 PM, Anonymous Anonymous said...

Does anyone have any thoughts as to how the electronics records prpoasal will affect the issues under discussion here?..Will they make patients or doctors more reticent to have their thoughts recorded at all?

At Wednesday, February 25, 2009 9:02:00 PM, Blogger Maurice Bernstein, M.D. said...

PT, I am confused how the story is directly related to the issue of patient modesty. I am concerned about the expression of bombastic declarations and insinuations regarding classes of healthcare providers both on this thread and the one on the "use and abuse of hysterectomy". I am certain that many female nurses as well as in other work activities would have pleasure looking at or manipulating a man's penis in a sexual context. But, really, can we accuse all nurses of having this intent while they are practicing their profession? The same goes for hysterectomies. Can every ob-gyn physician be accused of what sounds like criminal behavior when a hysterectomy is performed.. every single one.. is that rational, is that realistic, is that fair? Somehow, this blog is about ethics and what sometimes I read here is not a just and ethical expression of an issue.

Why should whole classes of people be painted with the same brush even if certainly there are individuals in that class who are truly unprofessional and may be sociopaths or psychopaths? This kind of painting has led to the segregation of races in the United States which only in recent decades has been challenged and begun to be mitigated.

I fully agree that there is a problem in that the medical profession does not look at individual patient modesty as an issue of professional concern. Otherwise, there would be no need for this 3 1/2 year long thread. But that is a problem that should be corrected rationally. Facts from both sides should be obtained and the problem resolved through practical means settled by both sides. Otherwise calling the medical profession names is just as bad as the profession ignoring the patient's needs. ..Maurice.

At Wednesday, February 25, 2009 11:21:00 PM, Anonymous Anonymous said...

Maurice, I read the hysterectomy thread and I did not get the impression that they were saying every single hysterectomy was the result of criminal behavior. Yes a large majority seem to be though. And criminal in the sense that the patient was not fully informed of the consequences. The statistic of 1/3 of American women having had hysterectomies by the age of 60 sounds outrageous to me. What is your opinion of that high figure?
Do you really believe that calling the medical profession names is as bad as ignoring patient needs? I know what I would rather choose. I think most of these discussions have been quite civil.
Anyway what do you conclude after all that has been written in the various threads?
Are we justified or do you think that we are a bunch of ungrateful whiners.
Not knowing any medical practitioners socially I really have no idea how they think. If you can give us positive stories of how they genuinely do care about their patients I for one would be heartened.

At Thursday, February 26, 2009 1:50:00 AM, Anonymous Anonymous said...

Dr. Bernstein,

I agree. As I have stated before, name calling and blanket characterizations serve no positive purpose, except perhaps to vent personal frustrations, which I guess may be therapeutic in a way.

My belief is that the solution lies in rational discourse, and it needs to start with each patient talking to their provider or facility and politely but firmly letting them know that privacy and modesty are important to you and that you expect them honor that in any procedure or treatment - that's step one.


At Thursday, February 26, 2009 2:46:00 AM, Anonymous Anonymous said...


Yep, patients get steamrolled because they don't know what to expect and it happens before they understand what's going on. While some of it may be because nurses think men really don't care, unfortunately it goes far beyond that - it's deliberate and it happens to all patients, not just males.



EMR is probably a subject for it's own thread (Dr. B. may already have one).

Security of the information, who has access and how much are my main concerns.

I belong to an HMO that has used EMR for many years, and for the reasons stated above, I am extremely careful about what information I provide and to whom. I limit it to the specific information that I feel is relevant to the situation at hand, keep it as succinct as possible, and deliberately redirect "open ended" questions.


At Thursday, February 26, 2009 5:27:00 AM, Anonymous Anonymous said...

Dr. Bernstein, could not agree with you more. For my part the providers have been to a very high percent of the time very professional and good people. I do not precieve the issue to be malintent as much as following the way it has always been, a lack of acknowldegement of the issue, putting their (facility) ease before patient comfort, there are a number of reasons this happens and it isn't always the provider, it can be the facility that controls this. It is also a societal issue, I was in Virgina recently and read where the prisons there passed regulations making it illegal for males gaurds to search female prisoners but not for female guards to search males. Not trying to open the prison-hospital debate again, but it does show how society thinks.

In addition to questions and attitudes being different after an experience in the hospital, I would suggest the answers will differ depending on what and how they are asked including what is left out. Do I have a preference for the gender of a not really. Do I have a preference for the gender of my doctor for a hernia or DRE...yes I do. Would you care about the gender of the Doctor during a genital exam...what about if they were being assisted by a member of the opposite gender....sweeping generalzations about paitent preferences from small groups asked questions without proper scientific controls is similar to accusing all providers of being perverts......I don't think either has any validity, the second is really troubling to me as it is inflamatory and inhibits open discussion....alan

At Thursday, February 26, 2009 1:11:00 PM, Blogger MER said...

I did a google search using "clinic all male staff" and got some interesting results. The following like talks about an all male staff in a veterans clinic. Interestingly, it doesn't discuss the modesty issue at all and says the all male team came together accidently and say they're considering some female nurses for the team. The implication is that gender doesn't matter. At the end, they quote some patient attitudes toward an all male staff. Frankly, I'm not buying the quotes they provide is representative. Here's that link:

Look at this article about an all male staff treating men with impotence. It's fascinating -- not once does the modesty issue come up. It's all under the radar. The implication is that the all male staff influences more men to get examined and treated -- but nowhere does it say so directly. Again, this subject is just not discussed at all. Here's this link:

This website from the Cambridge Medical Clinic -- a clinic that deals with erectile disfunction and other male problems, writes this:

"What about my privacy?

We understand your concerns about privacy and nothing is more important than treating you with dignity and discretion. Our facility is purposely very low-profile, with no signage that would indicate the nature of your visit. We utilize an all-male staff who sign a strict confidentiality and non-disclosure agreement. We scrupulously adhere to all HIPAA privacy policies, including limiting access to your medical records to authorized medical personnel only" The link is:

Most results from a search that includes "clinic all male staff" results in rules about all male staff, such as "all male staff must have a female chaperone when examining a female patient."

It's not common to find links like the last one I provided.

At Thursday, February 26, 2009 1:39:00 PM, Blogger MER said...

Here's a link from a men's clinic in Austrailia. Worth reading the whole brochure about men's health. But 2 or 3 pages in, they say this:

"The centre has an all male staff and designated male-only areas, which works to encourage men to open up about matters they wouldn't discuss at local health clinics."

So, these places are out there. Let's be activists. Let's show brochures like this to our local providers and hospitals. Let them see how it's being handled in othe places.

Here's the link:

At Thursday, February 26, 2009 1:58:00 PM, Anonymous Anonymous said...

LH I have had a lot of experience with providers of all level, while some have been bad, most have been positive. My father passed away recently, his journey was filled with numerous nurses, tech's, and doctors. I watched a nurse carefully lay a gown over him and pull his old one from other it so as not to expose it even though he was unconscious and she and I were the only one there. I watched her keep pulling his gown down to keep him covered while he was "out of his head" and fighting. I watched her rip into a doctor knowing full well there would be repurcusions when he failed to perscribe enough sedative to keep him down in his final hours, and she she tears with us when he passed away. I watched a male nurse volunteer to ride in the ambulance in his off hours off the clock when they could not free one up to go with him to a heart center. I watched a nurse come in and hold and rock my toddler daughter so I could go get something to eat and get out of the room for awhile when she was seriously ill. I have seen genuine compassion and care many more times than not....I have asked numerous times and still much of this issue is the medical system and how much is lack of compassion or care from the front line much of what they do is taught to them by a system that is profit opinion, and its just opinion, the blame lays heavily on the system...the majority of providers are great people....that is my experience...don't know if that is what you asked or not...alan

At Thursday, February 26, 2009 3:40:00 PM, Anonymous Anonymous said...


I am quite sure that most providers act in the best interest of the patient.

I don't think issues of sexual misbehavior have any place here in this blog, if someone breaks the law, that is a crime, not a modesty issue.

Today I was given a nerve block to address pain I have been enduring since my hip replacement 18 months ago.

The nerve block was the most painful thing I have ever endured, by a long way. I am hoping it will give me some respite from the pain longer term.

I was told in advance on the procedure that the radiologist would be giving the injection, guided by a radiographer and assisted by a nurse. I accepted that.

When I arrived I was asked to change into a gown and wear transparent paper pants. I simply said I would NOT be removing my own underwear and they accepted that. I was pleased it did not involve any confrontation.

When my procedure took place, I was face down and in agony several times (the radiologist hit bone about 8 times and had to readjust). I accepted that as being an undesirable but accidental consequence of the procedure.

What I took offence to (after the fact) was that in addition to those i was told would be there, a junior doctor had been invited to spectate, and 2 other voices were heard at various intervals having humorous conversations with the staff dealing with me. I repeat, I was in agony and really did not appreciate additional spectators.

At the time I was in too much pain to say anything.

I have been among those who have advocated repeatedly that we all speak out when we are unhappy, yet I was "struck dumb" during this procedure.

If I now write to the hospital and tell them how i felt, they will think 1) I am ungrateful for my treatment (which is totally untrue) and 2) that I am some sort of wierdo to be raising this issue at all retrospectively.

How would any of my treatment team feel about having spectators seeing them in great pain?

I feel disappointed with myself for having said nothing at the time.

At Thursday, February 26, 2009 3:48:00 PM, Anonymous Anonymous said...

The opinion re the links on male gyns seems to be that there is something wrong with the patient for having modesty issues. I do not apologize for being modest. I thought it was a virtue actually.
The other point is that although I would much much rather have a female gyn, I would use a male if no other was available. However, a male student is a whole other ball game. I find it really difficult to accept that a male in his early 20's is going to have the sensitivity to respect my embarrassment and discomfort for a pelvic exam. This is a new experience for him and I truly believe that he will be discussing it with his friends in a derogatory way at the pub at the end of the week. I have worked with many men that age, I know how they talk and think. Just because they are intelligent doesn't mean they are mature.

At Thursday, February 26, 2009 6:32:00 PM, Anonymous Anonymous said...

I love this article. An male gyn admitting that he would feel uncomfortable seeing a female urologist.

At Thursday, February 26, 2009 7:48:00 PM, Anonymous Anonymous said...

I had a very similar experience with hospice nurse when my sister died last eyar....The fact is tha there is a great deal of compassion....
It is just up to us to figure out how to get them to add consideration..(get the ones who do not show it now) for male modesty issues...I think that perhaps ..they just do not see it as being as stressful as the other things we deal with..

At Thursday, February 26, 2009 8:27:00 PM, Anonymous Anonymous said...

There are women who under hypnosis
claim to have been abducted by
aliens. These aliens would then
perform gyn exams on these women.
Keep in mind that these aliens
have traveled thousands of light
years just to perform a gyn exam on
these poor unsuspecting women.
Here on earth it was estimated that if it were possible to approach only 70% the speed of light that the energy requirement
would be 500 times the energy consumed by the U.S in one year.
If I am ever abducted by aliens
who want to perform any kind of
private exam on me I'll be sure
to tell them I want male aliens
only performing and observing the


At Thursday, February 26, 2009 9:19:00 PM, Blogger Maurice Bernstein, M.D. said...

PT, your so-called "tongue in cheek" stories fail to meet what is necessary to achieve in a rational discussion of patient modesty. It is not about hypotheticals, it is about what some men and women feel is ignorance or inequality of attention to patient modesty by the "earthly" medical profession. There is ample evidence by the writings on these modesty thread volumes that some find a definite problem exists. The goal here is to define the components of the problem and discuss ways to eliminate or mitigate it. I think after a couple of thousand or more commentaries giving personal experiences, we are all aware of the problem. Now let's work on a solution. ..Maurice.

At Friday, February 27, 2009 1:30:00 PM, Anonymous Anonymous said...

Has anyone flat-out refused to accept an opposite gender giving them some type of intimate exam or procedure? My doctor sent me to get a testicular sonogram and when I arrived for my appointment I found out it was an all-female staff. They seemed very surprised when I informed them that this is a job for a man not a women (It wasn't as harsh as it sounds, I was polite about it). I finally said forget it and left. I haven't been back to my doctor. Does this happen often? Should doctors warn guys that where he is sending them has an all-woman staff?

At Friday, February 27, 2009 2:06:00 PM, Blogger Maurice Bernstein, M.D. said...

Without bringing the concern up with the doctor in advance, there is usually no professional concern about nor even necessarily knowledge as to which gender will be performing the ultrasound. When a physician palpates an unknown and undefined mass in the scrotum, the mind-set of the physician when he writes a request for ultrasound is one of promptly establishing a diagnosis and if serious to organize treatment. Patient modesty in this regard would not be considered.

Otherwise, if a physician is about to perform a pelvic exam patient modesty and how the patient will experience the pelvic exam should be a significant issue in the physician's mind. So it all depends on the context. ..Maurice.

At Friday, February 27, 2009 3:10:00 PM, Blogger MER said...

To move from the theoritical to the real --

I hope most of us on this blog accept that it's counter productive to complain if we don't at least ask. If we ask for accommodation, especially ahead of time; if we tell our doctor that it is an issue with us for whatever reason -- if we do that respectfully and are still refused and/or treated unprofessionally -- then we have a real cause to complain and/or find another provider.

Idealistically, providers should consider the modesty issue for both genders and bring the topic up. But that's the ideal situation. In fairness, depending upon the context, providers have much on their minds and may overlook this issue with no malice. I'm not excusing them, necessarily. I'm just point out the reality. It becomes up to the patient to remind providers that this is an issue.

In the case mentioned above with an all female ultrasound staff -- it's best to let your doctor know ahead of time that those conditions are not acceptable to you -- that you will be willing to schedule around staffing at another facility to help with this accommodation. Be firm about your values, but be flexible with the system.

My point -- ask. Bring up the topic respectfully and in a way that demonstrates this is an important issue to you and that you will play your part to be flexible.

At Friday, February 27, 2009 3:38:00 PM, Anonymous Anonymous said...

The whole point is that the patient is often so distracted by their situation that the realities of the staff who will be involved are so far off the horizon that it is not until they face the situation that most just feel so awkward that they comply, those few that don't are obviously the wierdos, why should it be that patients need to guess what will happen and preempt it?

Surely the providers need to begin to be proactive and EQUAL and start to alert pateints to what they will encounter, not "bear trap" them.

At Friday, February 27, 2009 5:59:00 PM, Blogger Maurice Bernstein, M.D. said...

gve, the answer is that the professional who is also "distracted" (actually "fully engaged") in his or her mind about the creation of a differential diagnosis, about the appropriate sequence of events necessary for an acceptable workup and an immediate symptomatic management plan, truly has no thought about future gender selection for the patient even though the good physician should be fully aware of modesty issues of all patients being actively examined or treated by him or her at that moment. But regarding future gender selection for the patient's modesty: NO THOUGHTS.. unless the patient would bring it up. "Doctor, you told me that you are going to order an ultrasound of my scrotum. My request is that the technician to does that be a male. I feel uncomfortable if I am being tested by a female." This will simply and easily put the gender issue into the physician's mind. What happens next should be a response by the doctor about the realities available and what can or cannot be done in view of those realities.

What I have written is based on my own professional experience and my hunch of what other doctors might be thinking or NOT thinking about as they arrange a future study or procedure for the patient. And remember, I have been teaching the importance of patient modesty to first and second year medical students for 23 years! What was on my mind and NOT on my mind was exactly the same which I described about those other doctors. However, after being exposed to all these comments in the past 3 1/2 years here, naturally I am educated to preempt the patient and check about gender selection particularly regarding modesty sensitive issues. But I can reasonably say that for those doctors who were not exposed to the day in and day out comments here, in no way would they preempt the patient facing a gender dilemma. It would NOT on their minds! But, of course, how the doctor behaves towards the patient's request after being informed by the patient is another matter. I hope this explanation helps. ..Maurice.

At Friday, February 27, 2009 6:09:00 PM, Blogger MER said...


I'm just looking a things realistically. We may eventually change how medical professionals respond. But that kind of change really must come from inside the profession. But until then, we need to do two things:
1. Inform more men about how to approach this problem, if it is a problem for them.
2. Inform the medical profession that they need to pay attention to modesty issues.

There are many ways we can do this. But it won't be easy. My research (interviews) has convinced me that most people won't complain if a modesty violation happens to them. They won't even inform the hospital or doctor about it. Why? It's not that they're afraid, although that's part of it. I think it's more that we all have short memories -- and after whatever procedure we go through, we're usually so delighted that it succeeded (if it did) and that we're still alive and out of the hospital, that we often push this issue into the background. We also think of some of the caring professional people who worked with us and don't want to offend them. I'm not saying this is good. I'm just saying I think that this is how people respond most of the time. They don't think of the future. They're more focused on the present.

But I will tell you this. The more men who are proactive, who ask for this accommodation -- word will get out. But part of the key is that we keep a paper trail if we are refused. If we're refused politely, then we write a polite letter complaining about the double standard to the provider and copy to a few other people. If we're refused unprofessionally, we write blunt letters not only to the provider, but also to the licensing and ethics boards. This has to start with men like us who are aware of the problem and who are not afraid to be proactive.

All this has to start with individual patients. If we can get allies like Dr. Bernstein and Dr. Sherman to help us (and I do think we can get more if we try), that will help. We also need to try to get more women as allies, and female nurses. Women go through this, too. They understand it. Let's not make this a gender war. Modesty violations happen to both genders and we need to work together.

We can't write articles for the medical journals about this issue, but the doctors can. But we can write articles for the popular press -- op ed pieces. But if we do that we need to be prepared to get challenged -- so we need to be to provide research, articles, anecdotal evidence.

We can approach hospital CEO's and PR people and try to get to include this issue on their websites. We can show them those interesting brochures we've posted here that discuss modesty issues. We can contact those in charge of ethics issues at hospitals and ask them to hold a forum or discussion about this issue.

I find all the anecdotes written on this and other blogs interesting, but I'm getting tired of them. They are the same stories over and over again.

We need to start working, doing this. Small at first. One a local level.

At Friday, February 27, 2009 6:50:00 PM, Anonymous Anonymous said...

In my case, the doctor wrote a prescription (?) for a testicualr was for specific radiological centers (the company) that one had no male ultrasound techs....there are other centers in the area (owned by different companies) and next time I will call around and see if I can get one for the center that has male techs. Even with a doctors order you still have to call for an appointment here...and htat is th etim,e to find out if gender preference can be accomodated.

At Saturday, February 28, 2009 4:47:00 PM, Anonymous Anonymous said...

The majority of techs in ultrasound are women. Men don't think ahead of time when going for the test. They are caught off guard. The only way to avoid the problem is to call and find a clinic that has a male on staff. This can be difficult. As stated the only way to make things change is for men to walk out (as annon did) and the clinics will respond because they don't like having $$$$ walking away.

If women went in for a mamogram or an ultrasound of the breast and a male tech walked out to greet them, what do you think they would say (or their husband would say)?

How can female techs really expect men (and their wife if married) not to care? It goes against all logic and actually against respect and decency. Healthcare or not.

At Saturday, February 28, 2009 7:45:00 PM, Blogger MER said...


I disagree to some extent. You say the only want make things change is to walk out. Not true. Here's what men should do.
1. Make sure the doctor who orders the ultrasound knows your preferences, and ask him or her to help you get the accommodation you want. Some may advocate for you. They may call and talk with people at the clinic.
2. If your doctor suggests a specific clinic and you find out they have an all female staff and won't accommodate -- write a letter to your doctor and copy the clinic. If your doctor is part of a larger health car system, make sure you also copy someone in upper management with this letter. Be polite, but state firmly that your doctor and any others working in the system have an obligation --if he recommends this clinic to men -- to tell them upfront that all the techs are female and specifically what they will be doing during the procedure. If that's okay with the man, then fine. If it's not, they at least know up front and have an opportunity to find another provider. The clinic will not like seeing this letter. They wont' like the idea that they may lose business right off the bat if the truth be told. A letter like this may make them think about the possibility of hiring at least one male tech and trying to accommodate men.
3, If you eventually find another provider who will accommodate you -- send another letter to those you sent the first one to(make sure you copy the clinic that wouldn't accommodate you), and tell the story of how you were eventually accommodated and that the clinic that did accommodate you should be the one the hospital recommends.
3. If you are promised accommodation and show up at the clinic, and they either forget or have had a schedule change without telling you ahead of time -- then you can walk out. Follow up with letters to the appropriate places.

This is how I believe men can begin to create change.

At Saturday, February 28, 2009 8:20:00 PM, Anonymous Anonymous said...

Great post MER...but if your doctor is not the one who makes the appointment for you (maybe even if he does) you need to check with the clinic about the availability of a male technician. If they do not confirm that you will get one, you need to get in touch with your doctor and have him reissue th eprescription (or whatever it is called) for another facility..You would need to call around and find one that can and will accomodate you first you can ask the doctor to name this facility in his referal (my insurance pretty much lets the doctor decide when he needs to do that..). I am not sure why , but it seems every lab and specialty facility has their own form the doctor needs to use...
The main point is that your doctor may have no idea what gender of techs are available at a certain the patient should check them out by phone anyway...
This is just to add to your comment.

At Sunday, March 01, 2009 11:48:00 AM, Anonymous Anonymous said...

MER, just to clarify my comments as noted. Due to the limited remarks here it is hard to elaborate. I agree with your approach of changing things. When I stated the only way to change things is for a man to walk out, I really meant in the circumstance that "annon" was detailing. I fully agree with all of what you thought would be productive. But for those that "show up" to have a scan done and are totally oblivious to this subject matter and if it the first time for the patient, then, yes, I say walk out-refuse the female tech. Once a patient knows what they are going to be walking into they can prepare for the situation, as you stated. But many aren't aware and when they are in the doctors' office they don't know what lies ahead for them where the tests are performed. Doctors don't know usually who is on staff or the availablity.

At Sunday, March 01, 2009 2:08:00 PM, Blogger MER said...


I think we agree in essence.

But this is why it's important for men who do know the score to remind doctors that when they're referring their patients for sensative procedures and exams, they need to consider the modesty issue and thus staffing issues. It's not good enough to just refer a patient to a clinic that you know nothing about, in regards to staffing.
This is a very sensatative topic, and doctors are aware of this and have been taught about this issue -- as Dr. Bernstein has told us. My guess is that it won't take many reminders and/or letters for doctors and clinics to the message.
I'm convinced that the medical profession would much rather deal with this issue privately and figure out ways to accommodate those patients who want it -- rather than have the issue made public and then have to deal with bad publicity, potential business losses and/or mandated regulations.

At Sunday, March 01, 2009 3:35:00 PM, Blogger Maurice Bernstein, M.D. said...

Can anyone explain to me the psychodynamics, the emotional mechanism why a patient would find that exposing some parts of their body to an individual of the opposite gender who would or did carry out an action as appropriate for the need and in a fully professional manner create an issue of modesty. And this issue of such enormity that a patient would avoid a necessary examination or procedure appointment or walk out when made aware of the gender? What is it about the presence of a professional of the opposite gender that would precipitate these decisions? Is there a concern that one's body appearance is not "up to snuff" (not as sexy or as beautiful as one might consider as "standard" or "acceptable")? Is there a concern that the professional really has unprofessional perhaps sexual thoughts while carrying out an examination or procedure? In the case of a male, is it feared that with genitals exposed, the patient will have less control over sexual urges (compared to exposure to a male provider) and will be in a helpless embarrassment if by chance a penile erection, even just spontaneously, occurs and witnessed by the female? I really don't think that the cause of the modesty has been discussed here as yet.

Now, maybe as suggested, this thread is NOT about modesty but the right of privacy. That is, as a patient "I have the right to expose my body to the individual I choose and cannot be forced or coerced in anyway to expose my body to someone that I don't want." This attitude would have nothing to do with modesty but would have everything to do with patient autonomy.

So, what do you think is the cause that has led men and women write about their emotionally traumatic experiences here? There are still areas of discussion on this thread yet to cover. ..Maurice.

At Sunday, March 01, 2009 4:05:00 PM, Anonymous Anonymous said...

Dr B,

why do people need a reason?

If I feel less comfortable with females about when unclad, that is how I feel, end of discussion. How would you feel about being asked to rationalise your choice of restaurant or bowling alley etc etc. We all have feelings which my or may not be understood by others, asking for an explanation is not really going to get us anywhere. I don't want women involved in personal procedures because that is how i will feel more comfortable. I have fought my local provider hard to be allowed to receive urodynamics with an all male team - I have won, the female nurses involves have been less than gracious. I wonder how they would feel if they were asked to present themselves for a urology procedure to be carried out by 2 males......... It s not rocket science. As JW said, it is against all natural respect and decency, pretending it is not an issue is just a charade.

At Sunday, March 01, 2009 6:10:00 PM, Anonymous Anonymous said...


I think it’s fair to say that this thread is about both patient modesty/privacy. When I started posting here, I was simply venting because I had become frustrated in my situation and just wanted to release. Since then, I see things differently and care more about getting the message out to providers that it just shouldn’t be tossed to the side like the days garbage and it should be addressed with the patient. It’s been stated many times on this blog that people go through these procedures and find out later what happened to them when they were under. I can imagine that can be quite upsetting and so people try to find answers on the internet and like me, vent when they get the chance. What happens to the patient stays with the patient for his/her life, they just can’t write it off like providers and say that it was my job. They do it to get answers because their providers didn’t give them the full picture upfront. They also may find some comfort posting on blogs since there’s no emotional attachment to the readers. Jimmy

At Sunday, March 01, 2009 6:51:00 PM, Blogger Maurice Bernstein, M.D. said...

gve, one can give all the "natural respect and decency" that is humanisticly possible and yet a patient's concern may still not be able to be mitigated because of factors that, from a practical point of view, may, at the time, be difficult to change despite the attempts. One would be inadequate or inappropriate resources which are available. I may have already written this previously.

Understanding the personal reasons for a patient's concerns is worthwhile because depending on the reason, though education or other supportive means perhaps the concerns can be reduced. example. Suppose the main concern, perhaps the sole concern, was that the male patient feared that a penile erection might occur during a genital exam or procedure.
If the patient was educated that all physicians (including nurses) are aware of this reaction and have had similar experience with other patients and were specifically trained on how to respond if the patient is upset and that this doesn't represent a sexuality issue but a physiologic reaction wouldn't that help to reduce concern?

This is just one example of how understanding the underlying "reason" for the patient's requests would be of help to ease or settle the concern.

In a world where all options were available to everyone's requests and without consequences, that would be a different world than what we have now in medical care. But as it is, we need to know the facts about problems and within the limitations available try to mitigate them as practically as possible. I really don't know what further to say. ..Maurice.

At Sunday, March 01, 2009 7:04:00 PM, Blogger MER said...

Doctor –

The answers to your question are complex, and I don’t pretend to be an expert. I think we have discussed this before on this thread, but I’ll offer a few ideas.

First of all, I think the question can validly be reversed. Why would a profession allow a patient who needed care to walk away for this reason – unless the professionals were completely unaware of the issue? If that were the case, then it’s understandable. If they do know it’s an issue but refuse to deal with it – I’d like to know how they view the ethics of that decision.

Yes, it could be body perception issues. My guess that would be the case more with women that with men, but I could be wrong. Our current culture puts so much emphasis of buff bodies, that it’s easy to understand why some people would have a negative body image.

I think a big issue is control, especially with some men having women in control of most personal parts of their body. This may be the concept of power that I brought up earlier on this thread. Patient autonomy is an important factor.

A big issue is surprise. No one likes being surprised in personal situations like these. This is what some refer to as an ambush. Why didn’t someone tell me there were no male techs at this place? I called twice, once to make an appointment and again to confirm it. Why didn’t they let me know? Why didn’t my doctor tell me how embarrassing this might be? Of course, we’ve discussed this here. This feeling might create enough anger to cause someone to walk out.

Less control of sexual urges and possible erection with men? Yes, I do think that’s an issue. It’s no secret that the male sign of sexual arousal is more visible than that of the female. Whether the male patient is “actually” aroused or whether the erection is an uncontrolled reaction – it doesn’t matter. The result is the same. I’ve always been amazed at how some professionals react to this. “Don’t worry. It’s perfectly natural.” Well – it isn’t perfectly natural in that context. Yes, an erection may be a natural reaction to the genitals being handled. But in our culture, for a man to have an erection in front of a strange female who is touch his genitals is not “perfectly natural.” And for caregivers to ignore it? Again – the elephant in the room. Pretending it isn’t there doesn’t mean it isn’t there. It just means no one is willing to acknowledge that it’s there.

Unprofessional or sexual thoughts on the part of the caregiver? My guess is that this is the last thing on the mind of men in this situation – not sexual thoughts, anyway. Some men may have fears or concerns about private talk that may occur behind closed doors. But that may be more a matter of trying to control things you have no control over. This issue may be more important to women, since the majority of abuse cases involve male medical professionals abusing females. But I don’t think it’s an issue with most men.

But you seem to be referring specifically to a person who will walk away from an exam and/or avoid the exam or procedure. Perhaps this behavior has more to do with the perception of lack of respect – especially if the individual has made his preference known and that has been ignored. It would be quite rare for a person to do this – so I would think it would be more connected with a feeling that one’s dignity was at stake. Frankly, the real danger to our health care system isn’t about people walking away – it’s about people who won’t speak up, and then feeling not just uncomfortable or even embarrassed but humiliated and angry with themselves and the provider. This is what causes lack of trust.

The only way we’ll come close to getting an answer to this will be to do serious interviews with patients based upon – not theoretical feelings they may have about how they think they would feel about this issue – but interviews based upon experiences they have actually had and how they felt and feel about that reality.

Why do people write about their experiences on your blog. Finally – finding someone to listen to them who will not judge them but listen. Generally speaking, the medical profession doesn’t want to hear these stories. They don’t ask patients in exit interviews about modesty issues. As I’ve learned, most people are extremely reluctant to talk about privacy/modesty violations once they leave the hospitals. But once I get them to talk, they won’t stop. I urge them to write letters to inform hospitals/clinics about their experience to help them improve their service. Few do this. They just want to put it all behind them. For some, it’s almost like a post-traumatic stress situation. They push it far back into their minds and try to forget it.

The answer to your question, I believe, is "all of the above." How to divide all these reasons up and give them weight -- I don't know. but I think they represent the major reasons for what we're discussing.

I’d really like to hear a psychologist or a psychiatrist comment on this issue. Again, I want to be clear that these are just ideas based upon the reading and research I’ve been doing. I'm not an expert.

At Sunday, March 01, 2009 7:34:00 PM, Anonymous Anonymous said...

I don't think it is as simple as "the" reason. There are many reasons and some go back into each individual phsychic. Trying to come up with a general reason isn't really reasonable much less possible. If there is one thing that we have learned, we are all individual with different preferences and reasons. Some care more about what happens when they are out, I personally don't.

I can also tell you that to some degree I don'know. I also don'know why people have fear of public speaking, or fear of hieghts, or close spaces. I don't know why I like steak but not aspeargas. I find thin women attractive but not obese, I don't like full lips on women but society says I get my point. I do know that if I am exposed to a female I feel I may be judged and I care, where with a male...I don't care. I can tell you I was brought up to believe you should cover yourself in the presence of the opposite gender. I also have to tell you I would find little comfort in a "professional" telling me how they feel about the issue, it isn't about them any more than they would care what the opposite gender janitor felt if they were cleaning the restroom while they were trying to use it. A nurse could tell me all day that my erection wasn't a big deal to them, because it would still be humiliating for me. I guess part of this comes from the fact that I have personally heard personally, and read enough on sites like allnurses to know that many providers feel just like we do when they are in our shoes. So I guess the long and short, why...if feel judged, I have been brought up that way, I feel providers aren't exactly honest about this as per the hypocracy when they are patients, and while I can accept the can't, I do not feel there is nearly enough effort on providers part to truely determine what is a can't, and what is just don't. My question is why should I be made uncomfortable, why should I have to "deal with it", why should I have to fit my personal belief around what providers choose to provide. I have accepted can't several times and been OK, but I really question how often they can't truely happens vs just choosing to. And to be honest Dr. Bernstein I feel providers often just don't make the effort...a simple example, everyone knows patients hate those gowns, and granted they have their place...however most of the time there are reasonable options..and yet, there is little effort on providers part to do something about it...if they don't do something as simple as provider better options in clothing...why would we think there is much different in other I guess part of it is I have no reason based on history to believe the effort is being made to put any value of any degree on my comfort so I have to....alan

At Sunday, March 01, 2009 7:43:00 PM, Blogger MER said...


What you write below baffles me:

" example. Suppose the main concern, perhaps the sole concern, was that the male patient feared that a penile erection might occur during a genital exam or procedure.
If the patient was educated that all physicians (including nurses) are aware of this reaction and have had similar experience with other patients and were specifically trained on how to respond if the patient is upset and that this doesn't represent a sexuality issue but a physiologic reaction wouldn't that help to reduce concern?"

We're not dealing with the cognative domain here. We're dealing with the affective domain -- the emotions. You don't just "reason" with emotions

First, you acknowledge a person's emotions. They exist. That's it. You accept that they exist. What "gve" said may sound unreasonable to some -- "Why do poeple need a reason?" -- but from an emotional point of view it makes sense.

Now, after you acknowledge a person's emotion you can "treat" it with therapy. But is what we're discussing on this blog a mental illness? Is it a personality disorder? Or is it a valid way of perceiving reality based upon the social mores of this culture?

I've been an educator most of my life and I don't have the faith in "education" that you seem to have in these matters. It's not a matter of sitting down with a patient and explaining away his or her emotions using reason. That's not how it works.

If what you suggested really worked, we wouldn't have the problems we have around the world today. Today's strifes are based as much upon emotion as they are upon oil and land.

It's not a matter of just sitting down with the palestinians and israelis and rationally explaining the reasons for ending their conflict. We're dealing with a history of human emotions.

As human beings, our emotions have more power over us that we realize most of the time. I'm not saying that we have no control over them. But before we can even begin to control them we have accept them for the powerful forces that they are.

At Sunday, March 01, 2009 7:55:00 PM, Anonymous Anonymous said...

Dr. Bernstein, I have thought about the reason for why I feel the way I do about exposure of body parts...and it seems it is a little of some of the reasons you listed...and to be honest..there is a great deal of what I feel for which I can not account.
That is one of the reasons that I was so glad you invited others like those from clothesfree to share experiences and give additional perspective on the issue of modesty in the mind of different indiviuals..and how they came to feel that way.
I have not only have been trying to see how to deal with situations where exposure is necessary for doctor exams and tests in his office..,but also to try to see if I can also be better prepared in case of an emergency where I may have little or no say...It might be a bit of the feeling of loss of control too.
Even though we go to a doctor of our choosing most is not as volutary as it might appear to is because something is going on we can not tend to on our own...
I really think that most of those who post here would just as soon not have this issue....
I think that privacy and modesty are both important parts of this blog.
I wish I could give you a clear cut answer, but I don't have one ..

At Sunday, March 01, 2009 9:14:00 PM, Blogger Maurice Bernstein, M.D. said...

MER,all doctors should be dealing with the patient's emotions. They are taught that in medical education and if they don't they are simply technicians and not physicians. We deal with the patient's biological condition but we are also required as part of our profession to deal with issues of the patient's social condition as well as the patient's emotional condition. With regard to emotions which are not cognitive and not necessarily constructive and may even be irrational, a therapeutic approach to emotional reactions which may be excessive or non-beneficial to the patient is by establishing the basis for the emotional response and then education of the patient in ways to handle their emotions so that they are less symptomatic.

Sure, you could argue that discussing the issue and educating the patient to realistic approaches may be inappropriate or fruitless, and you have a right to your opinion, but how else can a doctor attend to the patient's emotional symptoms but use drugs. Sure, the doctor could prescribe a tranquilizer taken before the exam or procedure to relieve anxiety but is that better than having the patient understand the realities of their concerns through education? Yes, to tell the patient who remarks about fearing a spontaneous erection that this is not a rare phenomenon, it will pass and indeed that it occurs is proof of normal function and absent disease of the nervous and vascular system. That's education. If the physician is made aware of other emotional concerns or reactions, similarly educational support can be an important tool for management. ..Maurice.

At Sunday, March 01, 2009 9:51:00 PM, Blogger MER said...


I think we probably agree on the essential issue. The problem is that often these discussions seem to float down to the most extreme cases -- the man who walks away and avoids getting medical care. These cases need special considerations.

Mostly though, it seems that we're talking about relatively simple accommodation cases that could be solved with either creative scheduling or making a little extra effort in hiring.

Granted, all male or all female teams are not easy to accommodate. I do consider those to be extreme cases.

But most of the accommodations we're talking about shouldn't be that difficult ot handle -- if providers are really concerned with this issue and think it worthy of attention.

At Sunday, March 01, 2009 11:16:00 PM, Anonymous Anonymous said...

1) There was a time when female nurses would strike the penis if
a male patient had an erection.
As a result of this some resulted in permanent sterility. Do you
know even young boys were struck!
How sick is that!
2) The March issue of Business weekly has an article on extreme
customer service and the 25 top
companies. Sadly, none are healthcare companies!
3) The continual banter will never
solve this issue regarding double
standards and as such the solution
will never come from within the medical community.
4) Recently, at a luncheon I met
an attorney in general practice as
well as a medical malpractice attorney both who spoke interest
and assured me they would read
though these threads.
5) Medicare and Medicaid will no
longer reimburse hospitals for
patients who acquire infections
while in the hospital. No doubt
that most insurance companies will
soon follow. My point being if
nurses don't wash their hands do
you really think they care about
you much less your privacy.
6) My point with non earthly visitors being a) we've never been
visited b) evolution solves all
forms of ignorance.
7) I've never visited nor made any
comments on the hystero threads and
furthermore I couldn't care less about womens lack of privacy issues. They can blame it on the
female nurses, that just about
incompasses all nursing staff.
8) The entire female medical community believes that men don't
have any modesty issues. Talk about
painting entire classes of people
with the same brush! How would they
know? If men were not discriminated
against, this thread would never
9) As I've said repeatedly, modesty
in this context is misapplied. It's
improper diction. Privacy is a more
appropriate term.
10) It's discrimination pure and
simple when you accomodate one
gender and not the other either by
deliberately not hiring male nurses
or simply refusing to make any
accomodations. We all know what the
driving force behind that is!
One only needs to look at black
america to see that you can't reason with the ugly head of discrimination. That's why laws
need to be written.


At Monday, March 02, 2009 5:17:00 AM, Anonymous Anonymous said...

Dr. Bernstein
I think part of the problem here is we feel often providers try to put the responsiblity of this on the patient rather than make the effort to change on their part. I am not talking about the extremes. That very issue is one of the things that fuels at least the intensity of my emotions on this. I feel the focus of providers has/is more on how to make patients more comfortable accepting the situation that actually changing the situation. I would say gender of providers in scheduling in facilities to accomodate isn't even a consideration. I am not talking about hiring, I am talking about making sure there are, when possible a mixture of male and female....I would lay money that never even comes up....the patient must just deal with what is presented. The effort there is seen as unreasonable on the provider side..or isn't even a part of the emotion on my side is the perception that instead of looking for ways to accomodate which would cause effort on their part..they would rather we make the effort....that puts a negative on the whole concept that providers are putting us first....alan

At Monday, March 02, 2009 5:57:00 AM, Anonymous Anonymous said...


you said "if providers are really concerned with this issue and think it worthy of attention."

They are not concerned with it and they do not think it worthy of attention.

So what then......

At Monday, March 02, 2009 7:27:00 AM, Blogger Maurice Bernstein, M.D. said...

By the way, all lawyers and doctors and administrators are welcome to come and read these threads but even more welcome to actually write here their responses to the issues presented. ..Maurice.

At Monday, March 02, 2009 11:24:00 AM, Anonymous Anonymous said...

Providers are not concerned with the issue regarding male patients albeit female patients are always
welcome and accomodated.
Read that facilities mission statement and correspond with your
insurance carrier. I assure you
that every medical facility has
recieved a request and made accomodations for female patients.
Ask why you cannot be accomodated
and get their name. For me it has
nothing to do with so called modesty issues and everything to
do with past experiences of unprofessional behavior among female providers. I'll bet it is
nearly impossible for a male to
get a job as a mammographer and
most likely frowned upon for a male
nurse to work in L&D, despite the
fact that they both may be very well trained and professional.
Believe me I'd have no interest at
all in doing those jobs,however, if
female patients make a gender request that's their business and
it is the male patients business as
well to make a request.
On one of these sites It was stated that " can female nurses,cna's,techs leave their gender at the door". They may act professional but are they thinking professional. It was further stated
that physicians are trained to think professional. To me personally,its all irrational. Some
say that well most nurses are
professional. In what respect? Are
they professional if 55% of the time they are professional with
77% of their patients or 77% of the
time they are professional with 55%
of their patients. Where is the
empirical data? There is none!
To say that most are professional
is simply bad logic. How do you know and for that to be true 51%
of them would have to be professional 100% of the time all the time. After all they are not
trained to think professional,
therefore how can any of them be
professional. Maybe you've never
heard them gossip about male patients and yes they ALL do it.
My point is proven and one only
has to look to the prison system to
see that. It is considered a crime
of rape for a guard to have sex with a prisoner and according to
the justice department female guards excell in those statistics.


At Monday, March 02, 2009 11:35:00 AM, Anonymous Anonymous said...

In comment #10 of my previous thread I'd like to clarify.
In Black America, blacks have
for years been discriminated
against. They have realized that
discrimination cannot be reasoned
with and as such for many men the
double-standards of discrimination
in healthcare cannot and should not
be reasoned with. This has to be
changed within the legal system by
filing complaints of discrimination
through lawsuits and boycotting
each and every one of these facilities.


At Monday, March 02, 2009 1:57:00 PM, Blogger MER said...

gve wrote:

"you said "if providers are really concerned with this issue and think it worthy of attention."

They are not concerned with it and they do not think it worthy of attention.

So what then......"

First, I believe that some providers are concerned with this issue and do think it worthy of attention. I can't guess how many, but I'd bet that it's more than we realize. What bothers me most is their reluctance to bring this issue up with patients.

Second, "so what then...?"

If they appear not to be concerned with this issue, then you deal on a human to human basis with what they are concerned with. So...what are they concerned with..
Most care about making people well and helping people. That's why they went into the profession.
Most care about the business end of medicine, making a living.
Most care about their reputations.
Most care about the profession they are in and believe in the ethical principles in the oaths they have taken.
Most care about the dignity with which their spouses and brothers and sisters and mothers and fathers are treated within health care.

I could go on, but you get my point. I'm not suggesting you beg. I saying that men need to find that common ground with their providers where we can both respect the dignity and humanity of each other and at least work to solve or mitigate this problem.

There will be both medical profewssionals and patients who will be too stubborn to budge. But most people know what it means to be human and respect the dignity of their fellow humans.

At Monday, March 02, 2009 2:22:00 PM, Anonymous Anonymous said...

PT You sound like a misogynist. You are doing nothing for your cause by attacking what women have fought hard for regarding their modesty rights. By the way, I have read plenty of current comments on boards by male gynos who are extremely indignant that a woman would have the audacity to want a female gyno. They cannot fathom in the slightest why that would be. As if female patients have never been sexually abused by male physicians.
You should read the hystero threads. It is not about modesty, it is about castrating and desexing perfectly healthy women for money. And male gynos do it at a rate of 60% more than female gynos. Now that is a serious issue. Women still have a long way to go believe me.

At Monday, March 02, 2009 7:18:00 PM, Anonymous Anonymous said...

PT is absolute correct in viewing
this issue as another battle in the
war between the sexes.

LH, you sound like a woman.


At Monday, March 02, 2009 7:24:00 PM, Anonymous Anonymous said...

Your comment on finding common ground seems like an essential part to a soulution that will be workable and not leave a bad taste in anyones' mouth. A resolution based on mutual respect and understanding for each others position and abilities,,,and obligations without being heavy handed ( I gotta think that the golden rule applies and works)would be achieved amicably. Many of us were in the past, unsure if and how to speak up...I think many have given the various times and methods to do is a great beginning.

At Monday, March 02, 2009 7:47:00 PM, Anonymous Anonymous said...

ON VOY.COM, today.
Let's comment on this
point of view(assuming
you believe it). KYLE K.

"I don't understand what's wrong with being turned on during a medical procedure. After all, being turned on would not inhibit the procedure. Why not make medical procedures as pleasant and enjoyable as possible?
As a senior resident, that's the philosophy I take towards my patients; this I do withoug sacrificing quality of care. It just makes a lot more sense to assign a female for shaving a man. In fact, I'm sure that most females feel short-changed that very few male nurses are available to perform intimate procedures on them."

At Monday, March 02, 2009 7:57:00 PM, Anonymous Anonymous said...


I am not the enemy,nor am I a
misogynist. I agree with you that
bad things happen to both genders,
however,that is not my battle.
I find it concerning that you
would attack me for trying to defend myself against those that
practice misandry and discriminate
against men. I'm actually a
misanthropist, the hatrid of
humanity in general. No one can seem to do anything right.
Perhaps you should read about
the history of male circumcision
since you are on the subject of
One more thing for your sake,
watch out for little green men!


At Monday, March 02, 2009 8:52:00 PM, Blogger Maurice Bernstein, M.D. said...

PT, please let's keep the discussion civil without ad hominem innuendos.

Kyle K., if this view of accepting the "philosophy" of being "turned on" (I presume meaning sexual) during medical procedures is really from a physician, I would say that physician is on his way into big deep trouble with his supervisors and medical board.

Of course, every doctor is human and has their own sexual urges but the responsibility and permissions doctors get from society require that these urges be suppressed and not allowed to interfere with a professional doctor-patient relationship. I am certain that though this physician belief that he or she "may not be sacrificing quality of care" at that moment, there will be a time with this attitude when care will no longer be for the patient's medical benefit but will be for the sexual interests of the physician: a corruption of what society expects from its physicians.

If this "senior resident" is real, you can now see what we know as the "hidden curriculum" where our 3rd and 4th year med students, interns and early residents lose their ethical and humanistic teaching from earlier years as they get the "message" from such "senior residents". ..Maurice.

At Tuesday, March 03, 2009 5:13:00 AM, Anonymous Anonymous said...

PT: I think everyone here has shown a great respect of eachothers right to present opinions. However, the way we present those opinions will determine whether people take them constructively or dismiss them as ranting. If your purpose is to vent and confront then have at it, if you are truely interested in meaningful conversation and or looking to cause might think about how you communicate. I have had some surprising success by communicating with providers on a reasonable level with the thought I would elevate it needed...I didn't.

LH: I understand how you feel, males are ususally on the other end of this equation. Females are usually the ones who are the ones who are discriminated against and males are the ones saying "what about me, we are victims to"...the long and short is males are subject to the violation of modesty more often just due to the sheer make up of providers. over 50% of new med students are female, over 90% of nurses are female...the numbers just make it more prevelant that males will have opposite gender providers. Females can go to a female Dr. and will almost always have a female nurse or assistant, males will almost always also have a female nurse or assistant. And societies attitude is also against males in general on modesty as evidenced in multple areas which we have touched on before cross gender strip searches in prison, reporters in locker rooms, different sentences for teacher/student affairs depending on the gender of the teacher. All of these are indicative of the attitude society as a whole has reguarding male modesty vs female. Just as it was in the struggle women waged it is important to acknowledge the realities of the issue. That said, it does not minimize in anyway the severity of the issue when females are the victims of this, and they are indeed subjected to the same indignities, and when they occur they are just as wrong. But to try to say there is no difference between how frequently and the attitudes toward this between males and females is denying the obvious. Now if we truely want to promote will take men and women joining together to force the change. Blacks achieved progress only when whites joined with them, women started the journey toward equality only when men recognized the iniquality and joined with them...these "minorities" had to force the issue, but it took society as a whole recognizing the issue and joining in the effort. We can accomplish so much more together than apart.

I seriously doubt the post on voy, that site has a lot of fetish, role playing, and make believe on it. However, it brings an interesting issue to the surface, while providers claim the high road that it (nudity) really doesn't effect them in the medical setting, but every once in awhile there will be some revalation that indicates this isn't always the case, and more often if there is a slip inappropriate comment, a breach of policy, talking out of school, etc. the "we are only human" card is played. The problem as I see it is while 99% of providers do a great job being professional and not letting it show, denying that is is present makes it easier to not deal with it on a proactive level that focuses on preventing or limiting the incidents vs just learning how to deal with them. If they were to come out and say, well yes nude paitents effect me this way or that way but I have learned not to show it....society would have a whole different level of acceptance. We want to believe it has no effect, it is different for our own comfort. Those who question that....have a lot harder time accepting opposite gender care...I guess the long and short I think it still boils down to a don't acknowledge and we won't have to deal with it....PT, LH sorry if I seem judgemental, I don't mean to be, my opinion is just that and has no more value than yours....I alan

At Tuesday, March 03, 2009 10:59:00 AM, Anonymous Anonymous said...

I am beginning to understand the similarity between the attitudes of medical care givers and naturists. We both get blase about there being two body operating systems, male-female like Microsoft-Apple, so we easily lose focus on gender being more than a tech issue or being a big deal for modesty. We both work hard to respond to other people's attitudes, but underneath we still are pretty sure our values are in fact correct -- to cheefully accept the inescapability of life's essential yin-yang and then, without angst or fuss over operating systems, to treat everybody and every body with impeccable respect and dignity.

It is certain that neither medical care givers nor naturists are any less sexual in their private lives, but that doesn't get translated into routine settings. It's not a matter of heroic suppression or "not letting it show." It is just about being normal, treating others with respect, and internalizing attitudes in a way that gets translated into behavior that others immediately sense is genuine.

Issues with modesty/privacy must somehow derive from preconceptions about the danger of bad experiences, so the only solution would seem to be contravening good experiences. A good experience with a male student gyn or a female testicular ultrsound tech perhaps. This is definitely what happens with naturism. People have all sorts of preconceptions and security, body image, modesty and other concerns until they actually experience the opposite, and can really see and feel how naturist values get internalized and translated into behavior.

Dr B, you mention that you now "preempt the patient and check about gender selection particularly regarding modesty sensitive issues." I think this is wrong. It proactively injects gender concerns into a health situation, sending the wrong signal. Instead, while being alert to patient modesty issues, you should be reinforcing the message that the people you work with, regardless of gender, are supremely respectful. It would be like if I were preemptively to rush up to a new naturist to ask if they might be more comfortable hanging out with their own gender, instead of reinforcing through my own behavior that gender is a non-issue and that they can feel comfortable and secure with anyone. In both medical and naturist settings, our first responsibility is to communicate and ensure a norm of friendly and flawless respect, not to offer preemptive solutions that torpedo the norm by reinforcing worries. Then, within the context of a clearly communicated norm, we can respond to particular concerns. (CSM)

At Tuesday, March 03, 2009 12:10:00 PM, Blogger Maurice Bernstein, M.D. said...

CSM, I fully agree, my use of the word "preempt" may have been the wrong word. If I told the patient I was referring him for a scrotal ultrasound and then explaining in general the procedure and there was no hesitation to acceptance on the part of the patient to what I said, I would still say "Do you have any questions about the procedure and how it is carried out?" This is routine and should be handled in the same way by all referring physicians, however after reading these threads, I would be sensitive to any further hesitation and might say "Do you have any problems about who does the examination?" That is my "preemption" which other "thread uneducated" physicians surely would not ask.

I agree, since my philosophy is that an individual of any gender who is competent and professional should be appropriate for most patients and that if I were to start out asking all patients for gender preference I would be sending the "wrong signal" and instilling a thought that I myself believe is unnecessary. ..Maurice.

At Tuesday, March 03, 2009 12:33:00 PM, Blogger MER said...


It's interesting getting your perspective on this issue. But I see a few problems with your position and solutions.

You write:

"Issues with modesty/privacy must somehow derive from preconceptions about the danger of bad experiences, so the only solution would seem to be contravening good experiences."

You reduced causes and solutions to "must somehow derive" and "so the only solution." Beware of using words like "must" and "only."
You may be right about one of the causes of this and one of the "solutions", but you're looking at this very narrowly. And by even using the word "solutions" your assuming this is a problem. Now, it may be a problem for the health care system -- and it may be a problem for patients who can't get the accommodation the desire -- but you seem to suggesting it goes deeper than that into the psyche and personality of those who want same gender intimate care.

Secondly, embedded in your last parragraph are at least two interesting assumptions. The first is that somehow "naturalism" and/or a gender neutrality is the norm, and those who think otherwise are outside the norm. Secondly, in suggesting that Dr. Bernstein shouldn't addresss gender issues but rather should be "refinforcing" another message -- you're really talking about resociolization.

In an earlier post, I said that I've often found the attitude amoung naturalists I know, to be that naturalism is the "correct" or "best" attitude toward the body -- and those who think otherwise have problems that need to be corrected through therapy or other processes like you describe -- resociolization. That's the attitude I see in your last paragraph.

I think we see this resociolization process going on in medicine quite often. What you're suggesting Dr. Bernstein do is what's happening out there -- but without the explanation and message reinforcement. That is:
Preference for specific gender care is considered outside the norm, a psychological problem or a personality disorder -- something that needs to be corrected.
If not that, it's at least considered a disruption of the system and not in line with the health care culture.
Consciously or subconsciously, when the health care system pretendends that gender preferences either don't or shouldn't exist, they're reinforcing this resociolozation that you're recommending. By not asking patient preferences, or discussing these concerns with patients, they're doing what you suggest in a secret, hidden way.

Gender may be a "non issue" within the context of a nudist colony (as you suggest in your last paragraph), but to imply that it is a non issue in society in general is naive and/or presumptious. As your last paragraph suggests, you see yourself as the "norm" and those who don't agree with you as outside this narrow "norm." For you, it's either your version of the "norm" or "reinforcing worries."

When you write like that you're essentially saying that people who don't believe the way you do about this issue are not "normal." Frankly, these people who are not "normal" could very well argue and with probably more evidence that naturalists are the ones who are not normal. Of course, then both sides will have to somehow come up with an objective, absolute standard for what is normal and what isn't. Have you found that yet? If you have, please let us know what that is.

At Tuesday, March 03, 2009 12:45:00 PM, Anonymous Anonymous said...

I have to disagree with CSM and you on this one Dr. Bernstein. If we were starting from a historical point of no preconceptions about the preference of the patient that might work, but we are not. We are starting from a perspective set by the medical profession that we SHOULD be ok with opposite gender providers and if we are not, WE are the ones with something wrong. It has been noted numerous times here that patients start from the feeling of intimidation in the medical system. WE should except and not question what is provided us. CSM as a natrualist starts with the perspective that the genders are the same when it comes to the issue of nudity...not the same perspective the majority of society holds. Would it not be better to recognize the "harm" to patients with modesty issues by not being asked would be greater than asking a patient whom does not care and error on that side with something less leading such as asking if they have any concerns about how it is conducted, communicating results, and finishing with do you have any concerns about the gender of the you let them tell you how they feel instead of placing that thought in their head. While Dr. Bernstein may feel either gender is appropriate for "most patients", the naturalist seem to feel it is appropriate for all people......and I ask you, which creates the greater risk, asking a patient who wasn't thinking about it and either influencing them or awakening a concern that they had not thought of...or misreading a patient and them having an uncomfortable or some might even say truamatic visit which may inhibit or prevent them from seeking health care in the future. And then there is always the point that was brought up here before....what about the person who has never expereinced this type of procedure and may not even think about it until they are in the room/gown...isn't it better that at a minimum they can reflect that they were given the chance to influence this instead of the feeling of being "ambushed"......sorry but I disagree with your approach. I always look at issues on a continuim with a balance point. CSM is toward the extreme end of no modesty, some are on the other end of extreme modesty with no opposite gender, no way, no time, I think by your profession Dr. Bernstein and other providers would fall on CSM's side of the balance point but not not as far toward that end, and patients are scattered you disagree?.......Alan

At Tuesday, March 03, 2009 2:10:00 PM, Blogger MER said...

In your response to CSM, doctor, I note that you're not willing to "go all the way" with patients -- that is, complete, open communication. You're dancing around the issue rather than confronting it. What about real informed consent?

You seem to be taking the position that, although gender is an issue for some people, it shouldn't be, and I'm not going to encourge it, the medical profession knows what's best, even as far as privacy and modesty goes.

Alan is right. Although you're probably doing more than most providers, you're still setting up men to be "ambushed." You might ask if they've actually had this type of ultrasound before. That would give you an idea if they even had a clue as to what was going to happen. If they haven't, they are not really thinking about the implications of what will happen to them and by whom.

If gender is no big thing, then outright asking the patient's preference would be no big thing. But apparently it's a big thing in medicine today. If most men don't care, then most men would say "It doesn't matter" to me and thus, end of discussion. There seems to be a great fear that by asking the question you actually get an answer.

Go to Joel Sherman's blog. He's got a new thread and has presented some actual evidence, studies that show gender preference. Quite interesting. They show that patients do have same gender preference, about 50 per cent for men. How can medicne ignore this, unless, of course, these preferences are seen as "problems" that need to be "solved" by "resociolizing" patients.

It seems to me that the medical professions knows this is an issue, refuses to confront it openly with patients, accepts that some patients will be ambushed, believes that's okay because, as you write:

"any gender who is competent and professional should be appropriate for most patients"

Again, it's posed as a "should be" situation. Not an "the way it actually is" situation.

Also, when you talk about "appropriate," that means from a medical point of view, completely. How about "appropriate" from the patient's point of view?

Sorry, doctor, but what about patient autonomy? Give them all the facts and let them decide. Too often some doctors still think it best for them to decide for the patient without even asking.

Your discussion with CSM is revealing.

I do appreciate you bringing this issue out into the open, doctor. It just seems that the openness we experience on the blog is confined to this blog. It doesn't seem to be transferred into the exam rooms or hospitals in patient communication.

At Tuesday, March 03, 2009 2:27:00 PM, Anonymous Anonymous said...

A past comment about having a female shave a male, seems ridiculous to me. Years ago male orderlies did all of this type of thing and it was very acceptable by male patients. No questions asked. When they dropped this procedure I don't know maybe some time in the 80's.

The word, "professional" in my opinion is extremely over-used and exaggerated. Everyone is a professional nowdays. Real Estate agents, car dealers, ball players, the word is used constantly. No one is "professional" they are merely doing a job. And many were flipping hamburgers, or cutting hair a couple of years prior to handling your genitals. I don't mean to sound trite but if you think about it, it is a stranger paid by a company to do a job. So why is it at all normal or acceptable for a man or a woman to be fully exposed and handled by a person of the opposite sex. I am sick of hearing from the medical world that they should be allowed to do everything and anything without question just because they are on trained, on duty and oh, yes, "ARE PROFESSIONAL". If it isn't comfortable for a patient that should be the end of story.

At Tuesday, March 03, 2009 2:37:00 PM, Anonymous Anonymous said...

If men are to be so accepting of the oppisite sex during a medical procedure, what about all of the society rules?
Seperate changing rooms.
Seperate public restrooms.
Why are most male nurses/employees not allowed on the obgyn floor?
Why are males expected to drop everything we learned growing up that are parents, society and not breaking the law? Everyone remembers the Janet Jackson Super Bowl Halftime stunt. I did think it was in poor taste but honestly it did not bother me. All she really did was show one breast.
I can cope well with oppisite sex caregiving to but I want a proffesional and not just an employee.
EMPLOYEE vs PROFFESIONAL, there is a difference to me and proff. has earned the right to be called that. I was admitted to a hospital about three years ago because of a reaction to medicine and it basically shut my kidneys down. After a very long day at the doctors running test and going home for a bag and be addmitted to the hospital it was around 9:30 pm I just had been in my room for about two hrs. and some lady shows up with a gurney to take me for a x-ray. My doctor took x rays and two sono graph and they had allready been sent ahead of me because the person who took my history on the floor said they recieved all test and my doctors notes and my doctors office was in the hospital. I said absolutely not I was tired and sick. Well if you would have heard the stink that raised. My phone in my room wrang and a different lady was basically telling me off because I did not want to get wheeled down to x-ray at 9:45 pm, after being admitted that day. I do not think eithier of the two female employees liked being told NO. I also had a horrible nurse the next two days she always came in my room and complained how hard she was working to the point I felt awkward asking for anything. My point to all of this I want a proffesional and not an employee. Unless I am at a doctor for ED I know when it is perfectly normal for an erection. I was brought up to treat females with respect so having an erection infront of a complete female stranger is an uneven playing field. Just treat me with respect and as a paying customer and please do not assume what is best for me and is what is natural.

At Tuesday, March 03, 2009 3:22:00 PM, Blogger Joel Sherman MD said...

I think the conversation is misguided. In theory I'm greatly in favor of gender neutral care. But it's not the theory that's important, it's the reality as I've documented that patients do really care to a large degree. What's more important, the theories of how it should be, or what actually will get the most patients to accept and feel comfortable with their care?
We still don't know what percentage of people totally avoid medical care for these reasons, but they are not rare. Would anyone claim they don't deserve care if they can't do it the gender neutral way?

At Tuesday, March 03, 2009 3:29:00 PM, Anonymous Anonymous said...

I had an ultrasound study of the pelvis and I insisted on a male tech. After the exam I can't even imagine having this done by a woman. At one point I was standing fully exposed and the tech was moving the probe all around. My wife was standing there with me during the procedure. To have a female tech doing this would have been over the top. Why would anyone expect a male to go through this procedure with a female? I don't care how professional or trained they are. Absolutely not!
They need to understand how a patient might feel being fully exposed for a long period of time.
They need to ASK as others here have stated.

At Tuesday, March 03, 2009 5:32:00 PM, Anonymous Anonymous said...

Chuck I am a woman. Is that OK with you? I didn't know this was about male modesty only. Alan, don't apologize for your post, it is a voice of reason.
This topic has always been some where in my consciousness after my mother told me a terrible story of her violation of modesty some 40 years ago. She went to a hospital suffering from severe abdominal pains. They could not find the cause so she spent the time lying in bed writhing in pain. One day a male doctor suddenly turned up with about 15 male medical students in tow. Without uttering a word he pulled down the covers and pulled up my mother's gown and showed her vagina to all the male students. This happened without any warning let alone any asking. I think they chose her because she was young and too sick to fight back. As you can imagine my mother was mortified. When my father found out he was livid and they discharged themselves. The hospital staff were unsympathetic and told them that they were never welcome to return to that hospital!
So can you see why there had to have been huge changes made in regards to the way women are treated by providers?

At Tuesday, March 03, 2009 6:47:00 PM, Anonymous Anonymous said...

I turned 50 a few months ago, my insurance covers a colonoscopy under Health Wellness so I decided to get my first one over with. So I made an appointment with a male gastroenterologist who is In-Network, I did the prep the night before (yuck!) and my wife drove me to the surgi-center near the Doc’s office in the morning. Once there I found out the entire staff of the surgi-center is female.
Nurse S instructed me to go into the changing room (a bathroom), take everything off and put on a gown plus some ankle high socks to keep my feet warm. The gown opened in the back and had two ties, one up by the neck and another at waist level that had two places it could be tied, back or left side. I tied mine on the left side because I didn’t feel the lower back tie would cover me enough and I didn’t want to moon everyone there. As nurse S and nurse K walked with me over to my assigned bed, nurse S noticed the left side waist tie and asked me to untie it. She explained that since I would be on my left side during the procedure, it would be easier for the doctor if I untied it now before I got in bed rather than make him do it in the OR. Had I just used the lower back tie, maybe I wouldn’t have been asked to undo the waist tie at all. Nurse S and nurse K were standing on either side on me now, so I got close to the bed before untying it and quickly got into bed. Nurse S started an IV in my right arm (excellent job btw) while nurse K took my blood pressure on the other arm.
They were fine with my modesty up to the point that it interfered with the procedure they needed to do. I must admit their request made sense and was reasonable. But I also did what I could when I could to protect it all along the way because that is the way I want it. They didn’t dismiss it as silly or disregard it or unduly try to take it away.
They wheeled the bed and me into the OR about 45 minutes later. 3 nurses were there (N, V and didn’t catch one name) and the Doc. He asked me to lie on my left side, nurses put the EKG stickers on my chest and a pulse monitor on my finger, and they kept me covered the whole time. One minute I’m lying there listening to the beep-beep of the heart monitor, then next thing I know I’m in the recovery room. Didn’t feel or remember any of the procedure. I had a hard time believing they actually did anything. However, since my modesty was respected while awake, I have no reason to suspect anything inappropriate occurred while I was sedated. Btw, no cancer or polyps, yippee!

At Tuesday, March 03, 2009 7:48:00 PM, Blogger MER said...

I think gender neutrality in medicine to a large extent has transcended theory -- it's ideology. To some, it's the perceived reality. To others in the professions, the ones who actually see daily the reality of how many patients feel about it, gender neutrality is the utopia. It's the goal.

When the issue isn't ignored, patient preference for same gender care is sometimes treated like other diseases or bad habits -- smoking, overeating, lack of exercise, diabetes, addiction. Under the guise of "education," providers try to reshape the personality to fit into the ideological, politically correct position.

Most of the time, though, gender preference issues are ignored. You know how a little child will cover his or her eyes and think the adult nearby has disappeared because the eyes are covered? If we make believe it doesn't exist, it will just gradually go away and we'll reach our utopia. It's like a card game where Ideology is the trump card attempting to take out Reality.

I've quoted sources to suggest the current intellectual climate that believes gender doesn't really exist -- it's a total social construct. Sexual differences exist, of course. But gender is soemthing else. If you believe that, then it's perfectly acceptable to kneed and manipulate human clay into the shape you believe is better for everyone.

I'm not saying that there are not some gender traits that are socially constructed. But there is a good argument that is growing that shows many important gender traits seem to be embedded or hardwired.

Patients who are comfortable with their feelings about not wanting opposite gender intimate care (and there probably aren't many who profess it openly because it's not politically correct) -- these patients can be a threat. People aren't supposed to be comfortable with this. They're supposed to be embarrassed, looking for help, feeling shame.

I enjoy reading CSM's comments because he so often reflects the ideology I'm talking about. Note in his last post when he talks about --

"preemptive solutions that torpedo the norm by reinforcing worries. Then, within the context of a clearly communicated norm, we can respond to particular concerns."

Don't "preempt" the ideological correct position, our "norm," which is gender neutrality Rather, "clearly communicate" that position, ignoring gender preferences, and call gender neutrality the norm.

You'll "torpedo" our ideology if you confront the reality -- which is that people really want gender preferences . By bringing up the realilty, how people really feel, we destroy our ideological position of gender neutrality. We don't want to do that. Instead, let's bypass the reality,(how people really feel), make believe it isn't the norm, and call our new norm gender neutrality and make clear that this is our expectation.

When you walk down the street or in the woods, there's an atmosphere all around you, an ambiance. Some people are aware of it. Others just go their own way not even "seeing" what's all around them. They're oblivious to it.

Well -- there is such thing as an intellectual ambiance and atmosphere, too. It's all around us -- in the media, movies, radio, popular books, magazines, pop art, blogs, etc. We have these ideas and beliefs and often don't question why we have them or where they came from. We think we thought them up originally ourselves. Sometimes we don't even see these beliefs as beliefs. They're just the reality. We don't question them at all.

Gender neutrality is an ideology that is bigger than medicine and health care. We're just looking at it within a small context.

At Tuesday, March 03, 2009 8:53:00 PM, Blogger Maurice Bernstein, M.D. said...

CSM,MER and others, what a wonderful discussion, particularly to dissect the issue confronting us in some sort of analytic philosophic terms.

I have to be clear, though, on my position with regard to what I would say or not say to the patient to whom I would refer for a procedure.
Currently, the standard of informed consent for a procedure does not require the doctor to discuss the gender of the participants nor even give a detailed background to the patient of the participants educational or work history. If the patient requests such information, to the extent the doctor is aware, the doctor should respond.

I may not be aware of the day to day or hourly schedule of the office to which I would refer the patient. I may not be aware of the characteristics of each of the participants but I select the office out of knowledge of the director, the results that I have previously obtained and any feedback from my patients.

I cannot proceed any further to detail to my patients what to expect in gender. However, if there is apparent hesitation by the patient to my recommendation I would ask for the patient describe any concerns. If the issue of the gender of the technicians or nursing staff is brought to my attention, I would then tell the patient that I understand that this is a concern of some patients and I will see what I can do to meet their request. Obviously, I would then notify the office and see if the gender selection by the patient could be arranged. This is all, I think, I can practically do for the patient. I will not go into proselytizing the patient over into some gender neutral philosophy, even though, in all candor, I believe gender neutral with regard to healthcare providers is fair. I don't think that this is analogous to something I would say to all patients "stop smoking" or additionally if the patient was symptomatic "this smoking is only making your cough and shortness of breath worse"

I hope this explains my approach and clarifies what I wrote previously. ..Maurice.

At Tuesday, March 03, 2009 9:31:00 PM, Blogger MER said...

Frankly, I think the way you handle your patients is commendable, doctor. At least you're making an effort to confront this issue. We can debate exactly how this should be handled, how far the doctor should go. But at least you're dealing with it.

I think you've said before that the way you handle it is not the standard. What would be your educated guess as to the percentage of doctors who acknowledge this issue similar to the way you do?

At Tuesday, March 03, 2009 9:35:00 PM, Anonymous Anonymous said...

State boards of nursing maintain
the criteria that all patients are
to be treated with respect as well
as to their privacy.
Yet, most or all female providers
hold the contention that " men don't have any modesty issues."
Careful with this one!


At Tuesday, March 03, 2009 9:51:00 PM, Blogger Maurice Bernstein, M.D. said...

MER, in response to your question "What would be your educated guess as to the percentage of doctors who acknowledge this issue similar to the way you do?", I would answer "Not many at all." I think unless they read my blog or Dr.Sherman's blog or elsewhere where these views are posted, they will never consider in advance such gender selection requests when ordering an exam or procedure. ..Maurice.

At Tuesday, March 03, 2009 10:10:00 PM, Blogger MER said...

Your answer, doctor, seems to back up my contention that gender neutrality is so embedded in the intellectual culture of medicine that few doctors even "see" it. Since literally no patients bring it up, gender preference doesn't exist most doctors' minds.

Do you agree? Or would there be other reasons for ignoring this issue?

At Tuesday, March 03, 2009 11:03:00 PM, Anonymous Anonymous said...

In terms of "psychodynamics", I seem to have hit some nerves.

I don't see a problem accomodating requests for "same gender intimate care" and I am not talking about "resocialization." The battles of the Suffragettes are long over. There are international conventions on gender equality. Naturist values on gender equality are admittedly on an even higher level -- we don't even dream of imposing our values generally. But we are also not talking about Saudi Arabia. I was merely pointing out that, at a minimum, discrimination in the workplace based on gender cannot be an official or default policy. "Preference" according to race, creed, gender, etc, whether in housing or services, is always in danger of crossing the line of wrongful discrimination. This is not a matter of "resocialization" but of simple fairness and minimum rights under the constitution. While hospitals can and should make an effort to accomodate "modesty issues", they cannot legally discriminate against health care staff on the basis of race, creed, gender, etc. If it is being suggested that men and women should ban together to force health care to take the lead in reversing equal rights, then we are indeed in disagreement. If it is being suggested that men and women should have equal rights to manage their own bodies and express preferences for care, then we agree. If it is being suggested that health care givers should be a priori condemned on the basis of their gender rather than judged on their behavior and competence, then I must raise a flag that "preference" has crossed the line and is no longer defensible.

Is there is "something wrong" with patients who have modesty issues? Of course not. Does the medical community "harm" patients by being gender neutral by default? No. Are patients "intimidated" into not voicing gender-related discomfort or feelings that their modesty has been "ambushed"? Any sort of "intimidation" is both wrong and dysfunctional. The crux of the matter is for everyone to communicate and work together to assure quality care for the whole person, recognizing that there is no more basic right than the right to complete sovereignty over one's own body. Just don't use "modesty" as a surrogate for gender-discrimination or expect hospitals to start firing staff on the basis of gender. I am sticking to my point that health care must remain gender-neutral while accomodating the "psychodynamics" of patients who express gender-related modesty issues.

So "what about all of the society rules? Seperate changing rooms? Seperate public restrooms? Male nurses/employees not allowed on the obgyn floor? Janet Jackson? Oppisite sex caregiving ok, but a profesional, not just an employee?" The first ones are really a matter of public safety under the assumption that there is always a certain percentage of trouble-makers and troubled souls. In contrast, health care is not an uncontrolled public environment. The Janet Jackson incident was really about public sexuality in the public media, so it is even less applicable.

But the question about "employee vs professional" is illuminative. "Employee" suggests that general public norms for modesty are in force, while "professional" implies trust that higher standards of attitudes and behavior are enforced. I see this as an excellent threshhold for when "modesty" issues can be valid. Any time the "trust relationship" is not "certified", health care facilities should have an obligation to explicitly know patient preference. This includes when doctors bring a gaggle of students in tow -- they should ask in advance and if the patient is not in a state to respond, the default answer should be "no". In contrast, assigned nurses would be held to the higher standard and thus fall into the "certified" gender-neutral group. The system would similarly apply when a doctor refers a patient to another facility -- even if they don't know specifics, doctors could be expected to communicate expressed patient preference to the receiving professional. Could patients with modesty issues be comfortable with such parameters?

Thank you, Dr B, for your clarifications! (CSM)

At Wednesday, March 04, 2009 5:42:00 AM, Anonymous Anonymous said...

Great exchange, Dr. Bernstein first off I want to say again, I really appreciate what you have done here and the effort you put in this. I think you are exceptional....but on this round I still disagree. Last first, just becasue something isn't common doesn't make it right...failure to recognize equal rights in the 40's, 50's and 60's are obvious and perhaps extreme examples of common practices that were obviously wrong but common. The other thing you notice is gender nuetrality is often seen as the person it benefits. Gender nuretral benefits the medical society not the patient. The pushing of gender nuetral is much easier for the medical community to meet than accomodation so they push it. Likewise gender nuetral does not negatively effect providers, so it is easy to understand why the concept would be more acceptable. Yet often even those who preach gender nuetral in their area do not accept it in others. Dr. Bernstein if I am not mistaken you have indicated you do not fully agree with the concept of allowing female reporters in male locker rooms. Nor would most providers accept the concept gender nuetrality in sauna's, restrooms, locker rooms, even from the "professionals" who run the faclity. Someone also brought in the concept of professional, I read a thread where a female reporter from a college newspaper was considering filing a suit becasue she did not feel welcome in the male locker room...the 19 year old freshman stated...."she was doing her job and was a professional". A few months before she was a high school she is a professional. As previously stated professional is relative, just because a person has a certificate to use a ultra sound wand does not make them a professional. The other thing I have noticed is those who benefit for this concept do not recgnize the the inequality when they are the beneficiary, vs when they are not. Again using the reporter, while women screamed loud and long about the inequality of not being given equal access to male locker rooms claiming equal treatment for you hear anything about the unequal treatment of male vs female atheletes. Taking it to the medical side, how many of us have heard of, read of, or know of providers who recieve "special" consideration when they are patients and use the mantra "its different becasue I work here", go to allnurse and see how many female nurses openly admit they choose a female gyn. I was had a skin check at my dermotologist yesterday, I was chatting with the nurse/tech as she took my history and asked her what age one should start having skin checks, she said the recommened age differs depending on family history but your never to young. So I asked, have you had one...she looked taken back....NOOO, then realized what she said and tried to recover. She works with a male Dr....had not had an you really think she saw the Dr. as genderless....when you start trying to make exceptions the whole concept starts to fall apart, either providers are gender nuetral or the aren't, not only if they don't know them, or if they are the provider not the patient.

And it still comes to this simple point that I feel is the piviotal point of the whole, as providers are determining for the patient what should or should not be emotionally, culturally, and socially acceptable. This is not a medical call, this isn't telling me if I have a broken bone and what I should do to fix it, you are telling me how I should one can or has the right to tell someone how they should feel. You say I should feel being seen nude by a member of the opposite gender is ok if they are a medical provider, you can not be in the position to make that call for me. The nudist says you should be willing to accept nudity in all area's...and if you don't you should and are wrong....Your position benefits you and is influenced by your position and your perspective, whether you recognize that or not. I know a guy who worked in a slaughter house, he could kill an animal without even really bothers me to see I wrong in being bothered by seeing an animal slaughtered? He thinks so....error on the side of allowing the patient the choice based on being fully informed, you don't have an obligation to explore the alternatives, but at least let them know what they can expect and there are alternatives, let them find them....there is the concept of guilty by ommission....what you don't say can be just as wrong as what you do......alan

At Wednesday, March 04, 2009 10:15:00 AM, Blogger Maurice Bernstein, M.D. said...

IMPORTANT TO NOTE: I want to explain that since all comments are moderated by me before they are published here and since I am not 24 hours sitting at the computer and since occasionally do not publish the comments in the exact order they came to me and since the blog mechanism lists the comments in the order of the time they were originally written, there will be times when a visitor writes something but has not had a previous posting by another visitor available to read. This can lead to some inappropriate commentary by the more recent visitor. I offer my apologies for this occurring and hope generally this will be remain only a rare happening. The issue of this thread is nuanced enough to handle than to introduce more confusion by delayed postings. ..Maurice.

At Wednesday, March 04, 2009 10:58:00 AM, Blogger Maurice Bernstein, M.D. said...

I come to you for suggestions. Tomorrow, my second year medical students (3 male student and 3 female students) will be performing a complete history and complete physical exam (except for pelvic/rectal) on women patients in the gynecology ward of our county hospital. They have already examined both male and female patients in their medical education but this will be the first time they are on the gynecology ward and all have available a female patient. All patients will be asked by the student for permission to perform the history and physical and they will specifically ask permission about performing the breast exam. What the students will actually do will be determined by patient informed consent. From the visitors here, I would like to receive any suggestions about what to tell the students to make their experience and that of the patients they examine more valuable. ..Maurice.

At Wednesday, March 04, 2009 11:14:00 AM, Anonymous Anonymous said...

as per Dr. Bernsteins comment I posted earlier before I read CSM's reply. CSM, something that has been expressed here and other places is the observation that while most people with concern for modesty do not condemn or judge those who don't for their lack of modesty, it seems those with no concern feel compelled to not only justify their position but feel they have to convience the others why they are wrong. Why do you feel that as a naturalist, whom at best is a splinter group of society you have this moral high ground. To indicate that naturalist have a higher level of equality because of gender nuetraulity....what a stretch. Being naked doesn't mean you are not a means your naked and you like being naked. Other conclusions are individualistic, some are naked becasue they are pervs, some are racist, sexist, semites...Modesty does not mean one is sexist or holds the opposite gender as less than equal....nor does my preference for same gender provider mean that I am pushing discrimination or have "condemned anyone by gender". It has been stated over and over that her that no one is saying one gender is more qualified than the other. What they are saying is they are more comfortable for SPECIFIC PROCEDURES INVOLVING EXPOSURE, it is the situation not the person per se that causes the concern. And the situation is not based on hatred of that gender, it isn't even about them its about ME. Reversal of equal rights becasue I have a preference based on a societal norm that exposure to the opposite sex is suppose to be uncomfortable...give me a break. And the argument for societies view of cross gender exposure, safety...oh tell me, out of the 1,000's of beaches in the country, how many are topless, nude? But medical makes it ok, sort of like the Trauma in the ER which is a medical documentary series...they blurr the privates because.....society used to provide accomodation in this area through male orderlies, it was the medical community who pushed gender nuetrality for their own benefit....sorry but you really did touch a nerve, when you try to impose a minority view on the larger society and use examples meant to make the majority feel like they are we went from having something wrong with us for having a preference to being against equal rights for having that preference. Good grief, as long as we are using the absurb to jusfify, I think the fear of hieghts is ridiculous so lets make those with it ride the glass elevator until they get over it, and those that fear water...dunk em and if you don't see that...well you must be sexist or a commie. I try to accept your life style though you are the vast minority and not accepted as the norm by the majority of society..I would think you would at least be able to recognize your perspective is not the prevailing starting point for the majority of society and may not be right for everyone.....before you go accussing me of trying to "force health care to take the lead in reversing equal rights" just becasue I feel less comfortable getting a DRE or ultrasound from a woman, look at the glass house you live in, it is you my friend who has crossed the line...not I....sorry, you got me on a roll......alan

At Wednesday, March 04, 2009 11:56:00 AM, Blogger MER said...

Excellent post, CSM. I hope you don't think I'm going after you. I just like an intense debate, and I find you've got a good mind for that.

I think we agree on the essentials.

But I would like to point out something about a few comments you made: "Just don't use "modesty" as a surrogate for gender-discrimination or expect hospitals to start firing staff on the basis of gender."

What you're describing can actually happen (and has) under the BFOQ regulations. That's one reason why female nurses outnumber males in certain areas of health care, e.g. OB-GYN, nurisng homes, etc. One reason, I say, not the whole story. If the institution can demonstrate to the courts that one gender of patient will not use their services unless thay get same gender care, and thus the instituion will go out of business (this is called the "essence of business} -- And if the institution can convince the court the problem can't be solved through other means like scheduling, etc., they will be allowed to hire one gender over another. Which means they can fire one gender in order to hire another.

This has worked mostly in favor of women because female patients have been more vocal in refusing intimate care by male nurses and orderlies, especially in OB-GYN and nursing home situations. However, some male nurses have taken their employers to court over this issue and won.

My point is that, under the law, gender discrimination is allowed under situations involving a patient's right to control which gender has access to their body for intimate care.

Your second comment: "While hospitals can and should make an effort to accomodate "modesty issues", they cannot legally discriminate against health care staff on the basis of race, creed, gender, etc."

As I understand case law in this area, the courts do not mix race, creed and gender together when it comes to a person's right to control who views his/her body or does intimate care. The courts don't consider that right of a patient to discrimiante in personal body areas as equal to discrimination for reasons of race or creed. As I pointed out above, the courts do allow hospitals to hire one gender over another if the institution can defend their decision based on the court's criteria.

At Wednesday, March 04, 2009 12:51:00 PM, Blogger MER said...

Someone sent me the following link to a Youtube film called "The Day in the Life of a Candy Striper." It looks to be a real film done by kids about 16 years old, at a real hospital. The hospital is named at the end of the film.

Here we've got these kids wandering around a hospital, fooling around, filming. There's not once example of what candy stripers really do to help patients or the hospital. It's just messing around.

Now, I don't blame the kids. They're just kids. But where's the supervision? At one point, when they get into an elevator, a nurse tells them to put things away, that they don't belong on the floors. You'd think she'd be talking about the video and cell phone cameras. But no. She's telling them to put away the food they're eating.

Apparently, there's been a move to get candy stripers back into hospitals, though their access to patients seems to be more limited. Although I did find a sight that said they would put candy stripers in emergency rooms and in post surgery wards.

This is a real privacy (if not a modesty) issue. If anyone's interested, take a look at this video and give a response.

At Wednesday, March 04, 2009 1:54:00 PM, Blogger Maurice Bernstein, M.D. said...

MER, terrible! This behavior on the part of the Candy Stripers shows they were not educated as to what is the role of a hospital and what are the standards for behavior of everyone representing the hospital. They have probably been watching those "wonderful" TV doctor, medical office,hospital, ER shows and have seen all the extra-curricular activities that allegedly go on there. I also think these shows are bad for the adults too since they present uncommon presentation of diseases and disorders, patients treated with showmanship rather than with reality and ending with unlikely outcomes. They create in the public positive impressions of unsubstantiated results of therapy and has, in my opinion, contributed to irrational demands for tests and treatments leading, when followed, by increasing costs of medical care. ..Maurice.

At Wednesday, March 04, 2009 2:25:00 PM, Anonymous Anonymous said...

OK I am composed again. Sorry to rattle so much everyone. One quick comment, and sorry I have to run so I didn't look it up. But I read a court decision wherein the judge made the comment "the desire to shield one's naked body for members of the opposite sex is one of the most basic instincts in our society"....that is paraphrasing...but true...Ok sorry again I am out.....alan

At Wednesday, March 04, 2009 3:44:00 PM, Blogger MER said...


The source for you quote is Shulman v. Group Productions.

The court wrote that anyone who would usurp these bodily privacy rights we're talking about "is the master of the other" who uses the "primary weapon of the tyrant. . . One who intentionally intrudes, physicially or otherwise, upon the solitude or seclusion of another or his private affairs or concerns [including the provision of intimate care over his objections] is subject to liablity to the other for invasion of his privacy."

I think that's pretty clear.

At Wednesday, March 04, 2009 9:11:00 PM, Anonymous Anonymous said...

First, I can only say that
1."norm" is a term that is derived by an averaging of all of the things people feel...and like all averages it can not fully describe the feelings of any individual.
2. "gender neutral" is an idealised situation...that really does not exist....I have never met a person who was not either a male or a female.I have never met a living "android" human being.
Not being female I do not have much advice for your students on their gyn exams... except to be understanding that any refusal is not a rejection of them or their is a matter of personal feelings....and that although in this situation they may not share those felings they need to respect the right (the reality actually) of others to have them...and not take it as a personal attack or rejection.

At Wednesday, March 04, 2009 9:18:00 PM, Anonymous Anonymous said...

Dear M.B.

Quite contrary despite there is
evidence to the claim I'll ignore
My goal is to effect change through the legal system. Its
pointless to try and reason with
them. Along the way some societal
rules need to be changed as well.


At Thursday, March 05, 2009 9:03:00 AM, Blogger MER said...

I want to retract my last post. I did a little more research into that case and it is more complicated that I had thought. I'm not sure whether the court itself made that statement, or whether they quoted another source. The case, apparently, has more to do with medical privacy rights and the media. So we really need to understand the context of that statement. I'm not saying that the decision can't be applied to what we're discussing. I'm saying I don't have the legal knowledge to make that connection.

I'm more confident on my analysis of the BFOQ law. I did find a good analysis of that I was able to read and understand.

It would be enlightening if we could get a lawyer on here who really understands the case law involved in privacy issues.

At Thursday, March 05, 2009 11:33:00 AM, Blogger MER said...


As an expert in medical education and ethics, I would like your interpretation.

As I research various hospital codes of ethics, I find many similarities in wording. But I'm wondering how this wording is interpreted first. by the hospital and second, by patients. Do patients and hospitals define words and concepts differently?

Here is a paragraph from a hospital code of ethics. It's not untypical of many hospitals:

"Patients have a fundamental right to compassionate care that safeguards their personal dignity and respects their cultural and spiritual values. All {Hospital Name} employees involved in the care of a patient shall respect and support the patient's right to competent, considerate, and courteous treatment or service within our capacity without discrimination as to race, age, religion, gender, national origin, disability, or source of payment."

Now -- as a patient -- that seems pretty clear to me. Note the language:

1. Personal Dignity. That implies that the patient gets to decide what constitutes his or her dignity -- "personal" dignity. To me, that includes the gender of the intimate caregiver. If asked, I would think most patients would infer the same. How do hospitals interpret this?
2. The hospital says caregivers will respect each patient's cultural and spiritual values. Those are broad terms, and the implication is that the patient is in charge of these values. If our culture enforces certain body gender standards outside of the hospital, then those values should be clearly offered within the hospital. The hosital "culture" shouldn't trump the society's culture. Also, if you're bound to this standard, don't you have an obligation to find out what patient values are? Wouldn't that involve asking questins about topics like opposite gender care?How do hospitals define these standards?
3. Does the concept of respecting the patient's right to "courteous" and "considerate" care include same gender intimate care? As a patient, I would see that this would at the very least demand that caregivers make a good faith effort to get same gender care. Is this "good faith effort" policy in most hospitals?
4. Finally, there's a clear reference to no discrimination based upon gender. If one gender has a much greater access to same gender care than the other, isn't that a clear form of gender discrimination?

The fact that I'm even asking these questions, demonstrates to me the great communication disconnect that exists between hospitals and patients regarding all the nuances of oppositve vs. same gender intimate care. The issue is embedded within all these codes of ethics, but it is never confronted openly in clear language. It's the elephant in the room.

How do you interpret the standards I've quoted above, doctor?

At Thursday, March 05, 2009 1:32:00 PM, Blogger Maurice Bernstein, M.D. said...

MER, you ask me "How do you interpret the standards I've quoted above, doctor?"

I answer: "As written, including the words 'within our capacity'"


At Thursday, March 05, 2009 1:58:00 PM, Anonymous Anonymous said...

I would interpet "Within our capacity" meaning if we are physically able to. Many, if not nearly all accomodations would be possible if the right amount of effort was put to them. A same gender team would likely be able to be assembled if the facility was so driven, it may however require heroric efforts of rescehduling, transfers, etc which I think brings up the bigger issue, can vs reasonable. It is within the capacity of providers to inform patients that they may have options on the gender of providers, however it does not happen as providers evidently do not think it is reasonable or perhaps important. Thus I think in some cases it does come down to can "within our capacity", but more often it comes down to will as in do providers think it is reasonable. The imaging center I have spoken of has male and female techs, they can provide a choice...but won't if you don't ask, they could ask if you had a preference, but they don't. I think the current conversation with Dr. Bernstein is very enlightening and highlights the chasim between providers and patients. I don't think I have found more concern about the issue from any providers like we have from Dr. Bernstein and Dr. Sherman...but Dr. Bernstein himself made the comment that he feels gender nuetrality for providers is fair, and a competent provider of either gender should be appropriate for most patients...with that as a starting point, and given most providers appear to be less concerned about this than the two doctors "within our capacity" could be very limited compared to what can be done....alan

At Thursday, March 05, 2009 2:53:00 PM, Blogger MER said...


I don't think the answer is as simple as that.

First of all, how much of that "capacity" is within the control of the system and how much is not? We can debate that. How much of that "capacity" could be in control of the institution if it decided it had value?

Second, let's consider what we're really talking about: personal dignity, respect, cultural and spiritual values, courtesy, and consideration.

So -- what happens if the systemn decides it isn't within their capacity to grant those concepts? Can we just drop them? Or are they foundational concepts that must be within a hospital's capacity?

"Within our capacity" is one of those legal distinctions" (original meaning, fitness to stand trial) that allows those in to control to negate all the ideas that go before it.

With your answer, you basically say all those ideas have significance only the extent the system allows it based upon whatever "capacity" means according to who defines it. I read your answer as, essentially, "We define personal dignity and the other terms based upon how we also define "Within our capacity."

Of course, that goes against the idea of "personal dignity." Does a patient's "personal dignity" get defined by the systems "capacity" to grant it?

I would ask that your rethink your answer within the thoughts I've expressed in this post.

At Thursday, March 05, 2009 4:01:00 PM, Blogger Maurice Bernstein, M.D. said...

MER, it wasn't my phrasing of this hospital's code of ethics to include "within our capacity" however I can understand what is meant in the context of the "respect and support" and the "without discrimination" expressions. I believe that compassionate care does include that patients have rights and should be treated without discrimination. But I also know that under extreme conditions such as financial or a disaster (such as a major earthquake) or a pandemic, there will be triage where strict following of some of these rights may be an impossibility and "within our capacity" is a realistic limitation. If you want examples, yes, dire circumstances may limit "considerate" attention to treatment, where "considerate" might mean not having to wait with some uncomfortable symptoms for several hours or more but being attended to promptly. Another example, without "discrimination to age", in a deadly flu pandemic or a Katrina-style hurricane and life-supportive resources are limited, perhaps age discrimination would have to be considered when a decision must be made between an 80 year old patient and a 24 year old. Including the words "within our capacity" is not trying to deny the necessity to follow the rest of the code of ethics but simply recognizing a realism that a hospital has to live with.

As I already wrote, I really do interpret the words of the code of ethics you presented as they were written. To me they are not ambiguous. ..Maurice.

At Thursday, March 05, 2009 5:18:00 PM, Blogger MER said...

Thank you for your response, doctor.

As we've discussed on this thread, I think most of us agree that extreme situations are different and must be treated differently. I don't think most of us are referring to earthquakes, wars and other disasters that would affect a hospital's "capacity" to meet these values.

One of the problems is, as we've noted, most doctors are oblivious to gender choice issues when it comes to non emergency/disaster events. You've said that yourself. We (patients, at least), don't know for sure how bedside caregivers within any given system will value this issue and practice these values. Some anecdotes tell us they don't practice these values. Other anecdotes tell us tehy do practice them. It's one of those mysteries patients don't find out about until they end up within the system.

Again, it gets down to communication. Patients reading that ethics code statement will interpret it differently than will medical professionals. Patients will accept the "Within our capacity" statement within the context of real emergencies. Will they accept it when it comes to basic, non emergency treatment? I don't think many will. I believe patients think it should be within any hospital;s capacity to meet meet those value goals.

So -- assuming we agree that we can leave that "Within our capacity" statment in to include real emergencies, what realistic obligation do hospitals with ethics codes like that one have to
make a serious good faith effort to grant the values expressed? And do they consciously believe that those values refer to, among other things, a patients right to request, and their obligation to seriously meet the requests for same gender intimate care?

I think we agree that these values are foundational. Why doesn't the medical profession open up dialogues with patients to discuss what definitions of these words, how patients define them?

I have found several medical articles, for examples, coming out of Britain, discussing the meaning of "respect" and "dignity." I don't see this kind of discussion happening within this country. I don't think we can just take those words for granted and expect that everhyone has the same take on thi meanings. I believe the medical profession has an obligation to find out how their patients view this issue and then respond to it appropriately. Why is it so difficult to find studies that investigate patient gender choice for doctors, nurses, and intimate caregivers?

Philosophical statements like the one I presented are necessary. But hospitals also need to have specific strategies/plans to make sure the rubber meets the road. In areas of gender choice for intimate care, I don't think they do.

If they do, why is it such a secret? I can't find these ind of policies written down on any hospital sites.

At Thursday, March 05, 2009 7:07:00 PM, Anonymous Anonymous said...

Dr. Bernstein,

I can see the points that both you and MER are trying to make with regard to the statement "within our capacity". I can understand the potential limitations in a pandemic situation you describe, and do not disagree - you make the maximum effort do the best you can with what resources you have available.

While the pandemic situation does not really apply to the discussion at hand, I think the principle does. What I believe MER is trying to say (and correct me if I'm wrong) is that most patients would interpret the phrase "within our capacity" to mean "make the maximum effort to do everything possible", while in reality what many hospitals actually do is not what is possible, but simply what is convenient for them.

This is bad enough, but what is far worse is when the facility promises one thing, then does not live up to that commitment. If they agree to accommodate a patient's request for something like same gender care, then if circumstances change I believe they have an implicit duty to be proactive in advising the patient of the situation and giving them the opportunity to either accept the changes or reschedule the procedure or treatment. To do otherwise is lying by omission, and breaks the relationship of trust with the patient. Maybe some people can still trust someone that lies to them, but I'll bet most can't.


At Thursday, March 05, 2009 7:48:00 PM, Anonymous Anonymous said...

Capacity is also governed by the size and affluency of a community to support larger staffs...After talking to some folks who live in a rural area that is not very prosperous right now, I know that there are times an dplaces where doctors offices and hospitals are too small to be able to have large staffs....they try to get as much balance as they can, but are extremely limited in funds so they are limited in just how many different preferences they can cover fully. In the small rural area the hospital has several male nureses, no male cna's, balanced radiology and labs...they are faced with having to make cuts and can not layoff people on gender issues...but on seniority.
The issue of homophobia seems to be very real in the rural area as well..further complicating the matter...even though all of the males nurses are heterosexual in that hospital.
The doctors offices have practices so small that they must be happy with one nuse..and can't keep two on the payroll.....
I only mention these things because they are limiting factors beyond the ability of the medical community's control.

At Thursday, March 05, 2009 8:24:00 PM, Anonymous Anonymous said...

Thank you MER,

In bringing the issue of discrimination to light. I've been
saying that all along. It's an
ugly word and I believe most are
afraid to use it ,however,that is
the crux of the problem. Yes,legal
intervention is needed.


At Thursday, March 05, 2009 11:12:00 PM, Anonymous Anonymous said...

Beyond "codes of ethics" that impact modesty, I'm curious to find a practical threshhold where there was some sort of explicit mutually agreed "compact of trust" beyond which both male and female patients would know that both male and female health providers were bound to such high standards that gender-based modesty feelings would be less. What would such a "compact of trust" require? Or are the "psychodynamics" of modesty such that no opposite-gender "initimate care" is possible even with explicit trust in high personal and ethical standards? (CSM)

At Thursday, March 05, 2009 11:20:00 PM, Anonymous Anonymous said...

In response to earlier comments.

While naturists are indeed a small minority, we actually face the exactly the same issues unless we "trust" that health care staff share our values concerning opposite-gender respect. I kind of suspect that the number of extremely "immodest" naturists and extremely "modest" non--naturists are comparably limited, while the majority would follow the general trends of gender preference in situations where "trust" parameters were vague. I hope nobody here, including me, is in the mode of "judging" or "condemning" the feelings of any patient -- we all have an inalienable right to sovereignty over our own bodies, or as the court said, not to have our bodily privacy usurped by the intrusion of others. The fact that I don't have modesty issues with opposite-gender health staff doesn't mean that should be a norm -- it's just me, and you are you. It also doesn't mean that either of us would allow "intrusion."

Whether hospitals "will go out of business" by not responding to gender preferences or whether gender preference is an "essence of business" matter can be debated as a business and legal issue. But I just think that many of the trends in gender preference reflect people "playing it safe" because the "compact of trust" isn't there. This is certainly the case with naturist women -- in a hypothetical "all naturist" hospital, their preference feelings would be totally different. (I mean this in the sense of attitudes and values -- please imagine a hospital where all the staff are clothed normally!) It is, however, unclear to me if a hospital with "all naturist staff" -- where patients know that personal respect is impeccable and gender is a non-issue even for "employees" -- this would make any difference to patients who have personal modesty issues?

My feminist leanings perhaps showed too brightly in previous posts. Sorry. We however seem to agree that men and women health professionals can be equally competent, trustworthy and committed to the health of patients of either gender, but that the "modesty" issue is really about respecting the feelings of patients, and respecting those feelings equally whether patients are women or men. (CSM)

At Friday, March 06, 2009 4:03:00 AM, Blogger MER said...

leemac -- Sometimes "capacity" is governed by factors hospitals have no control over. More often, I believe "capacity" is defined by a value system. Just as budgets should cover what's absolutely necessary to exist -- beyond that they should cover what is considered of value. If hospitals generally have values of gender neutrality, theh gender preference isn't valued and thus not emphasized.

leemac -- You describe a small rural hospital that seems to be seriously trying to deal with the issue. But you can't deal with an issue unless you see it as an issue. They apparently do. In hard economic times, we can at least expect hospitals to make good fath efforts to work with patients. And I believe most do. But how can we be sure?

TT does sum up my point quite well.

I think what may bother many people is the silence on the issue. If TT, leemac PT or any of us on this blog were to suddenly find themselves in a strange city (Denver, Philadephia, Phoenix, etc.) and in need of some personal intimate care -- what would the standard be within American medicine? As a patient, based upon ethics standards like the one quoted, I would assume -- I have to believe and do, that most faciliteis would make that good faith effort. But we'd all probably have to ask, or wouild we?

Why don't we know for sure the answer to this question? Why couldn't we just, for example, check out the hospital or clinic website and find out. How would we be greated if we asked this over the phone to a receptionist? If a patient does make his wishes known, will the patient be notified if the schedule changes? Probably. Can we depend upon that? Probably not. Would it be a good idea to call to confirm the request. Probably.

Why do we have to ask these questions? Why aren't they standards in American medicine, considering the wording of that statement. If a good faith effort in this regard is the standard, why isn't it made public?

As you can see, my concern goes beyond the basic issue, even the double standard. It goes to the silence. That's what concerns me the most.

At Friday, March 06, 2009 8:39:00 AM, Anonymous Anonymous said...

My annual check up routine happens to fall this month. Visited the dermotologist and urologist this week. I was struck in both offices by the amount of attention given to the privacy issue...all toward HIPPA regulations, not personal privacy. I assume the HIPPA concern comes from the legal ramifications of failing to do so. There is nothing specific about physical modesty and the loosely worded reference to personal dignity. As stated, the predetermined position that gender nuetrality is the preferred model if not the "normal" position for providers, the other schools of thought on the issue only come in to play on a per occurance basis and only when brought up by the patient. Regardless of what the majority of patients want, and regardless of what providers know...they will not abandon the model they feel is appropriate until forced to for financial or legal reasons. That is why it is encumbant on patients to make these requests for themselves and it may eventually have residual benefit for the many who feel the same way but do not feel empowered to challenge.

CSM I think we are closer than the debate may indicate, while the naturalist life style is not mine, I see nothing wrong with it and do not feel society has a right to condemn or judge. I respect people who have that ability to shed societies norms and rules when they feel so justified for their own personal beliefs especially as in this case where there really is no harm to anyone.

Dr. Bernstein
In my opinion providers by the nature of their profession are required to assume a certain "command" over a person's well being, you are required to make decisions FOR people, you need to take this medicine, this treatment, while to some degree there is a partnership in making some decisions, sometimes you just have to nake the call for the patient. You can't negotiate or let patients choose which drug for example the will take. To me this requires you to set yourself up in some maybe many cases to apply the "Dr. knows best" to the relationship. You stated something to the jest that you believe gender nuetral providers are fine/right for most patients and therefore do not want to ask them if they have concern about the gender of the provider. Do you think that the fact that providers have to assume a certain amount of control over a patients treatment bleeds over into this area wherein providers take a "I know whats best" for the patient in terms of modesty and gender choice for patients that transcends the physcial aspects of care??........alan

At Friday, March 06, 2009 9:41:00 AM, Blogger Maurice Bernstein, M.D. said...

Alan, your analysis is a bit anachronistic and would be correct if discussing the doctor-patient relationship 40 or more years ago when physician paternalism was the doctor's professional behavior. Today, patient autonomy is the rage (some think it has gone too far) and what I and other physicians are ethically urged to do is not to dictate but simply recommend with adequate information given to the patient regarding options. We actually do this even with regard to "negotiating" (if that is the same meaning as "informed consent") which drug to take. I discuss with my patients the therapeutic value of the class of drugs and advise a specific drug which I think is appropriate but also note the pros and cons of that drug but also compare with alternatives. You have to work out the decision with a patient since different drugs have different costs, different dosing schedules and different safety issues. Patient compliance with whatever is selected is important for therapy. Actually, this discussion need take only a minute or two but it is important.

What I am getting at is that the "doctor knows best" attitude, by current ethical standards, should be gone. These days it is the "patient is a partner" and "doctors must consult with their patients". ..Maurice.

At Friday, March 06, 2009 12:55:00 PM, Anonymous Anonymous said...

Dr. Bernstein

I understand what you are saying, to a large degree patients are more engaged in their own care than before. My personal experience has been such that much more is explained (in general) than in the past. None the less, when it comes right down to it we have to rely on providers to make many of the decisions for us. If my PCP says you need to have your appendix removed, you need to have this test or that, there is discussion more to the purpose of educating, and sometimes when there is options my PCP will discuss the options, side effects, etc and will recomend but let me choose. However, if I see a new drug advertised for my high blood pressure and he doesn't think its right for me...he isn't going to perscribe it regardless of what I think. I want my provider to have a certain degree of I know what I am doing and what is best, not a dictator, not a democracy...we as patients we have to put a lot of our fate in our doctors hands becasue we just can not know as much as they do, they have to make certain decisions for us, if they in my chest, they decide 2-3-4 by passes. So, I just wondered if some of that transferred to making the decision that gender nuetral and or other modesty decisions were right for us....I didn't mean to imply that Dr.'s operated from a dictatorship amusing post in allnurse touched on your comment that some thought the "partnership in health" had gone to far when several nurses complained it went to far and patients expected to much say in what was happening these days...I was just wondering why you thought many providers seem reluctant to address or even acknowledge the issue...alan

At Friday, March 06, 2009 3:53:00 PM, Anonymous Anonymous said...

It is actually recommended in that a person find a doctor that is on a equal communication line with and the doctor/patient relationship is on equal footing, NOT the old "parent-child relationship." The patient today is much more informed and educated and should absolutely be in charge of his own health. I must say I have run across some doctors that have egos that will not allow this but still insist on being the parent.

At Friday, March 06, 2009 7:01:00 PM, Anonymous Anonymous said...

I agree with you , MER. I ws merely showing that not all of the problems faced by those of us who want same sex care is of an attitude caused by indivierance or ignorance. The person who told me of that hospitals woes is a relative of mine who is on the board of trustees...They have had to work hard to be an attractive employer to bring in medical people in the first place...and now they are really afraid they will not be able to cover the basic needs and mandates they have already. They realy are trying..
CSM, it is not jsut a matter of trust...I have female friends I trust about as much as I trust anyone. Trust is important in my determining if the healthcare worker is going to be near me in non-intimate situations...I am simply estremely bashfull as I have been goes beyond trust far as impeccable respect...would that include my desiring same gender care...Especially for intimate care (I would not be happy even with a male..but would not feel so embarrassed.)
MER I happen to live in one of the cities you mentioned...and it is scary for me because I know how I would be treated at the hospital closest to me. I can only assume all other places are like this...Yes, it would be great if a standard of providing same gender were to be found across the country.

At Saturday, March 07, 2009 5:26:00 AM, Anonymous Anonymous said...

We have asked several times and not sure we got an answer why are patients modest, why do they or perhaps are not able to accept the gender nuetrality model providers offer up.
I would like to take it a different direction. We have beat the don't up pretty well. My question is "why do providers not acknowldege or promote the concept that gender is a factor, one that perhaps they may or may not be able or willing to deal with, but a factor of some degree. Is it they feel they can not deal with it so if is better to down play it, do they truely not feel it is an issue or shouldn't be, do they take it as a personal indictment of their intentions? Many providers acknowledge they have personal preferences, most providers even at work do not function as if they are gender nuetral ie. unisex restrooms, showers, changing rooms, etc. so why do we have the scenerio that a service based industry chooses to over look a service that could increase the comfort and therefore satisfaction of their customer base....alan

At Saturday, March 07, 2009 8:07:00 AM, Blogger Maurice Bernstein, M.D. said...

Alan and others: you can ask again and again why the gender selection issue of patients is not on or in the mind of physicians and I can give you the answer again and again, "they are just not thinking about it, therefore they are not fretting about it and therefore they are not acting about it." Of course, I am sure most doctors would be uncomfortable in a unisex public toilet but that is in a different social/professional situation. As I have said, except for Dr. Sherman and myself (or some physician who has only been lurking here and not writing) who have been reading these threads day in and day out for the past 3 1/2 years, would be the only ones who surely recognizes all your concerns.

Yes, being individually pro-active in your personal situations by reminding the physician or clinic or hospital about your desires is an essential approach at this time to attempt personally to get what you want. However additionally, as I have written in the past, you must become group activists and together with the others spread the word of your concerns. As you recall, I attempted to "spread the word" myself by my article in the American Medical Association News, allegedly read by "200,000" physicians. I really have never had any feedback by e-mail or apparently written to this blog. But that was just one attempt. And that was just by me.

Why not start by going to the anti-hysterectomy group HERS Foundation and see how they "spread the word" telling women about the "horrors of hysterectomy and the deceit of the physicians who perform it". Maybe starting an organization like they have would move your challenge to the medical profession along.

But don't keep asking "why don't they".. the physicians, they just don't. ..Maurice.

At Saturday, March 07, 2009 11:55:00 AM, Blogger MER said...


I agree with your answer to Alan. Patients need to be more proactive. An organization would help.

But I have to disagree with your last sentence:

"But don't keep asking "why don't they".. the physicians, they just don't. .."

I think it's important for patients to understand why doctors probably don't see this issue. I've suggested why in past posts, which I will not rehash now. The why is important in developing strategies to deal with the problem.

You consistenty ask on this blog why some patients have this modesty issue? Why isn't the answer to that question, the same -- "Don't keep askking the question -- they just do."

I do agree with you that we keep asking the same questions over and over again on this blog, and keep giving anectdote after anecdote. I have proposed some things to do, as have you, as has Dr. Sherman -- and we do agree that that's what needs to be done.

One thing I think men can do -- get the language changed in these ethics codes and hospital privacy statements to acknowledge the gender choice issue. Guarantees won't happen, but we can go for a "good faith effort" that, if not met, will be recorded in the charts. That will begin to get some stats available.

There will be resistence. And if the hospitals and doctor organizations won't accept this, then men can go to state legislatures and see that this langauge is embedded in state law, that the notion of privacy clearly refers to this issue.

Even if men lose this battle in some state legislatures, it's an interesting story. The media will pick up on it. The medical profession may be surprised as to what happens when you open up a can of worms like this. All kinds of stories will become public because people will feel more free to discuss them in the open.

I'll present some suggested language for this in another post.

At Sunday, March 08, 2009 3:20:00 AM, Anonymous Anonymous said...

Historically, male patients as a
group have been demonized to justify discrimination against
them. One only has to look at the
male restrooms as an example.
Ever notice that for many male
restrooms walking by as the door
opens exposes people standing at
urinals, coincidence?
I believe it was on page 2 or so
of this thread a woman stated that
she can't imagine how men can
"dangle" together over a urinal.
That was all arranged and done
long before I was born. But,as a
male I'm guilty as hell! The notion
somehow that all men are dogs precludes us from any notion of
respect for privacy and as such
carries over to the medical arena.
Thus, the double standards that
exist or should I say the current
standards of discrimination. There
are many other examples whereby
men are villified and simply adds
to the mentality. The question continues to be posed," why are patients modest"?
For many its developed through
a lack of trust. As a male patient
I'm given the scraps so to speak.
" This is what we have for you male patients take it or leave it and we don't care if you have insurance or not we are still getting paid"!
"Furthermore, since you males
don't have modesty issues we don't
care about your privacy. Don't expect us to close the curtain when
you are changing. Don't expect us
to cover you up when you are a
trauma patient. Do expect us to
quickly cover up female patients
"Our female patients will complain and leave if by very rare
chance the mammographer is male,
however,we won't think twice if
you male patients need a rectal
temp or a foley,we will gladly
" If you are a male nurse please
don't apply in L&D as some of our female patients have insurance and are $$$ the bill and to the patient
who goes by the name PT, we don't
care if your privacy has been disrespected and you were treated unprofessionally. GET OVER IT!".


At Sunday, March 08, 2009 8:00:00 AM, Anonymous Anonymous said...

MER you have picked up on the general point I was trying to make. I think it is also important to realize this issue goes further than just doctors, it includes nurses, tech, assistants etc and perhaps to an even greater degree. My point is why does a profession that waves the flag of concern for the whole person ignore what they have to know is an issue to atleast some patients. It would help to know it this is a numbers issue or an attitude if indiference or even anomostiy toward the issue of modesty. I am not throwing stones at you Dr. Bernstein because I have a great deal of respect for you, but do you not feel that the fact that you would see the issue of why PAYIENTS have modesty as being a factor...but why Dr's don't care isn't..its just the way it is. Isn't this telling, doesn't this tell us that providers think this is our problem...and could this not be the root of the problem, providers know...they just don't think its their problem...its ours. And as with most problems, the first step to fixing it is acknowledging the problem...something providers do not seem willing to do....

At Sunday, March 08, 2009 4:03:00 PM, Blogger Maurice Bernstein, M.D. said...

I want to make my premise clear. It is this: I think all doctors are thinking the same way I was thinking before I started and began reading these threads. Gender preference as a modesty issue is NOT in the minds of doctors. PERIOD! A good, humanistic doctor will, when informed by the patient, I'm sure will try to accommodate the patient. But without being so informed, no doctor is going to bring up the issue. Patient modesty deals with attention to a cautious examination of the patient in an environment free of unnecessary onlookers and with attention to concerns about the inference of sexual behavior on the part of the physician. That's it! What is in the mind of doctors is the need to attend to the clinical details of the physical exam or procedure but in keeping with the patient modesty as noted above but not gender selection. Of course, now that I am educated I would more likely start out by asking the patient "Is there anything which concerns you about the upcoming procedure for which I can help?" With this open-ended question, I then would be listening for any hint of gender concern and immediately directly question the patient about that concern.

So again, it is my belief that it not that doctors are ignoring the possibility of gender modesty in their patients, there is nothing to ignore since they are fully unaware of the problem. Anyway, that's my assumption, not based on any survey, but based on my own experience as a physician. ..Maurice.

At Sunday, March 08, 2009 6:30:00 PM, Blogger MER said...

I think I understand your position, doctor, but I want to make sure. The reason you're asking that open ended question -- rather than just asking gender preference is that you don't want, through the power of suggestion, to create a "problem" that doesn't exist? By suggesting a gender choice you may get one where you wouldn't have if you didn't ask?

You have stated before that, after your opened-ended question, if the patient does request a specific gender you will help to make that happen if possible. So you do believe in the patient's right to make the request and your obligation to help within reason.

I can understand that position. But here's a thought.

If you've never been on a boat in the ocean before (or any body of water), and I agree to take you out on my boat, and say to you: "Is there anything which concerns you about the upcoming trip for which I can help?" --

What would you say?

Without having had the experience, you may not ask:
-- Do I need to bring my own lifevest?
-- Does it get cold out on the water. Should I bring a fleece and a jacket? Or hat?
-- What if I get seasick? Should I take anything beforehand?
-- What's good footwear for a boat?

Or -- should I voluntarily give you some of this information considering you really don't have any idea as to what the experience will be like.

What if I were to ask --

Have you ever been on a boat in the ocean before?
Do you tend to get motion sick in cars or airplanes?
Have you ever taken motion sickness tablets?
Do they tend to work?
Perhaps you should consider taking some motion sickness tablets before the trip.

I think I can see your point. But I question the value of such an open ended question to patients who really don't have a clue as to gender issues they may face when the get to the radiology department, or to the ultrasound clinic or to the urologist.

Wouldn't it be more open to give patients who are truly ignorant of the procedure a heads up and, thus, a choice?

At Sunday, March 08, 2009 8:24:00 PM, Anonymous Anonymous said...

The argument could be made that, where physicians and nurses have successfully internalized gender-neutral non-sexual attitudes and behavior, it is in the interest of the "modest" patient NOT to raise modesty too vigorously as a gender issue, thus "resocializing" health care professionals to be self-conscious about gender, but rather to frame modesty issues as a gender-neutral matter of personal privacy and choice. The point being that a patient's request for "same gender intimate care" explicitly indicts professional integrity unless it is carefully presented as a matter of the patient's own personal attitudes and hence preference. By keeping it focused on patient comfort, rather than on any judgment about the "correctness" of patient attitudes or the "lack of sensitivity" of health care providers, a mutually agreed modus operandi can perhaps more easily be found. Thus also keeping the handling of ethical or professional misconduct on a distinct, separate track. (CSM)

At Sunday, March 08, 2009 9:15:00 PM, Blogger MER said...

That's an excellent point, CSM. The old saying -- chose your battles. As long as that strategy tends to work, which I think it will most of the time.

But I don't think that a patient's request for same gender intimate care necessarily indicts professional integrity if the reqeust is made tactfully. Does a woman requesting a female doctor or nurse for intimate exams or care indict the professional integrity of males? I don't think it's taken that way generally within the health care system. So why should it be taken that way for men? We can't control how people respond. That's up to them.

Also, I think gender-neutral and non-sexual attitudes and behavior are different topics. Although the non-sexual behavior and attitude of medical professionals have been internalized successfully, I'm not convinced that the gender neutral one has. It appears that way, but I think it's more on the surface. When you take into consideration their own personal attitudes about same gender care (and for their close family), the attitudes of medical professionals are more mixed and ambivalent.

But, you do make a good point. The battle to change the system, if one decides to do that, should not take place in the doctor's office or with the floor nurse or medical tech. They are not the enemy. Neither is the system, really. It should be an argument of personal values, attitudes and dignity -- a personal, private request form one person to another.

At Sunday, March 08, 2009 9:18:00 PM, Anonymous Anonymous said...

Dr. B., here is an interesting web address for your consideration:

At Sunday, March 08, 2009 9:52:00 PM, Blogger Maurice Bernstein, M.D. said...

And here is the view of a female urologist. The author of the article, writing about the lady urologist quoted her as saying:
“Pretty much any woman I see is relieved to see a woman, or they’ve sought out treatment with a woman so that’s why they end up seeing me.” But, “the men wanted to see me” “They felt I listened better, I was more attentive to their overall needs and I was a little more gentle when I examined them.” ..Maurice.

At Sunday, March 08, 2009 11:00:00 PM, Anonymous Anonymous said...

CSM Your point about maybe making nurses/doctors think about gender is exactly what should happen......It is my feeling that gender-neutral is an impossibility. (You are a many neutral gender people have you seen? you have only seen male/female)...only feeling neutral...I do not care how they feel about their own care...they may choose gender care or whatever...I do think only by stating loudly and firmly that I do have concerns and preferences that my feeliongs are going to be given due consideration and respect. I think the problem is that they have become oblivious to gender issues....This means someone needs to bring them out of whatever daze or dream world they are living in.
This afternoon I had a discussion with a neighbor and one of her friends (both nurses) about same gender care I had asked about finding a male dermatologist as my neighbor thinks i need to screeen for skin cancer)...when I said I did not like being exposed to a male doctor to begin with...and absolutley would not do so with a female doctor and did not want female techs or nurses, one of them decided she would help me out of my'"bashfullness"...she said I should volunteer to be a practice patient of some sort..She could arrange it and see that I was only seen by male student doctors and nurses...then by females as well...she was sure it would "cure" me..
I think that the fact that I needed to be cured (in her opinion) spoke a lot about how medical folk feel.. I think they have "internalised" gender issues in the same way a victim of an accident or crime blocks out reality.

At Monday, March 09, 2009 3:13:00 AM, Anonymous Anonymous said...

Maurice I posted here before as a person who considered herself very modest and one to want a female doctor for intimate exams. However, I have to admit when I discovered a lump in my breast a few years ago, the fear of cancer overrode any modesty issues. I went to my male PCP for a exam and he was extremely professional about it. I truly did not get one ounce of feeling of voyeurism from him. I haven't let him do a pap smear yet though. lol.

At Monday, March 09, 2009 5:03:00 AM, Anonymous Anonymous said...

We have a little of is the glass half full or half empty. I would guess part of the difference of opinion comes from the fact that patients see Dr.'s as the lead in the medical community, so we see change to a large degree as falling on their table. Speaking for me personally I can not see how a Dr. while focused on the physical side...can not recognize that modesty is at a minimum...a part of treatment. I do not doubt what you are saying at all Dr. Bernstein..I am just can't understand how it can't atleast enter the mind. Obviously we understand this for women i.e. using chaparones for male Dr./female there is some recognition there, granted some may be for self protection. To me a very simple solution, as I stated I did my routine last week, dermotologist and urologist, filled out new sheets for each, got the privacy statement from each, a simple line...rate your modesty 1 to 10, is there anything that would make this less of a concern....providers chart everything, give us 5 pages on hippa, and yet..never ask about this. How many people are really concerned about someone seeing their chart vs their privates...simply asking that on the front end would solve a lot of issues, the patient could indicate right from the start no pressure, the provider doesn't have to ask or guess...

I read the article on the female urologist, I could not help but wonder how much of medicine and this thread in paticular is perception. In the article they asked how many of the women felt they were being paid the same as men in urology, most indicated no...yet, the did not ask if they had any proof or concrete reason. The female urologist also said "men wanted her"...I would be interested in knowing exactly how she determined this. I think it is pretty standard for providers to assume, especially female providers assume while females prefer them because they are the same gender...males prefer them becasue they are women and as such more gentle and understanding....interesting article, it would be interesting to know just how these women came up with these perceptions, actual study or just what they think...alan

At Monday, March 09, 2009 10:02:00 AM, Anonymous Anonymous said...

leemac, I think you and I are at the same point, we have the feeling that the medical community looks at the issue as not only is it incumbant on us to address the issue, we do have "issues" if we are concerned. We question why is it not an concern for providers for us as their patients. And while I agree with Dr. Bernstein in that to a degree it doesn't matter as any change that comes will come from the efforts of patients, not providers. I still think we need to challenge providers to look within and question why they feel this way, why in a service industry to they feel its up to us, why in an industry that bills its self as caring...don't they care? I think it allows an easy out for providers by not challenging them to look at their role in this issue.

I would also, and I mean this literally not cynically. I would like for you to ask your neighbor a few questions, has she ever volunteered to be a practice patient..if not why not knowing how helpful it would be for the students and assuming the exposure isn't an issue for anyone. And two, does she use or prefer a male or female gyn. It seems pretty common for providers to have a preference though they do not recognize ours. There is an interesting read in allnurse, one nurse comes right out and says she has already told the staff at her hospital, if she comes into the ER, her bra and underwear are to stay on.......I would be interested to hear how your neighbor differentiates between her modesty and her patients...alan

At Monday, March 09, 2009 12:21:00 PM, Blogger MER said...

Some studies show that female doctors do spend more time with their patients than do male doctors, and that they tend to communicate better. But studies also show that male doctors spend more time with their male patients than with their female patients, and female doctors spend more time with their female patients than with their male patients. These studies indicate that these doctors feel more comfortable dealing with their own gender (in general). (see "Doctors Talking to Patients, Patients Talking to Doctors" by Judith Hall, et. al.)

No question -- some men prefer women doctors. No question -- some women prefer male doctors.

Women like that urologist are entering a profession with few women in it. Of course, she wants to attract clients. It's a business. As Alan pointed out, her perception is interesting. Are women doctors just "more gentle" than male doctors just because, well, women are just more gentle than men? Is that just the way it is? Or is that a generalization or even a stereotype?

Now, in fairness to this doctor, the entire context of this discussion is within a speciality that has been and is dominated by men -- urology. Within that context, it does make sense that, by having more women urologists, you give both women and men more of a choice. That's good.

But there still seems to be this attitude, sometimes, that it's a "relief" for women to have more female doctors, but not a "relief" for men to have male doctors and male nurses upon request. Isn't that interesting?

At Monday, March 09, 2009 2:54:00 PM, Anonymous Anonymous said...

Dr. Bernstein:

Just came across an interesting
series of blog postings on an
ultrasound technician job seekers
site. It appears "Joe from Canton"
can't find employment doing scrotal
ultrasounds despite the fact that he thought there would be a demand for male techs in this area. But
female supervisors are telling him that's simply not so. They say male patients like women techs doing this testing, just fine.

The link:

I'm posting one of the replys Joe just received from "Bill in Oakland". It sounds like some of the thoughts I've read here on your blog.

Perhaps your readers would like to comment on this.

"Joe, there are many guys out there who would prefer a male tech for all forms of pelvic ultrasound. But not all men want them.

The unscientific polling indicates that about a third of men are homophoebic in this regard. There is some justification for this beyond their own fears as it is
generally accepted that the percentage of homosexuals in medical support fields is
twice the national average.

Regardless of this possible factor, another third of men feel very uncomfortable with females
performing these pelvic procedures and tests and would much prefer having a male tech option. Since there are so few males available as ultrasound techs you would
think getting a job would be easy for you if a third of the male population would prefer your involvement. So what's up?

Well, if they hire a male then that male needs to be chaperoned with female patients. This is a drain on staff. It's easier for facilities to go "all-female" staff and force this on men. They've learned that if they do the same to female patients
they'll soon be hearing crys of "sexual abuse" or even "rape". Now, regardless of this, male patients have as much right to modesty as females and BFOQ anti-discrimination law that extends from 1964 allows facilities
to staff according to modesty requests. Unfortunately, right now, across this land, these requests are being, ignored, suppressed, undocumented, and male patients mocked for their modesty concerns.

In your search for employment remember that when you hear female staff supervisors tell you they have no requests for male techs for intimate pelvic care it's a BIG LIE designed to protect their gender-status jobs and all-female working environment. Bill in Oakland"

ROBERTO in Lincoln

At Monday, March 09, 2009 2:57:00 PM, Blogger Maurice Bernstein, M.D. said...

I know that most who are writing to this thread are, in part, involved in trying to understand patient modesty in terms of the psychodynamics of physician thinking and are not enthusiastic about needing to discuss such dynamics with regard to patients since it is proposed that the issue is really about rights and privacy of patients.

Unfortunately, I still am interested in patient psychodynamics particularly as reflected in different cultures because I think it does play a role in this discussion.

I think that most of us have been very pleased with having CSM from the naturism culture join us in the discussion. (By the way, I apologize if I failed to identify any other naturist who wrote here.) I am still trying to find a resource to readily make contact and invite members of other cultures such as professional nude models and pornographic actors and actresses to write about their own patient modesty issues, if any. Is there any visitor out there that can help me make a connection to these cultures? I think representatives of those cultures as well as those of Hindu, Muslim, Oriental, American Indian and others could provide insight into patient modesty, if not of themselves, but also what they understand may be that of others in their culture.

There I go..wandering back to the very issue that started this 3 1/2 year journey with the thread "Naked" based on the title of the New England Journal of Medicine Perspective article by surgeon Atul Gawande, M.D. where he starts out describing his conversations with physicians from different cultures and points out deficiencies in the guidelines for physicians in the United States with regard to patient modesty.

So.. any help from my visitors about getting those from other cultures to visit and write here will be most appreciated. ..Maurice.

At Monday, March 09, 2009 10:32:00 PM, Anonymous Anonymous said...

Recently I saw an advertisement for
a heart institute. There was a pic
of the staff,40 nurses and all female. That in a major city with
many nursing schools and not one
male nurse.
Its discrimination x 2 when they
don't hire a male nurse and impose
all female staff! Why are most female nurses grossly overweight
and considering the fact that its
well known obesity and diabetes go hand in hand. The bumper stickers or the shirts at the mall
always make you wonder. Hug a nurse
or love a nurse. I wouldn't even
want to play football with these
people as i'd have to wear some
serious protective gear let alone
have sex with these people.
Once at a military hospital I
saw a nurse lead two young candy strippers into the icu where a male
patient was lying nude in bed. The
nurse never bothered to cover the
patient either. It is said that
a third of men want same gender care while another third want
opposite gender care and the remaining third don't know.
I have a friend who works as
an ultrasound tech. He tells me
that male patients that arrive
for a testicular exam are happy
that a male is doing the procedure.
Additionally, he told me of a male patient who had a prescription
for a testicular ultrasound.This
male patient then proceded to have
the exam done,7 times. He would call around to a new facility and ask if there were a female tech doing the exam. He managed to have
it done 7 times in two days before
they caught on to him.
That in my opinion is fraud. It
is no different than seeking drugs
at different facility for a fix.
This desire no doubt was caused
at one point by an exam that perhaps was inappropriate but now
resulted in a fetish. How many
health tax dollars are wasted by
people like this. No doubt this
individual belongs to the one third
of those who request opposite gender care. Where does it end. As
the desire grows whats next on the list. Flashing young children at
a school yard.
What about the other third who
don't know or care. Well, maybe their turn has not arrived yet
as I'm sure they will fit into one of these two groups at one point or


At Tuesday, March 10, 2009 5:26:00 AM, Anonymous Anonymous said...

PT-Please stop attacking female nurses it does nothing to advance the subject and it makes us all look bad when someone not as fimiliar visites the blog. Yes some nurses are overweight both male and female. I am not overweight but I could do many things to improve my health but sometimes I choose not to, as I am sure we all fall into that case. Attacking an overweight female nurse and basically saying they are not fit to be a nurse because they are overweight. If a mother or father is overweight should there children be taken away and put in normal body weight foster homes? My mother is overweight and all three of her children played sports in school and where educated in not to over eat. She is an incredible mother and I am very glad to have her as my mother. We should treat healthcare workers with the respect we want to be treated with. There is always an option when it comes to healthcare, sometimes we may not like the options but we are trying to work on that and this will take time but it is happening.


At Tuesday, March 10, 2009 9:21:00 AM, Anonymous Anonymous said...

Daniel, I don't think PT is guilty of attacking female nurses. He stated a point and a question as to why so "many" are overweight" when they know the health implications. Many a doctor is also overweight. It looks "bad" when you enter a healthcare facility and there is a whole string of workers standing outside by the door puffing on cigs.

Smoking and excess weight, formula for health problems. And they are in the field- they should know better. It is like a mechanic not taking care of his car. No oil changes, bald tires, black smoke billowing out the exhaust pipe. Would you take your car to him?

At Tuesday, March 10, 2009 2:06:00 PM, Anonymous Anonymous said...

JW- Well call me wrong for saying PT was attacking female nurses this time? What about the previous posts when he calls "all female nurses pervs"?
I just spent six hundreds dollars on preventive maintenance on my car and I do not smoke nor am I overweight, so you are barking up the wrong tree here. I think if someone does not like seeing employees smoking of a healthcare provider they can write and call and complain. I do not see the reason to prejudge someone who is overweight because that in part is what upset people with patient modesty that healthcare employees prejudge patients in assuming we are all not modest or we are okay with opposite sex healthcare? Back to the smoking I have not been to a hospital where an employee could smoke within three blocks of the hospital. Should we question the billing dept. next on this blog?

At Tuesday, March 10, 2009 3:13:00 PM, Anonymous Anonymous said...

PT, It's when you hear stories like that about the guy who had 7 ultrasounds that you realize why men's modesty issues are not taken as seriously. Don't blame the nurses. Blame your sex crazed fellow men.

At Tuesday, March 10, 2009 3:41:00 PM, Anonymous Anonymous said...

I have to agree with Daniel, one can take the one comment and read it either way, but I think if you go back and review PT's comments about playing football, having sex, etc. along with previous posts I would have to guess they were more than comments on the health aspects of obesity. That said, PT please don't take that as judging you, obviously you have some serious problems with medical staff and females in general. I haven't walked in your shoes so I have no idea what is at the root of these intense feelings.
But I agree 100% with Daniel, judging all health personell as a whole is no different than what we complain they do...assume all patients don't care. The only way this makes any head way is to work with health providers, its easier to pull than push especially if you can get them to walk part way with you. We all toss up the defenses when we feel attacked. Wait until they specifically do something to attack other wise you can alienate someone who might be on your side..or at least not resisting you until you tick them off. It would be great to get a few on this site to discuss and learn from what is being said here, if they feel all that is going to happen is they are going to get hammered...why would the bother?
That said, while I hope we can get other perspecitive of modesty...I still don't think providers get a free pass, thats just the way they are is not acceptable. Bigots, sexist, racists are just the way they are to....slave owners were just the way they were....unacceptable behavior is unacceptable behavior period, people think and act the way the do for a reason, whether that be learned, out of percieved nesecity, priorities, just the way it is doesn't cut it. I am sure some guys who abuse their wives do not see their transgressions as an issue, and while I hardly classify providers in the same vien as abusers, the failure to acknowledge the emotional harm they inflict on patients has some similar traits. They both think the problem lies with the person who is harmed, they don't think they have done anything wrong, they have either done it so long or been exposed to it so long it isn't even something they think about....yet expect the "victims" to accomodate or change to accept their version of right. I do not mean to make light of domestic abuse, it is far more serious than what we are dicussing. However, there are more similarities than providers might admit....sorry Dr. Bernstein, I will try to let it end there with me on that subject...but I still don't think the problem gets solved if we just accept..."thats just the way they are"....not all of them are like aren't, Dr. Sherman isn't, Dr. Alex C. from Dr. Sherman's site isn't, my PCP isn't....what makes them different...alan

At Tuesday, March 10, 2009 4:11:00 PM, Blogger Maurice Bernstein, M.D. said...

Alan, as I have written previously, the problem with the "other doctors" is that they are ignorant of this particular modesty issue. They are not educated about it. They are not aware. It is NOT on their minds. As I have said, I think that most doctors would try to respond to try to mitigate the patient's concerns if they are informed about the concern and if they can.

We are going to move on to Volume 11 shortly. I hope we can make these discussions as civil as possible. I think it is time to avoid using anecdotes since throughout these 3 1/2 years we have read enough examples here. Anecdotes are generally presented with no documentary evidence for verification and at times are from a productive discussion viewpoint just not pertinent nor applicative..."way off the main issue". Even if the visitor is riled up and frustrated about medical providers attention to their concerns, please don't use anecdotes any further here. We here all know your concerns. Write constructively not destructively.
I hope I don't have to edit the commentaries.

As I noted above, with this being comment number 132, I think we better migrate over to Volume 11. I'll try to put it up later today. ..Maurice.

At Tuesday, March 10, 2009 8:48:00 PM, Blogger Maurice Bernstein, M.D. said...

This Volume 10 is now closed for further comments. Continue the discussion on "Patient Modesty: Volume 11". ..Maurice.


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